Twin Oaks Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Laplace, Louisiana.
- Location
- 506 West 5th Street, Laplace, Louisiana 70068
- CMS Provider Number
- 195303
- Inspections on file
- 26
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Twin Oaks Nursing Home during CMS and state inspections, most recent first.
The facility failed to timely report an injury of unknown source with serious bodily injury to the State Survey Agency as required by its abuse and incident reporting policy. A resident with cognitive impairment, upper and lower extremity limitations, and dependence on staff for transfers and ADLs complained of left shoulder pain, and an NP ordered an x-ray that showed an age-indeterminate proximal humerus fracture with displacement, later described by the physician as an acute displaced angulated fracture. Despite the resident’s condition and the unclear origin of the injury, the Administrator and DON concluded the injury was not of unknown origin based on the resident’s osteoporosis diagnosis, did not suspect abuse, and did not report the incident through the State Incident Management System within the required 2-hour window, resulting in delayed reporting to the State Survey Agency.
A resident's room was found to have a strong unpleasant odor, soiled linens left on a bed, a spill near the door, and debris scattered on the floor. These conditions were confirmed by a CNA and acknowledged by the DON as not meeting required standards for cleanliness and comfort.
A resident's nebulizer tubing was not changed and dated weekly as required by physician orders and facility policy. Observations showed the tubing was dated over a month prior, and staff interviews confirmed it should have been changed weekly but was not.
A menu substitution was made for a meal, replacing brussel sprouts with beets, without documentation or approval from the RD. The dietary manager did not notify the RD of the change, and there was no evidence that the required approval process was followed.
Surveyors identified that food items in the facility's refrigerator and freezer were not properly dated or covered, and some items from outside sources were not labeled as required. Additionally, expired sanitization test strips were found in use for the dishwasher, with staff confirming these practices did not meet facility policy.
The facility did not provide written notification to the State's LTC Ombudsman for the discharge of two residents, as required. Documentation review showed that the necessary notifications were not present in the residents' records.
A facility-wide assessment did not include documentation addressing the behavioral health needs of the resident population, staff competencies related to behavioral health, or necessary facility resources, despite 42 residents being identified with such needs. This deficiency was confirmed by the administrator during the survey.
A resident was struck in the face by another resident, resulting in a swollen upper lip, as witnessed by a CNA and documented by an RN. Despite clear evidence of physical harm, facility staff did not classify the incident as abuse, contrary to facility policy.
The facility did not report a physical altercation between two residents, where one sustained a swollen upper lip after being struck, to the statewide incident management system as required. Despite a CNA witnessing the event and documentation of injury, the administrator did not consider the incident abuse and failed to make the mandated report.
A resident with a new diagnosis of bipolar disorder was not referred for a required PASARR Level II evaluation. Despite documentation of the new diagnosis in the psychiatric assessment, there was no evidence that the facility initiated a referral or completed the necessary screening, as confirmed by the social worker.
A resident was found with gauze and a ketchup packet in his throat after a drop in blood pressure led to a hospital visit. The facility's investigation was incomplete, failing to interview key staff and a fellow resident present during the incident. The administrator acknowledged inaccuracies in the report regarding the resident's wound care orders.
The facility failed to provide adequate nail care for two residents with hemiplegia, as their nails were observed extending past the tips of their fingers and toes. Despite care plans indicating the need for assistance with ADLs, including grooming, there was no documented evidence of nail trimming for one resident over a two-week period. Staff confirmed the need for nail care, highlighting a deficiency in maintaining residents' cleanliness and grooming.
A resident was observed receiving oxygen therapy at varying levels without a physician's order or a developed care plan. Despite being cognitively intact, the resident's care plan lacked documentation for their oxygen therapy. Interviews with nursing staff confirmed the absence of necessary orders and care planning.
The facility failed to ensure nursing staff signed off on medication counts at shift changes for two medication carts, as required by their Controlled Substances Policy. Interviews confirmed that LPNs did not document narcotic counts, and the DON acknowledged the oversight.
A resident's confidentiality was breached when a sign detailing their dialysis schedule was posted on their door, visible to anyone in the hallway. An LPN recognized this as a HIPAA violation, and the DON confirmed the sign should not have been displayed.
A facility failed to complete a correct Level 1 PASARR for a resident with Major Depressive Disorder, Anxiety, and Schizophrenia, who was receiving daily antipsychotics. Despite these diagnoses, no referral was made for a Level II PASARR evaluation. This error was acknowledged by the facility's social services staff.
A resident was not referred for dental services despite having a care plan that included dental appointments and periodic visits. The resident, who had significant dental issues, was not listed on the facility's dental treatment schedule, and there was no documented evidence of a dental evaluation. Observations showed the resident had no upper teeth and grey-colored bottom teeth, and the resident expressed difficulty in chewing and a need for dental care. Facility staff confirmed the oversight.
The facility failed to maintain infection control by storing clean mop heads in a contaminated laundry area and not ensuring proper PPE and hand hygiene during incontinence care for a resident on Enhanced Barrier Precaution. A CNA did not wear a gown or perform hand hygiene between glove changes, as confirmed by the Assistant Director of Nursing.
A resident with Alzheimer's and other conditions alleged that the nursing home administrator pushed her, an incident documented in a police report and a Physician's Emergency Certificate. Despite the resident informing the police and facility staff, the allegation was not reported to the state agency as required. Interviews revealed that the regional administrator was unaware of the incident until later, and the Director of Nursing did not report it to corporate management.
A resident alleged that an administrator pushed her, but the facility failed to investigate the claim as required by its policy. Despite the resident's statement being documented in a police report, there was no evidence of an investigation, and interviews confirmed the lack of action.
The facility failed to provide documented training for the Administrator in essential areas such as QAPI, behavioral health, ethics, and resident rights. This deficiency was confirmed by the Regional Administrator, who acknowledged the absence of training documentation.
The facility failed to protect residents from verbal and physical abuse by other residents. Incidents included a resident striking another in the face, a verbal and physical altercation between two residents, a resident hitting another in the head, a resident slapping another, and a resident verbally threatening another. These incidents were witnessed by staff and confirmed by the Administrator.
The facility failed to report an allegation of resident-to-resident abuse and did not report incidents of physical abuse in a timely manner. A resident verbally threatened another, and two incidents of physical abuse were reported past the required 2-hour mark. The administrator confirmed the delays and indicated she was solely responsible for reporting.
The facility failed to investigate an incident of verbal abuse between two residents, both with moderate cognitive impairment. Despite the incident being discussed in a leadership meeting, no investigation was conducted, as confirmed by the facility's administrator.
Failure to Timely Report Injury of Unknown Source with Serious Bodily Injury
Penalty
Summary
The facility failed to timely report an injury of unknown source with serious bodily injury to the State Survey Agency as required by its Abuse, Neglect, and Misappropriation of Funds Program policy. The policy stated that if abuse was determined, could not be ruled out with reasonable certainty, or if the source of an injury was unknown and could not be determined, the Administrator would report the incident through the State Incident Management System. An incident report submitted through the State Incident Management System showed that an injury of unknown origin with bruising to the left shoulder was reported for Resident #1 on 12/16/2025 at 4:15 PM, and that the resident had reported this issue the week prior. Nursing documentation showed that on 12/09/2025 at 9:42 AM, the resident complained of pain to the left shoulder. Resident #1’s quarterly MDS with an Assessment Reference Date of 12/09/2025 documented that the resident was not interviewable or was confused (BIMS score of 99), had upper and lower extremity impairments, and was dependent on staff for transfers and ADLs. A nurse practitioner was notified on 12/11/2025 that the resident complained of left shoulder pain and ordered an x-ray. The radiology report dated 12/11/2025 revealed an age-indeterminate fracture of the proximal left humerus with mild displacement, and a physician progress note dated 12/16/2025 described an acute displaced angulated fracture through the surgical neck of the humerus with medial displacement of the shaft. The Administrator and the DON each stated they determined the injury was not of unknown origin based on the resident’s osteoporosis diagnosis and did not suspect abuse; therefore, they did not report the incident to the State Survey Agency within the required two-hour timeframe.
Resident Room Not Maintained in Clean and Homelike Condition
Penalty
Summary
Surveyors observed that one resident's room was not maintained in a safe, clean, and comfortable condition as required. The room had a strong unpleasant odor, and soiled linens with an odor were piled on the roommate's bed. Additionally, there was a small puddle of an unknown liquid by the door, and the floor was scattered with small pieces of paper, a straw, and other white debris. These findings were confirmed by a CNA during an interview, who acknowledged the presence of the odor, soiled linens, trash, debris, and the spill. The DON also confirmed these observations and acknowledged that the room should not have been in that state. No information about the resident's medical history or condition at the time of the deficiency was provided in the report.
Failure to Change and Date Nebulizer Tubing Weekly
Penalty
Summary
The facility failed to ensure that respiratory nebulizer tubing for a resident was changed and dated according to physician orders and facility policy. Specifically, the physician's orders required that all respiratory tubing, supplies, and storage bags be changed and dated every Sunday during the overnight shift. However, multiple observations over several days revealed that one resident's nebulizer tubing was dated more than a month prior and had not been changed as required. Interviews with two LPNs and the DON confirmed that the tubing should be changed weekly, and the DON acknowledged that the tubing had not been changed since the date indicated on the tubing, which was several weeks past due. The deficiency was identified through direct observation, record review, and staff interviews.
Menu Substitution Not Approved by Registered Dietician
Penalty
Summary
The facility failed to ensure that menu substitutions were approved by the registered dietician as required. On 08/11/2025, the approved lunch menu included white beans, ham, steamed rice, and brussel sprouts, but the meal served consisted of white beans, rice, and beets. The dietary manager did not document the substitution of beets for brussel sprouts and did not notify the registered dietician for approval of this change. Interviews with the dietary manager and administrator confirmed that the substitution was neither documented nor communicated to the registered dietician, who also confirmed he was not notified. There was no documented evidence to show that the registered dietician was informed of or approved the menu revision.
Deficient Food Storage, Labeling, and Sanitization Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and safety practices. Food items stored in the three-door refrigerator and freezer, including disposable bowls of dry cereal, a partially used container of frozen chicken liver, and cups of a pudding-like substance, were found to be undated and, in some cases, uncovered. Staff interviews confirmed that these items should have been labeled with an opened date and covered as per facility policy. Additionally, food items from outside sources, such as a bottle of frozen hydrate alkaline water and an electrolyte drink, were stored in the facility's freezer without proper labeling to indicate their origin, contrary to the facility's policy of only accepting food from approved suppliers. Further, the facility was found to be using expired sanitization test strips for its low-temperature dishwasher, with the expiration date having already passed. Staff confirmed that these expired strips should not have been in use. These findings were based on direct observations and staff interviews, and the facility's own policies were reviewed to confirm the requirements for food storage, labeling, and sanitization monitoring.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide written notification to the State's Long-Term Care Ombudsman regarding the discharge of two residents. Record reviews and interviews confirmed that one resident was discharged on 03/05/2025 and another on 01/11/2025. There was no documented evidence that the Ombudsman was notified in writing of either discharge, as required. This deficiency was identified through review of the electronic medical records and the absence of corresponding notification documentation.
Facility-Wide Assessment Lacks Behavioral Health Considerations
Penalty
Summary
The facility failed to ensure its facility-wide assessment addressed the behavioral health needs of its resident population as required. Record review showed that 42 residents were identified as having behavioral health needs. However, the facility's most recent facility-wide assessment, last revised in September 2024, did not contain any documented evidence that it addressed the behavioral health needs of the resident population, staff competencies related to those needs, or the facility resources necessary to care for residents with behavioral health needs. This deficiency was identified for three sampled residents reviewed for behavioral health needs. During an interview, the administrator confirmed these findings.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. According to the facility's policy, abuse includes the willful infliction of injury resulting in physical harm. Documentation in the electronic medical record showed that a resident complained of pain and was found to have a swollen upper lip after being struck in the face by another resident. A certified nursing assistant witnessed the incident and confirmed that the resident was repeatedly hit in the face. Despite these findings, interviews with facility staff, including a quality assurance nurse and the administrator, revealed that they did not consider the incident to be physical abuse. The quality assurance nurse stated that the altercation was not abuse because the aggressor was reacting to the other resident digging in his bag. The administrator also did not classify the event as abuse, even though physical harm was observed and documented.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the statewide incident management system (SIMS) as required by policy. According to the facility's policy, any incident where abuse is determined or cannot be ruled out must be reported to the state surveying agency. Documentation showed that one resident complained of pain and was found to have a swollen upper lip after being hit by another resident. A CNA witnessed the incident, observing one resident repeatedly hitting another in the face. Despite these findings, the administrator did not consider the event to be abuse and did not report it to SIMS, as confirmed during an interview.
Failure to Refer Resident for PASARR Level II After New Bipolar Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident who received a new diagnosis of bipolar disorder was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. The resident was initially admitted with a Level I PASARR approved for a temporary period and later received another Level I PASARR screening indicating Level II services were not required. However, after a psychiatric assessment documented a new diagnosis of bipolar disorder, there was no evidence in the electronic medical record that a Level II PASARR screening was completed or that a referral was made to the appropriate state agency. The facility's social worker confirmed in an interview that no new referral for a Level II PASARR screening was made following the new diagnosis.
Incomplete Investigation of Alleged Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident who was found with gauze and an empty ketchup packet lodged in his throat after being sent to the hospital due to a drop in blood pressure. The facility's policy requires evidence of a thorough investigation for all alleged violations, but the investigation into this incident was incomplete. The facility's report speculated that the gauze was obtained during emergency transport or at the hospital, despite the resident having an active wound care order for gauze application to his knee. The facility's camera footage was reviewed, but it was out of focus, and the facility did not interview all potential witnesses present during the incident. Key staff members and a resident who were present during the lunch meal service when the incident occurred were not interviewed by the facility's administrative staff. The housekeeper, dietary aide, and another resident who shared the table with the affected resident were not questioned or asked to provide statements about their observations. The administrator confirmed the lack of interviews and acknowledged that the facility's report inaccurately stated that the resident did not have wound care orders. This oversight in the investigation process led to a deficiency in addressing the allegation of neglect properly.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were admitted with diagnoses of hemiplegia affecting one side of their bodies. Resident #28, who had impairment on one side of her upper and lower extremities, was observed on two occasions with toenails and fingernails extending past the tips of her nailbeds. This observation was confirmed by both a Certified Nursing Assistant (CNA) Supervisor and a Wound Care Nurse, who acknowledged that the resident's nails needed trimming. The resident's care plan indicated a requirement for assistance with activities of daily living (ADLs), including maintaining cleanliness and grooming, which was not adhered to in this instance. Similarly, Resident #40, who also had a self-care deficit due to right side hemiplegia, was observed with nails extending past the tips of his fingers on two separate occasions. A review of his ADL records showed no documented evidence of nail trimming over a two-week period. The Director of Nursing confirmed the need for nail trimming during an interview. Both residents' care plans emphasized the importance of being kept clean, dry, and well-groomed, yet the facility failed to meet these care requirements, resulting in the identified deficiency.
Lack of Care Plan for Resident's Oxygen Therapy
Penalty
Summary
The facility failed to develop a plan of care for a resident receiving respiratory care by nasal cannula. Observations revealed that the resident was receiving oxygen at varying levels, initially at 2 liters per minute (LPM) and later at 4 LPM, without a corresponding physician's order. The resident's Minimum Data Set indicated they were cognitively intact, yet there was no documented plan of care for their oxygen therapy. Interviews with the Licensed Practical Nurse and the Assistant Director of Nursing confirmed the absence of a physician's order for the resident's oxygen care. Additionally, the Director of Nursing acknowledged that no care plan had been developed for the resident's oxygen therapy.
Failure to Document Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that nursing staff signed a verification of an accurate medication count at the beginning and end of each shift for two medication carts. This deficiency was identified through record reviews and interviews, revealing that the facility's Controlled Substances Policy was not adhered to. The policy requires that controlled drugs be counted at the end of each shift by both the nurse coming on duty and the nurse going off duty, with any discrepancies reported immediately to the Director of Nursing (DON) or designee. However, documentation of these counts and signatures was missing for numerous shifts across two medication carts over several months. Interviews with nursing staff confirmed the lack of compliance with the policy. For instance, an LPN admitted to not signing the narcotics book after completing the narcotic count with the nurse going off duty. The DON also acknowledged that narcotic counts were not documented as required on the specified dates. This lack of documentation and adherence to the policy indicates a failure in the facility's process for ensuring the accurate dispensation of controlled medications.
Resident Confidentiality Breach Due to Improper Signage
Penalty
Summary
The facility failed to protect the confidentiality of a resident's medical information, specifically for one resident out of a sample of 32. During an observation, it was noted that a sign titled 'Appointment Sheet' was posted on the exterior side of the resident's door facing the hallway. This sign included the resident's name and detailed their dialysis schedule, indicating pick-up times. In an interview, an LPN acknowledged that this was a violation of the Health Insurance Portability and Accountability Act (HIPAA), as it exposed the resident's medical condition, end-stage renal disease, to anyone passing by. The Director of Nursing confirmed that such a sign should not have been posted on the door.
Failure to Complete Correct PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed correctly for a resident diagnosed with Major Depressive Disorder, Anxiety, and Schizophrenia. The resident was admitted with these diagnoses and was receiving antipsychotics daily. A review of the resident's Minimum Data Set (MDS) indicated these mental health conditions, yet the Level 1 PASARR completed earlier did not result in a referral to the appropriate state-designated authority for a Level II PASARR evaluation and determination. This oversight was confirmed during an interview with the facility's social services staff, who acknowledged that the Level 1 PASARR was completed incorrectly and that a Level II PASARR should have been requested.
Failure to Refer Resident for Dental Services
Penalty
Summary
The facility failed to ensure that a resident was referred for dental services, as evidenced by the case of Resident #25. The resident was admitted on an unspecified date and had a care plan with a goal date of 08/21/2024, which included approaches for arranging dental appointments and periodic dental visits due to the potential for dental issues. However, there was no documented evidence that Resident #25 was evaluated for dental services, and the resident was not listed on the facility's dental treatment schedule dated 08/19/2024. Observations on 08/05/2024 revealed that Resident #25 had no upper teeth, only front bottom teeth, and the remaining bottom teeth were grey in the middle. During an interview, the resident expressed the need to see a dentist, mentioning difficulty in chewing food and a desire to prevent further tooth loss. Interviews with facility staff confirmed the lack of documentation and evaluation for dental services for Resident #25.
Infection Control Deficiencies in Laundry and Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two key areas. Firstly, clean mop heads were improperly stored in the contaminated laundry area, directly above soiled linen barrels. This was observed on two separate occasions, and both the Laundry Supervisor and the Administrator confirmed the inappropriate storage of clean mop heads in the contaminated area. Secondly, the facility did not ensure that staff adhered to proper hand hygiene and personal protective equipment (PPE) protocols during incontinence care for a resident with a diabetic ulcer on Enhanced Barrier Precaution (EBP). A Certified Nursing Assistant (CNA) was observed performing incontinence care without wearing a gown and failing to perform hand hygiene between glove changes. The CNA acknowledged the lapse in protocol, and the Assistant Director of Nursing confirmed the expected procedures were not followed.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal and physical abuse involving a resident to the required state survey agency. The incident involved a resident who was admitted with diagnoses including Alzheimer's disease, schizophrenia, depressive disorder, dementia, and anxiety. The resident alleged that the nursing home administrator pushed her, an incident that was documented in a Physician's Emergency Certificate and a police report. Despite the resident informing the police and facility staff about the incident, the allegation was not reported to the state agency as required by the facility's policy. Interviews conducted during the investigation revealed that the resident's responsible party and the facility's Ombudsman were informed of the incident. The nursing home administrator initially acknowledged the report but later denied the interview, claiming inconsistency in reporting the source of information. The regional administrator confirmed that he was unaware of the allegation until the day of the interview and verified that the incident was not reported to the state agency. Additionally, the Director of Nursing was aware of the allegation but did not report it to corporate management, further contributing to the failure to report the incident as required.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of physical abuse involving a resident. According to the facility's policy titled 'Policy for Prohibition of Abuse, Neglect and Misappropriation of Property,' all alleged violations of abuse must be thoroughly investigated. However, there was no documented evidence that the allegation made by a resident, who claimed that the administrator pushed her, was investigated. The police report confirmed the resident's statement, yet the facility did not present any documentation of an investigation. Interviews with the administrator and the regional administrator confirmed that the allegation was not investigated.
Lack of Documented Training for Administrator
Penalty
Summary
The facility failed to implement an effective training program for its staff, as evidenced by the lack of documented training for the Administrator. The Administrator, hired on 07/22/2015, did not have documented evidence of receiving training in key areas such as Quality Assurance and Performance Improvement (QAPI), behavioral health, ethics, and resident rights. This deficiency was confirmed during an interview with the Regional Administrator, who acknowledged the absence of documentation for these essential trainings.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents. This deficiency was identified for six residents. Resident #3 struck Resident #4 in the face in the dining room, witnessed by the Food and Nutrition Manager and confirmed by the Administrator through video review. Resident #5 and Resident #6 were involved in a verbal and physical altercation in the hallway, with Resident #6 being verbally abusive and Resident #5 shoving Resident #6 into a clothing cart. The incident was witnessed by the Laundry Supervisor and confirmed by the Administrator. Resident #7 hit Resident #8 in the head in the dining room, witnessed by another resident and confirmed by video review. Resident #2 slapped Resident #9 in the dining room, witnessed by the Treatment Nurse and confirmed by the Administrator. Resident #1 verbally abused Resident #10, threatening to kill him if he didn't shut up, which was confirmed by the Administrator and an LPN. These incidents indicate a failure to protect residents from abuse by other residents, as required by regulations.
Failure to Report Abuse Timely
Penalty
Summary
The facility failed to ensure an allegation of resident-to-resident abuse was reported to the State Survey Agency. Specifically, Resident #1 verbally threatened Resident #10, and this incident was discussed in a leadership meeting but was not reported to the state agency as required. The incident was documented in a nurse's note, and the LPN on duty acknowledged that an incident report should have been written but was not. The administrator confirmed that a State Incident Management Systems (SIMS) report should have been filed but was not completed. Additionally, the facility failed to report incidents of physical abuse in a timely manner for two residents. An incident involving Resident #6 was discovered and reported to SIMS past the required 2-hour mark. Similarly, an incident involving Resident #9 was also reported to SIMS beyond the 2-hour reporting window. The administrator confirmed the delayed reporting times and indicated that she was the only one with access to SIMS and responsible for reporting.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of verbal abuse between two residents. Resident #1, who has a history of moderate cognitive impairment and various medical conditions, was documented in the nurses' notes as having shouted a threatening remark at Resident #10. Resident #10 also has moderate cognitive impairment and exhibits frequent physical and verbal behavioral symptoms directed toward others. Despite the incident being discussed in a Morning Leadership Meeting, there was no evidence that an investigation was conducted. The deficiency was confirmed during an interview with the facility's administrator, who acknowledged that the incident constituted resident-to-resident abuse and that an investigation should have been conducted but was not. The facility failed to provide any evidence of an investigation into the verbal abuse incident, indicating a lapse in their protocol for handling such allegations.
Latest citations in Louisiana
The facility failed to maintain an effective pest control program when multiple live roaches, roach feces, and dead roach carcasses were observed in a room shared by two residents, including on and under a personal refrigerator and beneath items placed on top of it. Housekeeping, maintenance, and a CNA each reported seeing roaches in the room on the prior day, and subsequent observations by maintenance and the administrator confirmed ongoing roach activity in the same area.
A resident with end stage renal disease, bone density disorder, chronic pain, and osteoarthritis was care planned and assessed as totally dependent for chair/bed transfers, requiring a mechanical lift with two-person assist. On one occasion after dialysis, an LPN and a CNA brought a mechanical lift into the room but, after the resident reportedly expressed not wanting to use it, the CNA manually transferred the resident from wheelchair to bed by lifting under the resident’s arms while the resident held the CNA’s waist. During this non–care-planned manual transfer, a popping sound was heard from both shoulders and the resident complained of arm pain; subsequent x‑rays and hospital evaluation confirmed acute fractures of the left clavicle and right humerus. The facility’s investigation, including review of camera footage and staff interviews, established that the mechanical lift was not used as required by the resident’s care plan, and that the injury occurred during this improper manual transfer rather than during a clothing change as initially reported.
A staff member in Social Services routinely emailed detailed resident information, including face sheets and a full census listing names, dates of birth, payer sources, room numbers, diagnoses, allergies, and advance directive details, to a contracted outside provider so the provider could identify which residents were not receiving their services and then approach them. These disclosures involved all residents in the facility and were made without obtaining or documenting any resident or responsible party consent, despite a facility policy requiring protection and confidential handling of medical, financial, and social records.
A resident with an order for Glucerna 1.2 at a specified rate and duration was instead observed receiving Isosource at 60 ml/hour. Record review confirmed the physician’s order for Glucerna 1.2, while observation and interview with an LPN verified that Isosource, a different enteral formula, was being administered. The DON later stated that the LPN should have verified the physician’s order before administering the tube feeding.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying a 29% error rate during one observed medication pass. A resident had multiple medications ordered for 9:00 AM, including aspirin, calcium carbonate, vitamin C, carvedilol, furosemide, potassium chloride ER, thiamin, timolol ophthalmic drops, and docusate sodium. An LPN administered all of these medications at 11:24 AM, outside the facility’s policy window of one hour before to one hour after the scheduled time, and did so without a physician order to change the administration times. The DON confirmed that this timing did not comply with the facility’s medication administration policy.
A resident was readmitted from the hospital with handwritten physician orders for multiple medications, including acetaminophen, Eliquis, buspirone, losartan, mirtazapine, quetiapine, senna, and Vistaril, to be given on specific schedules and as needed. Review of the eMAR showed that none of these medications were administered for an extended period after readmission. In interviews, the DON stated that nurses are responsible for clarifying orders upon a resident’s return from the hospital, and an LPN acknowledged that the medications should have been restarted and administered as ordered but were not.
A resident with physician orders for Glucerna 1.2 via enteral feeding at a specified rate and duration did not have the administration of this feeding documented in the eMAR on two days, even though surveyors directly observed the feeding being administered at the ordered rate on both days. The DON acknowledged that nursing staff should have recorded the enteral feeding administration in the medication administration record, but this documentation was missing, resulting in incomplete medical records.
A treatment nurse performed wound care on a resident with a diabetic toe wound without following the facility’s hand hygiene policy. The facility’s policy required staff to wash hands after removing gloves and clarified that gloves do not replace handwashing. During the observed dressing change, the nurse removed the old dressing and gloves, did not perform hand hygiene, donned new gloves, cleansed the wound, then again removed gloves and applied new ones without hand hygiene before applying calcium alginate and a dry dressing. The nurse later stated she had not cleaned her hands between glove changes because there was no hand sanitizer available in the room and she did not wash her hands instead, and the DON confirmed that hand hygiene should have been performed between each glove change.
Surveyors found that a CNA’s personnel file lacked documentation of the required 12 hours of annual in-service education, including dementia care and abuse prevention. The CNA had been employed for over a year, and facility leadership confirmed there was no evidence that the mandated annual training had been completed.
A resident sustained burns after spilling hot coffee from a lidded Styrofoam cup while using an over-bed table. The incident review and interviews showed kitchen staff did not check coffee temperatures before sending it to the floor, and an observed canister of coffee measured 158.1 degrees F. The facility policy stated hot liquids should be monitored to prevent scalding.
Failure to Maintain Effective Pest Control in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the environment was free of pests and insects, affecting a room shared by Resident #1 and Resident #3 and having the potential to affect 89 residents in the facility. On 04/30/2026 at 8:30 a.m., during an observation with the housekeeping staff member (S3Housekeeping) in this room, a live roach was seen crawling on the wall, on top of Resident #1’s personal refrigerator, and underneath the desk-style phone on top of the refrigerator. S3Housekeeping stated she had seen one roach in the same room the previous day. Around 8:40 a.m., the maintenance staff member (S2Maintenance) reported that a CNA (S4Certified Nurse Aide) had informed him the previous afternoon about a roach on the wall in that room. At 8:45 a.m., further observation of the same room with S2Maintenance revealed roach feces and dead roach carcasses on top of Resident #1’s refrigerator, and when S2Maintenance lifted the phone and a book from the top of the refrigerator, live roaches ran out from underneath. At 8:53 a.m., the CNA (S4Certified Nurse Aide) confirmed she had noticed a roach in the room the day before. Later, at 12:45 a.m., the administrator (S1Administrator) reported that when he accompanied maintenance to the room and the refrigerator was lifted, a couple of live roaches ran out from underneath it. In a subsequent interview at 4:30 p.m., S1Administrator confirmed there were live roaches in the room of Resident #1 and Resident #3 and acknowledged they should not have been present.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate assistance during transfers by not following the resident’s care plan, which required use of a mechanical lift with two-person assistance. The resident had been admitted with diagnoses including end stage renal disease with dependency on renal dialysis, other specified disorders of bone density and structure, chronic pain, and osteoarthritis. The resident’s annual and quarterly MDS assessments documented intact cognition with a BIMS score of 15 and indicated the resident was totally dependent for chair/bed transfers. The care plan, initiated at admission, specified that transfers were to be performed using a mechanical lift with two staff assisting. On the date of the incident, the resident had returned from dialysis and required assistance transferring from a wheelchair to a bed. According to interviews, a CNA and an LPN were involved in the transfer. The LPN reported that a mechanical lift was rolled into the resident’s room, but the CNA stated the resident did not want to use the lift. Despite knowing that the resident was care planned for mechanical lift use, the CNA proceeded to transfer the resident manually by placing her arms under the resident’s arms while the resident wrapped her arms around the CNA’s waist. During this manual transfer from wheelchair to bed, a popping sound was heard from the resident’s shoulders and the resident immediately complained of pain in both arms. Progress notes from that day documented that staff heard an audible pop from both shoulders while assisting the resident and that the resident complained of pain. The physician was notified, x-rays of both upper extremities were ordered, and the resident was transferred to a local emergency room at the family’s request. Facility x-rays and hospital records confirmed acute fractures of the left clavicle and right humerus, described in the hospital record as an acute mildly displaced left distal clavicular fracture and an acute mildly displaced fracture of the right proximal humeral diaphysis. The facility’s incident report later documented that the LPN and CNA did not utilize a mechanical lift during the transfer from wheelchair to bed, and the administrator confirmed through interviews and review of camera footage that the transfer had been performed without the mechanical lift, contrary to the resident’s assessed needs and care plan. Initially, the resident, the LPN, and the CNA all reported that the injury occurred while staff were assisting the resident with a change of clothing. The hospital record also reflected the resident’s report that the injury occurred while staff were assisting her with changing clothes while she was in the mechanical lift. However, during the facility’s subsequent investigation, the administrator reviewed camera footage showing the mechanical lift being brought into and then removed from the room within a short period of time, and questioned whether that time frame was sufficient to complete a lift transfer. Both the LPN and CNA acknowledged that it was not enough time and ultimately admitted that the lift had not been used and that the injury occurred during a manual transfer from wheelchair to bed, not during clothing change. This sequence of actions and inactions—specifically, the decision to disregard the care-planned mechanical lift transfer and instead perform a manual transfer—led directly to the resident’s bilateral upper extremity fractures and constituted the cited deficiency.
Unauthorized Disclosure of Resident Medical Information to Outside Provider
Penalty
Summary
The facility failed to maintain residents' right to confidentiality of their medical records when a staff member in Social Services transmitted resident information to a contracted outside provider without obtaining consent. Review of the facility’s Resident Rights and Dignity policy, revised 03/07/2011, showed the facility was to safeguard all resident records and handle release of information in a manner that protected resident rights. Contrary to this policy, review of an email dated 10/15/2025 from the Social Services staff member to a contracted provider showed that face sheets for multiple residents were attached. These face sheets contained residents’ names, dates of birth, Social Security numbers, admit dates, Medicare/Medicaid numbers, drug allergies, care providers, pharmacy names, emergency contacts, diagnoses, and advance directive information. Further review of another email dated 03/20/2026 from the same Social Services staff member to the contracted provider showed that a facility census for a specific date was sent, which included information on all 80 residents in the facility. The census listed each resident’s room number, name, date of birth, status in the facility, primary payer source, and room rate designation. In interviews, the Social Services staff member stated that every month to every quarter she sent a daily census to the contracted provider so they could identify residents not receiving their services and then approach those residents about services. When surveyors requested evidence of resident consent for release of medical records to this provider, the Social Services staff member and the Chief Operating Officer both confirmed that the facility had no documentation of consent obtained prior to releasing the residents’ information, and acknowledged that the information had been sent on at least two occasions.
Incorrect Enteral Feeding Formula Administered Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident received the correct enteral feeding formula as ordered by the physician. Review of the resident’s April 2026 physician orders showed an order for Glucerna 1.2 to be administered at 50 ml/hour for 12 hours per day, with an increase to 60 ml/hour for 21 hours per day if tolerated. During observation on 04/21/2026 at 1:20 PM, the resident was noted to be receiving Isosource at a rate of 60 ml/hour instead of the ordered Glucerna 1.2. In a subsequent interview and observation at 1:31 PM, an LPN confirmed that Isosource was being administered at 60 ml/hour and acknowledged that this was the wrong enteral feeding type compared to the physician’s order for Glucerna 1.2. Later, the DON stated that the LPN should have verified the physician’s order for the resident’s enteral feeding prior to administration. This deficiency centers on the administration of an incorrect enteral feeding product despite a clear physician order specifying a different formula and rate, as confirmed through record review, direct observation of the feeding in progress, and staff interviews.
Medication Error Rate Exceeded Due to Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5 percent, as required, resulting in a calculated error rate of 29 percent during a medication pass for one resident. Facility policy stated that medications were to be administered within one hour of their prescribed time unless otherwise specified. Review of the resident’s April 2026 physician orders and eMAR showed multiple medications scheduled for 9:00 AM, including aspirin EC 81 mg daily, calcium carbonate 600 mg twice daily, ascorbic acid 500 mg daily, carvedilol 25 mg twice daily, furosemide 20 mg daily, potassium chloride ER 20 mEq daily, thiamin HCl 100 mg daily, timolol maleate ophthalmic 0.5% one drop to both eyes daily, and docusate sodium 100 mg daily. On the observed medication pass, the LPN administered all of these medications at 11:24 AM, outside the facility’s accepted administration window of one hour before to one hour after the scheduled 9:00 AM time. The LPN acknowledged that the medications were scheduled for 9:00 AM and should have been given between 8:00 AM and 10:00 AM. The DON confirmed that medications were to be administered within that one-hour-before to one-hour-after window and that the LPN should not have administered the medications at 11:24 AM without a physician order to change the medication times. Based on 31 opportunities for error and 9 errors identified, surveyors calculated a medication error rate of 29 percent.
Failure to Restart and Administer Physician-Ordered Medications After Hospital Readmission
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff did not administer multiple physician-ordered medications following the resident’s readmission from the hospital. The resident was readmitted on 03/09/2026, and the handwritten physician order sheet dated that day directed that the resident receive acetaminophen 500 mg, 2 tablets every 6 hours as needed; Eliquis 2.5 mg, 1 tablet twice daily; buspirone 5 mg, 1 tablet three times daily; losartan 25 mg, 2 tablets daily; mirtazapine 7.5 mg, 1 tablet nightly; quetiapine 25 mg, 2 tablets nightly; senna 8.6 mg, 1 tablet twice daily; and Vistaril every 8 hours as needed. Review of the March 2026 eMAR showed no evidence that any of these ordered medications were administered between 03/09/2026 and 03/19/2026. In interviews, the DON stated that nurses were responsible for clarifying orders with the physician when a resident returned from the hospital, and a clinical support LPN confirmed that the resident’s medications should have been restarted and administered per the written orders on 03/09/2026 but were not.
Failure to Document Enteral Feeding Administration in eMAR
Penalty
Summary
The facility failed to ensure nursing staff documented the administration of ordered enteral feeding in accordance with professional standards for one resident receiving tube feedings. The resident had physician orders in April 2026 for Glucerna 1.2 at 50 ml/hour for 12 hours daily, with instructions to increase to 60 ml/hour for 21 hours daily if tolerated. Review of the resident’s April 2026 electronic medication administration record (eMAR) showed no documentation that Glucerna 1.2 was administered at 60 ml/hour for 21 hours on 04/21/2026 and 04/22/2026. However, surveyor observations on 04/21/2026 at 9:40 AM and on 04/22/2026 at 2:41 PM confirmed the resident was receiving Glucerna 1.2 at 60 ml/hour at those times. In an interview, the DON stated that when nurses administered the Glucerna 1.2, they should have documented the administration in the medication administration record. This lack of documentation of enteral feeding administration, despite direct observation of the feeding being provided, constituted the deficiency in maintaining medical records in accordance with accepted professional standards.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a treatment nurse failed to perform required hand hygiene during wound care for Resident #1. The facility’s “Using Gloves” policy, revised 03/10/2011, stated that employees were to wash hands after removing gloves and that gloves did not replace handwashing. Resident #1 had a physician’s order in April 2026 for treatment of a diabetic wound on the left second toe, including cleansing with normal saline or wound cleanser, patting dry, applying silver alginate to the wound bed, and covering with a clean dry dressing three times weekly and as needed. During an observation on 04/21/2026 at 10:43 AM, the treatment nurse removed the existing dressing, removed her gloves, did not perform hand hygiene, and then applied new gloves. She then cleaned the resident’s left second toe wound, again removed her gloves, did not perform hand hygiene, and applied new gloves before placing the calcium alginate and dry dressing. In an interview immediately afterward, the treatment nurse stated she had completed hand hygiene before and after the wound care but had not done so between glove changes because there was no hand sanitizer in the room and she did not wash her hands as an alternative. The DON later confirmed that the nurse should have performed hand hygiene between every glove change. This sequence of observations, interviews, and record review showed that the nurse’s actions during wound care did not follow the facility’s hand hygiene and glove-use policy, resulting in the cited infection control deficiency.
Failure to Provide Required Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as S12CNA, received at least 12 hours of in-service training annually as required. Review of S12CNA’s personnel file showed that this CNA was hired on 03/23/2025 and did not have documentation demonstrating completion of the required 12 hours of annual in-service education, including topics such as dementia care and abuse prevention. During an interview on 04/23/2026 at 4:23 PM, the Chief Operations Officer (S1) confirmed that the facility had no documented evidence that S12CNA had completed the mandated 12 hours of in-service training for the year.
Hot Coffee Served Without Temperature Monitoring
Penalty
Summary
The facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds and burns for one resident. The report states that 112 residents consumed meals and beverages prepared by the facility's kitchen. A review of the facility policy on hot liquids stated that residents with risk factors for injury from hot liquids should have precautions implemented, and that food service staff should monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. Resident #79 was involved in an incident on 02/24/2026 when the resident spilled coffee while in bed and sustained redness to the left arm and buttocks area. The incident report stated that the resident was trying to get coffee from the table when the cup fell, and that a non-spill cup would be given to the resident. During an interview, the resident stated she had burns on her left forearm and left hip after spilling hot coffee from a Styrofoam cup with a lid while placing it on the over-bed table. The dietary manager stated that staff did not check coffee temperatures before sending coffee to the floor, and a brewed canister of coffee was observed at 158.1 degrees F.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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