Inspection Reports for
Colonial Oaks Living Center
4312 ITHACA STREET, METAIRIE, LA, 70006
Back to Facility Profile7 Reports
Inspection Report — Apr 8, 2025
Annual Inspection CMS
Date: Apr 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, staffing, medication administration, infection control, and environmental conditions at Colonial Oaks Living Center.
Findings
The facility was found deficient in multiple areas including conflicting advance directive documentation for a resident, unclean shower room floors, delayed staff response to call bells, unsecured medication carts, inadequate dishwasher and sink sanitization parameters, and improper storage of oxygen personal care items.
Deficiencies (6)
Conflicting advance directive documents were found in Resident #11's physical chart, including both full code and Do Not Resuscitate (DNR) orders.
Shower room floors in Shower rooms e and f had buildup of an unknown black substance and were not maintained in a clean manner.
Staff failed to answer call bells in a timely manner for 3 residents (Resident #7, Resident #48, Resident #333), with wait times ranging from 30 minutes to 6 hours.
Medication Cart a was left unlocked and unattended by a Licensed Practical Nurse.
The kitchen dishwasher water temperature was below required levels (90°F vs. required 150°F) and the 3 compartment sink sanitizer final rinse was 0 PPM instead of required 180-200 PPM.
Oxygen personal care items for Residents #133 and #135 were not contained in plastic bags when not in use, contrary to facility policy.
Report Facts
Residents affected: 1
Shower rooms observed: 3
Shower rooms with deficiencies: 2
Residents reviewed for call bell use: 24
Residents with call bell delays: 3
Medication carts observed: 4
Medication carts unsecured: 1
Dishwasher temperature observed: 90
Dishwasher temperature required: 150
Dishwasher rinse temperature required: 180
Sanitizer final rinse PPM observed: 0
Sanitizer final rinse PPM required: 180
Sanitizer final rinse PPM upper limit: 200
Residents sampled for oxygen use: 6
Residents with oxygen item deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S16 Ward Clerk | Certified Nursing Assistant (CNA) | Indicated Resident #11's chart should only contain the most recent advanced directive |
| S17 | Licensed Practical Nurse (LPN) | Indicated Resident #11 was a DNR and would not provide CPR |
| S2 | Director of Nursing (DON) | Confirmed Resident #11 should not have conflicting advanced directives; confirmed call bell wait times were too long; confirmed medication carts should be locked; indicated respiratory equipment should be stored in plastic bags |
| S1 | Administrator | Confirmed conflicting advanced directives for Resident #11; confirmed shower room floors needed cleaning; confirmed medication carts should be locked; confirmed dishwasher findings; confirmed respiratory equipment storage |
| S13 | Certified Nursing Assistant | Indicated shower room floors were dirty and needed cleaning |
| S14 | Housekeeping Supervisor | Confirmed buildup of black substance on shower room floors |
| S15 | Floor Tech/Porter | Indicated it had been over a month since shower room floors were cleaned |
| S8 | Licensed Practical Nurse (LPN) | Left medication cart unlocked and unattended; indicated medication carts should be locked |
| S10 | Culinary Aide (CA) | Indicated dishwasher water wash temperature was 90°F and sanitizer was used |
| S9 | Dietary Manager (DM) | Indicated dishwasher water temperature was below required; discussed sanitizer PPM; confirmed dishwasher use despite low temperature |
| S11 | Licensed Practical Nurse (LPN) | Indicated CPAP and breathing treatment masks should be stored in plastic bags |
| S12 | Licensed Practical Nurse (LPN) | Indicated Resident #133's CPAP was not in a plastic bag |
Inspection Report — Feb 5, 2025
Routine CMS
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality, including nursing services, pressure ulcer care, fall prevention, staffing adequacy, pharmaceutical services, and medical record documentation.
Findings
The facility failed to follow physician orders for daily weights and pressure relieving cushion use for Resident #3, did not implement individualized fall prevention interventions, failed to maintain adequate CNA staffing on certain days, did not maintain proper reconciliation documentation for controlled medications on several medication carts, and had inaccurate medical record documentation regarding pressure relieving cushion use.
Deficiencies (6)
Failed to ensure a physician's orders for daily weights was followed for Resident #3.
Failed to provide appropriate pressure ulcer care by not placing a pressure relieving cushion on Resident #3's wheelchair as ordered.
Failed to ensure individualized fall prevention interventions were implemented for Resident #3, including absence of visual call for assistance sign, bed alarm, and fluorescent tape on wheelchair brakes.
Failed to ensure adequate CNA staffing for 2 of 3 days reviewed, with fewer CNAs working than scheduled and required.
Failed to maintain a system to reconcile controlled drugs for 3 of 4 medication carts reviewed, with improper or missing initials on Controlled Drugs-Count Records.
Failed to ensure Resident #3's electronic Medication Administration Record (eMAR) was accurately documented regarding pressure relieving cushion use.
Report Facts
Falls: 12
CNA staffing count: 5
CNA staffing count: 4
Weight entries: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S14 CNA | Restorative Aide | Interviewed regarding daily weight checks and staffing adequacy |
| S13 CNA | Restorative Aide | Interviewed regarding daily weight checks |
| S3 | Assistant Director of Nursing (ADON) | Confirmed active physician orders for daily weights and lack of documented evidence |
| S2 | Director of Nursing (DON) | Confirmed lack of documented evidence for daily weights, pressure relieving cushion, fall prevention interventions, staffing, and medication reconciliation |
| S1 | Administrator | Confirmed deficiencies related to daily weights, pressure ulcer prevention, fall prevention, staffing, medication reconciliation, and medical record documentation |
| S9 | Licensed Practical Nurse (LPN) | Interviewed regarding pressure relieving cushion absence and inaccurate eMAR documentation |
| S6 | CNA Supervisor | Interviewed regarding CNA scheduling and staffing requirements |
| S7 | Licensed Practical Nurse (LPN) | Interviewed regarding medication cart controlled substance reconciliation |
| S4 | Clinical Care Coordinator | Interviewed regarding medication cart controlled substance reconciliation |
| S5 | Minimum Data Set (MDS) LPN | Interviewed regarding medication cart controlled substance reconciliation |
Inspection Report — Jun 5, 2024
Complaint Investigation CMS
Date: Jun 5, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's discharge process, specifically focusing on whether discharge procedures were properly followed for Resident #1.
Complaint Details
The complaint investigation focused on Resident #1's discharge process. It was substantiated that the facility discharged Resident #1 to the responsible party's address instead of the resident's home, did not provide a list of home health agencies for selection, and did not obtain signatures acknowledging receipt of discharge instructions.
Findings
The facility failed to ensure the discharge process was properly followed for Resident #1, including inaccurate discharge location, failure to provide information for selecting a home health agency, and failure to provide or obtain signed discharge summary and instructions prior to discharge.
Deficiencies (3)
Failed to ensure a resident's discharge location was accurate (Resident #1).
Failed to ensure a resident and/or resident's responsible party was provided information to select a home health agency (Resident #1).
Failed to ensure the resident and/or responsible party received the discharge summary and instructions prior to discharge (Resident #1).
Report Facts
Residents investigated for discharge planning: 3
Residents affected by deficiency: 1
Discharge date: May 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 Social Services Director | Social Services Director | Wrote note on 03/08/2024 and confirmed failure to verify discharge address and provide home health agency list |
| S2 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed usual discharge procedure and acknowledged failure to obtain signed discharge instructions for Resident #1 |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Nurse who discharged Resident #1 and confirmed no discharge summary form was signed or reviewed with resident or responsible party |
| S2 Director of Nursing | Director of Nursing | Confirmed awareness of discharge plan and acknowledged errors in discharge location and procedure |
Inspection Report — Apr 11, 2024
Annual Inspection CMS
Date: Apr 11, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure a resident's bathroom door closed properly, late submission of resident assessments, improper labeling of enteral feeding bags, urinary catheter drainage bags touching the floor, delayed staff response to call lights, expired food items available for consumption, and improper hand hygiene practices during incontinence care.
Deficiencies (7)
Failed to ensure a resident's bathroom door would close.
Failed to complete and electronically submit resident assessments to CMS in a timely manner for 8 residents.
Failed to ensure an enteral feeding bag was properly labeled with date, time of initiation, and infusion rate.
Failed to ensure indwelling urinary catheter drainage bag and tubing did not touch the floor for 3 residents.
Failed to assist a resident with transfer assistance timely after call light activation.
Failed to ensure expired food items were not available for resident consumption.
Failed to perform proper hand hygiene after removing gloves during incontinence care for 1 resident.
Report Facts
Residents with late assessments: 8
Residents affected by catheter drainage bag deficiency: 3
Residents affected by delayed transfer assistance: 1
Expired food items observed: 3
Residents affected by hand hygiene deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Indicated bathroom door should close, aware of late assessments, commented on catheter bag infection risk, and hand hygiene protocol |
| S4 Certified Nursing Assistant | Certified Nursing Assistant | Tried to close resident's bathroom door and was unable |
| S5 Housekeeping Supervisor | Housekeeping Supervisor | Indicated bathroom door cannot close all the way and it should |
| S3 MDS Coordinator | MDS Coordinator | Indicated resident assessments were not completed or transmitted timely |
| S1 Administrator | Administrator | Indicated professional standards for enteral feeding bag labeling and catheter bag handling, and expired food items should not be available |
| S6 Dietary Manager | Dietary Manager | Indicated expired food items should not be available for resident consumption |
| S7 Certified Nursing Assistant | Certified Nursing Assistant | Turned off resident's call light without providing assistance |
| S8 CNA Supervisor | CNA Supervisor | Indicated resident waiting over an hour for assistance was too long |
| S9 Physical Therapist | Physical Therapist | Assisted resident to wheelchair after delayed response |
| S10 Certified Nursing Assistant | Certified Nursing Assistant | Failed to perform hand hygiene after glove removal during incontinence care |
Inspection Report — Sep 27, 2023
Complaint Investigation CMS
Date: Sep 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a new intervention following a resident's fall to prevent future falls.
Complaint Details
The visit was complaint-related due to failure to report and document a resident's fall and failure to revise the care plan accordingly. The complaint was substantiated by interviews and record review.
Findings
The facility failed to ensure that a new care plan intervention was developed and implemented after Random Resident R4 fell on 09/11/2023. The fall was not reported or documented by staff, and the Director of Nursing was unaware of the incident.
Deficiencies (1)
Failure to implement a new intervention following a resident's fall to prevent future falls.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Named in interview regarding unawareness of resident fall and failure to revise care plan. |
| S3 Certified Nursing Assistant | Certified Nursing Assistant | Named in interview regarding witnessing the fall and uncertainty about reporting. |
| S2 Licensed Practical Nurse | Licensed Practical Nurse | Named in interview regarding questioning about the fall incident. |
Inspection Report — Jul 17, 2023
Annual Inspection CMS
Date: Jul 17, 2023
Visit Reason
The inspection was conducted as an annual survey of Colonial Oaks Living Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Mar 27, 2023
CMS
Date: Mar 27, 2023
Visit Reason
The inspection was conducted to assess compliance with food safety standards, specifically to ensure that expired food items were not available for resident consumption.
Findings
The facility was found to have multiple expired food items in the kitchen that were available for resident consumption, which posed a potential risk to residents. The dietary supervisor and administrator acknowledged that these expired items should not have been accessible.
Deficiencies (1)
Expired food items including creamy peanut butter, light corn syrup with vanilla, and caramel flavored dessert sauces were found available for resident consumption.
Report Facts
Residents affected: 87
Total residents: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Interviewed regarding expired food items found in the kitchen | |
| Administrator | Acknowledged that expired items should not have been available |
Viewing
Loading inspection reports...
