Inspection Reports for
Resthaven Living Center
1301 HARRISON STREET, BOGALUSA, LA, 70427
Back to Facility Profile8 Reports
Inspection Report — Dec 11, 2024
Routine CMS
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations including respiratory care, nurse staffing data posting, and accuracy of medication administration records.
Findings
The facility failed to provide appropriate respiratory care by not changing oxygen tubing and humidifier bottles as ordered. Nurse staffing data was not posted daily as required. Medication Administration Records were inaccurately documented for two residents regarding oxygen tubing changes and lab collections.
Deficiencies (3)
F 0695: The facility failed to provide safe and appropriate respiratory care by not changing Resident #3's oxygen tubing and humidifier bottle weekly as ordered.
F 0732: The facility failed to post current nurse staffing information daily, affecting all 85 residents.
F 0842: The facility failed to ensure accurate documentation of Medication Administration Records for Residents #3 and #290, including false documentation of oxygen tubing changes and lab collections.
Report Facts
Residents affected: 85
Residents reviewed: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Licensed Practical Nurse | Documented oxygen tubing and humidifier bottle changes inaccurately for Resident #3 |
| S15LPN | Licensed Practical Nurse | Documented PT/INR lab collection inaccurately for Resident #290 |
| S5LPN | Licensed Practical Nurse | Assigned nurse who confirmed oxygen tubing and humidifier bottle were not changed as ordered for Resident #3 |
| S2DON | Director of Nursing | Confirmed deficiencies and reviewed documentation related to oxygen tubing changes and lab collections |
| S1ADM | Administrator | Confirmed nurse staffing data was not posted daily |
Inspection Report — Dec 11, 2024
Annual Inspection CMS
Date: Dec 11, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey and complaint investigations to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to post recent survey results for resident review, inaccurate resident assessments, inadequate respiratory care, failure to post current nurse staffing data, lack of certified dietary manager, improper food storage, inaccurate medication administration records, and failure to maintain proper infection prevention and control practices.
Deficiencies (8)
F 0577: The facility failed to ensure the most recent annual and complaint survey results were available for resident review.
F 0641: The facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 19 sampled residents reviewed for MDS.
F 0695: The facility failed to provide necessary respiratory care by not changing Resident #3's oxygen tubing and humidifier bottle weekly as ordered.
F 0732: The facility failed to post current nurse staffing data daily, affecting all 85 residents.
F 0801: The facility failed to employ staff with appropriate competencies by lacking a certified dietary manager, affecting 84 residents.
F 0812: The facility failed to store food in accordance with professional standards, with multiple expired food items found in the kitchen affecting 84 residents.
F 0842: The facility failed to ensure accurate documentation of Medication Administration Records for 2 of 19 residents reviewed, including false documentation of oxygen tubing changes and lab collections.
F 0880: The facility failed to maintain an infection prevention and control program by not ensuring staff wore proper PPE while providing direct care to a resident on Enhanced Barrier Precautions.
Report Facts
Residents affected: 85
Residents affected: 84
Residents affected: 19
Residents affected: 1
Residents affected: 2
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Licensed Practical Nurse | Documented oxygen tubing and humidifier bottle changes inaccurately for Resident #3 |
| S15LPN | Licensed Practical Nurse | Documented PT/INR lab collection inaccurately for Resident #290 |
| S3DA | Acting Dietary Manager | Confirmed lack of certification in food service or dietary management |
| S1ADM | Administrator | Confirmed lack of certified dietary manager and staffing report issues |
| S2DON | Director of Nursing | Confirmed multiple deficiencies including survey posting, respiratory care, staffing, medication records, and infection control |
| S5LPN | Licensed Practical Nurse | Assigned nurse for Resident #3, confirmed oxygen tubing and humidifier bottle were not changed as ordered |
| S13CNA | Certified Nursing Assistant | Failed to wear gown while providing direct care to resident on Enhanced Barrier Precautions |
| S14CNA | Certified Nursing Assistant | Failed to wear gown while providing direct care to resident on Enhanced Barrier Precautions |
| S9IP | Infection Preventionist | Confirmed PPE requirements for residents on Enhanced Barrier Precautions |
Inspection Report — Apr 23, 2024
CMS
Date: Apr 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, quality of care, medication management, documentation, and hospice services at Resthaven Living Center.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to document neurological assessments after unwitnessed falls, improper management of psychotropic medication orders, incomplete medication administration records, and lack of coordination with hospice services.
Deficiencies (5)
F 0641: The facility failed to ensure resident assessments accurately reflected the resident's status, as Major Depressive Disorder was not coded as an active diagnosis in the MDS for Resident #4.
F 0658: The facility failed to ensure staff documented neurological assessments after unwitnessed falls for Residents #1 and #3, with incomplete or missing documentation for multiple fall incidents.
F 0758: The facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated duration, as Resident #3 had orders without documented end dates.
F 0842: The facility failed to maintain accurate medication administration records, as narcotic medication administered to Resident #3 was not documented on the MAR by the nurse.
F 0849: The facility failed to designate a staff member responsible for coordinating hospice care and failed to maintain up-to-date hospice binders for Resident #3.
Report Facts
Unwitnessed falls: 3
Unwitnessed falls: 5
PRN psychotropic medication orders: 2
Morphine dose: 0.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S10LPN | Licensed Practical Nurse | Named in medication administration documentation deficiency for Resident #3. |
| S1DON | Director of Nursing | Interviewed regarding multiple deficiencies including MDS coding, neurological assessments, medication documentation, and hospice coordination. |
| Consultant Pharmacist | Interviewed regarding PRN psychotropic medication order requirements. | |
| S5LPN | Licensed Practical Nurse | Interviewed about neuro checks following Resident #1's falls. |
| S6LPN | Licensed Practical Nurse | Interviewed about neuro checks following Resident #1's falls. |
| S3LPN | Licensed Practical Nurse | Interviewed about hospice binder use for Resident #3. |
| S2MDS | Interviewed regarding MDS assessment accuracy. |
Inspection Report — Nov 29, 2023
CMS
Date: Nov 29, 2023
Visit Reason
The inspection was conducted to evaluate compliance with care standards related to activities of daily living and to review the accuracy of payroll staffing data submissions.
Findings
The facility failed to provide necessary nail care to a resident requiring assistance with activities of daily living, resulting in long, thick, discolored fingernails. Additionally, the facility failed to electronically submit accurate payroll information for direct care staffing as required.
Deficiencies (2)
F 0677: The facility failed to ensure a resident unable to perform activities of daily living received necessary nail care, resulting in long, thick, discolored fingernails with buildup under the nails. Nursing staff did not report or address the resident's grooming needs as required.
F 0851: The facility failed to electronically submit complete and accurate direct care staffing payroll information for Fiscal Quarter 3, resulting in missing employee link records and a triggered One Star Staffing Rating.
Report Facts
Deficiencies cited: 2
Fiscal Quarter: 3
Nail length: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3RN | Nurse interviewed about resident's nail care | |
| S6CNA | Reported resident's long fingernails to S5LPN | |
| S5LPN | Nurse to whom nail care concern was reported | |
| S2DON | Director of Nursing who confirmed nail care was not performed | |
| S1CHRD | Responsible for entering payroll information in PBJ system |
Inspection Report — Aug 18, 2023
Complaint Investigation CMS
Date: Aug 18, 2023
Visit Reason
The investigation was conducted due to allegations of verbal abuse by a licensed practical nurse (S3LPN) towards residents #1, #2, and #3 at Resthaven Living Center.
Complaint Details
The complaint was substantiated. Interviews with residents #1, #2, and #3, as well as staff and administration, confirmed verbal abuse by S3LPN. The employee was suspended pending investigation and subsequently terminated.
Findings
The facility failed to protect residents from verbal abuse by an employee. The allegations were substantiated based on interviews with residents and staff, and the employee was terminated. The facility implemented corrective actions including staff training and monitoring.
Deficiencies (1)
F 0600: The facility failed to protect residents from verbal abuse by an employee towards residents #1, #2, and #3. The employee was rude, used inappropriate language, and was terminated following the substantiated investigation.
Report Facts
Residents affected: 3
Date survey completed: Aug 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Accused employee in verbal abuse allegations and terminated after investigation. |
| S2DON | Director of Nursing | Interviewed and confirmed the abuse allegations and employee suspension. |
| S1ADMIN | Administrator | Verified substantiation of verbal abuse allegations and employee termination. |
Inspection Report — Jun 21, 2023
Complaint Investigation CMS
Date: Jun 21, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to meet professional standards in administering and documenting pain medication for a sampled resident.
Complaint Details
The complaint investigation focused on medication administration and documentation for Resident #3. It was substantiated that Tylenol was given without a physician's order and was not documented on the MAR as required.
Findings
The facility failed to document administered medications on the Medication Administration Record (MAR) and did not obtain physician's orders for PRN pain medication for Resident #3. Interviews and record reviews confirmed these deficiencies.
Deficiencies (1)
F 0658: The facility failed to document administered medications on the MAR and did not have physician's orders for PRN pain medication for Resident #3. Documentation and orders were incomplete despite medication administration.
Report Facts
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2LPN | Interviewed nurse who administered Tylenol without order and did not document it | |
| S1DON | Interviewed Director of Nursing who confirmed documentation and order requirements |
Inspection Report — Apr 24, 2023
Complaint Investigation CMS
Date: Apr 24, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident who was injured during transport in the facility's van due to improper restraint.
Complaint Details
The complaint allegation that Resident #2 was improperly restrained during transport was substantiated. Resident #2 slid out of her wheelchair when the van driver applied brakes abruptly and was injured. Interviews with staff confirmed the lap seatbelt was not secured due to the driver being in a hurry.
Findings
The facility failed to ensure Resident #2 was properly restrained with a lap seatbelt during transport, resulting in the resident sliding out of her wheelchair and sustaining a left tibia and fibular fracture requiring surgery. The facility implemented corrective actions prior to the State Agency's investigation and was found to be in compliance as of 03/28/2023.
Deficiencies (1)
F 0689: The facility failed to ensure residents remained free from accident hazards during transport. Resident #2 was not properly restrained with a lap seatbelt, causing her to slide out of her wheelchair and sustain fractures requiring surgery.
Report Facts
Residents affected: 1
Incident time: 1728
Plan of correction start date: Mar 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 CNA | Van Driver | Named in the finding for failing to secure Resident #2's lap seatbelt during transport. |
| S1 ADM | Administrator | Interviewed regarding the incident and confirmed restraint policies. |
| S2 DON | Director of Nursing | Interviewed and responsible for oversight of corrective actions. |
Inspection Report — Dec 8, 2022
Annual Inspection CMS
Date: Dec 8, 2022
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of residents' advance directives, failure to implement care plans such as providing a landing mat for a resident at risk of falls, improper catheter care leading to urinary catheter bags being placed on the floor, and unsanitary food storage and kitchen equipment conditions.
Deficiencies (4)
F 0578: The facility failed to ensure residents' advance directives were consistently documented, with conflicting code status orders for Resident #90.
F 0656: The facility failed to implement a care plan for Resident #90 by not providing a physician-ordered landing mat at the bedside.
F 0690: The facility failed to ensure appropriate catheter care for Resident #41, with urinary catheter bag and tubing observed on the floor multiple times.
F 0812: The facility failed to store and prepare food properly and maintain kitchen equipment in a sanitary condition, including undated opened food items and dirty kitchen equipment.
Report Facts
Residents reviewed: 32
Residents reviewed for care plans: 20
Residents observed with urostomy and catheter: 5
Residents affected by food storage deficiencies: 96
Viewing
Loading inspection reports...
