Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lafayette Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was discharged to another facility, but the MDS did not include the required discharge assessment. The MDS Coordinator, RN, stated the assessment was missing and late, and that she normally combines different assessments but did not complete this one. Facility policy required the discharge assessment to use the discharge date as the ARD and be completed within 14 days.
A resident’s MDS did not accurately reflect an active thyroid disorder in Section I. Record review showed the resident had hyperthyroidism and was receiving Methimazole for that diagnosis, but the Annual MDS coded thyroid disorder as No. The Regional MDS Nurse stated the resident was coded incorrectly for not being documented as having the active diagnosis of thyroid disease.
Failure to provide adequate nutrition support for two residents with significant weight loss. One resident with CVA, dysphagia, T2DM, hypothyroidism, and HTN had poor PO intake and an 8.66% weight loss, but the RD’s recommendation for fortified foods was not reflected in the diet order. Another resident had variable intake and a 6.81% weight loss, but the RD’s recommendation to increase Med Pass from QD to BID was not implemented; staff reported communication gaps between the RD, DON, and unit manager.
A resident with a g-tube feeding order was observed receiving automatic water flushes at 50 ml/hr instead of the ordered 60 ml/hr. An LPN and the UM LPN confirmed the incorrect rate, and the RD stated nursing was responsible for ensuring the flushes matched the order. The resident’s order, nutrition assessment, and progress note all reflected a 60 ml/hr flush rate.
Failure to document a skin assessment for a resident’s right forearm skin tear. The resident was observed with a dressing on the arm and said he bumped himself and got a skin tear that was being dressed daily, but the chart had no order, progress note, or skin assessment for the injury. Staff interviews showed the injury was not clearly documented in the record, even though the MD later said he had been called and ordered it covered if bleeding.
Infection control standards were not followed for a resident on EBP when an LPN provided enteral medication care without a gown, for another resident when an RN handled a gown that fell on the floor without removing PPE or performing hand hygiene and then used it for care, and for a third resident when nebulizer mask and tubing were observed in a bag dated weeks earlier instead of being changed weekly. The residents had feeding tubes, gastrostomy status, COPD, and asthma, and facility staff and policy identified gowns, hand hygiene, and weekly respiratory equipment changes as required.
A facility failed to ensure the accuracy of an MDS assessment for a resident, indicating anticoagulant medication use without corresponding physician orders. The MDS Coordinator confirmed the inaccuracy, which contradicted the facility's policy requiring accurate documentation of medical issues.
A resident receiving IV medication did not have their PICC line checked for patency by aspiration before medication administration, contrary to facility policy. An LPN failed to follow the protocol, which was confirmed by the DON and outlined in the facility's procedures.
The facility failed to administer oxygen therapy as prescribed for three residents. One resident received 5 L/M instead of the ordered 2 L/M, another received 2 L/M instead of 4 L/M, and a third received 3 L/M instead of the ordered 2 L/M. Staff confirmed the discrepancies, and the DON emphasized the need to follow physician orders.
The facility did not ensure food was served at safe temperatures during breakfast service. Observations revealed a sausage patty at 130°F, below the required 135°F, and yogurt at 47.8°F, above the 41°F limit. The Dietary Manager confirmed these discrepancies, acknowledging non-compliance with facility policies.
Staff at the facility failed to sanitize resident-care equipment between uses, risking the transmission of infections. An LPN did not clean a blood pressure cuff after using it on two residents, and an RN neglected to sanitize an oxygen saturation probe. Both staff members acknowledged their oversights. The facility's policy requires cleaning and disinfecting equipment between uses, as confirmed by the RN Consultant and DON.
The facility did not post daily nurse staffing information as required. An observation revealed that the staffing form was outdated, showing a date two days prior. The Administrator admitted delays in posting, especially on Mondays, due to balancing staffing for multiple days. The facility's policy requires daily morning postings to ensure information is accessible to residents and visitors.
Missing Discharge Assessment Submission
Penalty
Summary
The facility failed to encode and transmit the discharge assessment to the State within the required timeframe for one resident. Resident #1 had a physician order dated 3/19/2026 indicating discharge to another facility, and the discharge summary documented transfer by facility-provided transportation on 3/19/2026 at 11:00. A progress note dated 3/20/2026 confirmed the resident had been discharged to the receiving facility and was to follow up with the PCP there. Review of the resident’s MDS showed no discharge assessment documented. During interview on 4/8/2026 at 3:20 PM, the MDS Coordinator, RN, stated the discharge assessment was missing, was due 14 days after discharge, and was considered late, adding that she normally combines different assessments and did not complete the discharge assessment. The facility policy titled MDS 3.0 Completion stated that the discharge assessment must be completed using the discharge date as the ARD and completed within 14 days of discharge.
MDS Did Not Accurately Code Active Thyroid Disorder
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected Resident #20’s active diagnoses by not coding a thyroid disorder in Section I. Record review showed the resident had an active diagnosis of thyrotoxicosis, also known as hyperthyroidism, and a physician’s order dated 1/25/2025 for Methimazole 10 mg by mouth once daily for hyperthyroidism. However, the resident’s Annual MDS dated [DATE] coded Section I3400, Thyroid disorder, as No. During interview on 4/8/2026 at 1:16 PM, the Regional MDS Nurse stated the resident was coded incorrectly in Section I for not being documented as having the active diagnosis of thyroid disease.
Failure to Implement Nutritional Recommendations for Residents with Weight Loss
Penalty
Summary
The facility failed to provide care and services to ensure acceptable nutritional status for two residents with documented weight loss and poor oral intake. One resident had diagnoses including fx, CVA, dysphagia, T2DM, hypothyroidism, and HTN, with weights showing an 8.66% loss from 133.9 lbs to 122.3 lbs over about one month. A nutritional risk screen noted the resident’s weight was trending down, PO intake was 0-25%, and recommended fortified foods with meals, while the physician order remained a regular pureed diet with honey thick liquids and a daily Magic Cup supplement. Progress notes showed the dietitian identified the weight loss and recommended additional kcal support, but there were no notes showing communication with the physician about the weight loss or the dietitian’s recommendations. Staff interviews showed the unit manager expected the physician to be notified when there was a 5-pound loss and that the dietitian would then be contacted, while the CDM stated fortified foods were not being provided and that recommendations were normally sent by email for nurses to enter into diet orders. The RD confirmed the fortified food recommendation was not reflected in the diet order. A second resident had a 6.81% weight loss from 138 lbs to 128.6 lbs in about one month. The dietary note documented variable PO intake, some meal refusals, and recommended increasing Med Pass from once daily to twice daily with weekly weights. The physician order remained Med Pass once daily, and staff interviews showed the resident was still receiving the once-daily order. The RD stated the recommendation had been made, but it was not increased to twice daily, and the unit manager stated she was not aware of the dietary recommendation because the DON had not forwarded it while the DON was out.
Incorrect Feeding Tube Flush Rate
Penalty
Summary
The facility failed to provide the appropriate milliliter per hour rate for automatic water flushes via feeding tube for Resident #8. During an observation, Resident #8’s automatic water flushes were running at 50 ml per hour, and an LPN confirmed that the flushes should have been running at 60 ml per hour. The LPN stated she would need to go back and adjust the flushes, and a Unit Manager LPN also confirmed the flushes were running at 50 ml per hour. Resident #8 had a physician’s order dated 2/16/2026 for Osmolite 1.5 at 65 ml/hr with a flush rate of 60 ml/hr via g-tube for 20 hours daily. The nutritional assessment recommended increasing flushes to 60 ml/hr while infusing, and a progress note documented enteral nutrition at 65 ml/hr x 20 hours with 60 ml water flushes x 20 hours. The Registered Dietitian stated the flushes were increased to 60 ml and that nursing was responsible for ensuring the flushes were running at the correct ordered rate. The facility policy stated enteral nutrition must be administered consistent with the practitioner’s orders.
Failure to Document Skin Tear Assessment
Penalty
Summary
The facility failed to accurately document a skin assessment for a resident with a skin tear on the right forearm. During observation, the resident was seen sitting up in bed with a small dressing on the right forearm, and the resident stated he had bumped himself on Saturday and got a skin tear that the nurse dressed and changed daily. However, review of the physician’s orders showed no order for a skin tear on the right arm, and the medical record did not contain a skin assessment for the injury. The resident’s progress notes also did not document any incident involving the right arm skin tear or any provider documentation. Staff interviews reflected a lack of awareness of the injury by one LPN, while the Unit Manager stated that a skin tear would usually require orders. The President of Operations stated the nurse should have entered a note in the system to show where the skin tear came from, and the physician later stated he had been called over the weekend about the skin tear and ordered it to be covered if bleeding. The facility policy required accurate, complete, and timely documentation in the medical record and stated that licensed nurses would conduct a skin assessment for skin tears.
Infection Control Failures With Barrier Precautions, Hand Hygiene, and Nebulizer Equipment
Penalty
Summary
The facility failed to follow infection control standards for Resident #8, who had an order for Enhanced Barrier Precautions due to an indwelling medical device every shift. During an observation, an LPN entered the resident’s room, performed hand hygiene, donned gloves, but did not don a gown before checking the resident’s gastric tube placement and administering medication enterally. The LPN later stated that the resident was on enhanced barrier precautions and that a gown should have been worn. The Infection Preventionist and the President of Operations both stated that gloves and a gown are required for residents on enhanced barrier precautions, and the facility policy identified feeding tubes as a high-contact resident care activity requiring targeted gown and glove use. The facility also failed to perform hand hygiene for Resident #6 during enteral-related care. While preparing to flush the resident’s G-tube and resume enteral feeding, an RN donned gloves and a gown, then picked up a gown that had fallen on the floor and returned it to the holder without removing PPE or performing hand hygiene. The RN later placed that gown on the resident’s bed and instructed a CNA to use it while assisting the resident with a shower. The RN confirmed the gown had been picked up from the floor, returned to the holder, and used, and confirmed she did not remove PPE, perform hand hygiene, or don clean PPE after handling the gown. Resident #6 had diagnoses including cerebral infarction, dysphagia, and gastrostomy status, and had an order for Enhanced Barrier Precautions for an indwelling medical device every shift. The facility further failed to provide weekly changes for Resident #48’s nebulizer equipment. During observations, the resident’s nebulizer was on the bedside table, and the mask and tubing were in a zippered plastic bag dated 3/25/26. Staff stated that oxygen/nebulizer accessories such as masks and tubing were changed every Wednesday and placed in a labeled plastic bag, and leadership stated the same expectation. Resident #48 had diagnoses including COPD and asthma and an order for ipratropium-albuterol inhalation solution twice daily for COPD. The facility policy stated that nebulizer tubing and delivery devices should be changed weekly or as needed if soiled or contaminated.
Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident reviewed for unnecessary medications. The resident's Medicare Admission 5-day MDS indicated that the resident was receiving anticoagulant medication, as noted in Section N - Medications. However, a review of the resident's physician orders revealed no current or previous orders for anticoagulant medication. During an interview, the MDS Coordinator acknowledged that the MDS was inaccurate. The facility's policy on conducting accurate resident assessments requires that a qualified health professional correctly document the resident's medical, functional, and psychosocial problems, which was not adhered to in this case.
Failure to Follow IV Therapy Protocols
Penalty
Summary
The facility failed to ensure that a resident received intravenous therapy in accordance with professional standards of practice. Resident #55, who was admitted with diagnoses including surgical aftercare and infection due to an internal fixation device, was prescribed Cefepime HCl Injection Solution to be administered intravenously. During an observation, a Licensed Practical Nurse (LPN) prepared the resident's Peripherally Inserted Central Catheter (PICC) for the administration of the medication but did not check the patency of the line by aspirating for blood return before flushing or administering the medication. The LPN stated that it was not necessary to aspirate prior to flushing or administering intravenous medication, which contradicted the facility's policy. The Director of Nursing confirmed that the facility's policy required checking the patency of the PICC line by aspiration of blood before flushing and administering medication. The facility's policy and procedure documents also outlined the requirement to confirm the patency of vascular devices as per protocol, which was not followed in this instance.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure that residents received oxygen therapy as prescribed by their physicians, affecting three residents. Resident #31 was observed receiving oxygen at 5 liters per minute, despite a physician's order for oxygen at 2 liters per minute as needed for oxygen saturation below 90%. The resident confirmed they were unaware of the oxygen setting, and a registered nurse acknowledged the discrepancy, confirming the oxygen should be set according to the physician's order. Similarly, Resident #5 was observed receiving oxygen at 2 liters per minute, contrary to the physician's order for 4 liters per minute to maintain oxygen saturation above 90%. A licensed practical nurse confirmed the resident should be receiving 4 liters per minute, and the Director of Nursing stated that orders should be followed even if they are as needed. Resident #44 was observed receiving oxygen at 3 liters per minute, while the physician's order specified 2 liters per minute as needed to maintain oxygen saturation above 92%. The resident indicated they only used oxygen while lying down, and a certified nursing assistant stated they informed the nurse when the resident needed oxygen. A licensed practical nurse mentioned they would document if the resident's oxygen saturation fell below 92% and would administer oxygen accordingly. The Director of Nursing emphasized that oxygen settings should be adjusted by nurses in accordance with physician orders. The facility's policy on oxygen administration and physician medication/treatment orders requires adherence to physician orders, which was not followed in these cases.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that residents received food at a safe and appetizing temperature during meal service. During an observation of the breakfast tray line, it was noted that the temperature of a sausage patty was 130 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit for hot foods. Additionally, a 4-ounce strawberry yogurt was recorded at 47.8 degrees Fahrenheit, exceeding the maximum allowable temperature of 41 degrees Fahrenheit for cold foods. The Dietary Manager confirmed these temperature discrepancies and acknowledged that the temperatures did not meet the facility's policy and procedure standards, which are aligned with state and US Food Codes and HACCP guidelines.
Failure to Sanitize Resident-Care Equipment
Penalty
Summary
The facility failed to ensure proper sanitization of resident-care equipment between uses, leading to potential transmission of communicable diseases and infections. During an observation, a Licensed Practical Nurse (LPN) was seen taking a blood pressure reading for one resident and placing the blood pressure cuff back on the medication cart without sanitizing it. The LPN then used the same cuff on another resident without cleaning it. In an interview, the LPN acknowledged the oversight, stating that the cuffs were cloth and should have been wiped down with a sanitizer cloth after each use. Additionally, a Registered Nurse (RN) was observed using an oxygen saturation finger probe on a resident and returning it to the medication cart without sanitizing it. The RN admitted to forgetting the need to clean the probe before and after each use. The facility's policy, which aligns with CDC recommendations, requires that reusable resident-care equipment be cleaned and disinfected between uses to prevent indirect transmission of pathogens. Interviews with the Registered Nurse Consultant and the Director of Nursing confirmed the necessity of cleaning such equipment with sanitary wipes and following the appropriate dwell time as per the product instructions.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily as required. During an observation on October 21, 2024, at 9:15 AM, it was noted that the Daily Nursing Staffing Form displayed in the main entry hall was outdated, showing the date as October 19, 2024, instead of the current date. In an interview on October 24, 2024, the Administrator acknowledged the delay in posting the staffing sheet, stating that it is typically posted by 11:00 AM, but Mondays can take longer due to balancing staffing for three days. The facility's policy, last reviewed on December 29, 2023, mandates that the Nurse Staffing Sheet be posted daily each morning to ensure information is readily available to residents and visitors.
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What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mayo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Center | 14.8 mi | ★★★★★ | 11 | 0 |
| Live Oak Healthcare And Rehabilitation Center | 20.2 mi | ★★★★★ | 1 | 0 |
| Surrey Place Nursing Center | 20.3 mi | ★★★★★ | 6 | 0 |
| Aviata At Big Bend | 25.7 mi | ★★★★★ | 11 | 3 |
| Cross City Nursing And Rehabilitation Center | 30 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.