Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Pruitthealth - Shepherd Hills during CMS and state inspections, most recent first.
Hand hygiene and sanitation practices were not consistently followed during wound care and resident contact. An LPN removed a soiled dressing for a resident with diabetes, PVD, CHF, a suprapubic catheter, moderate cognitive impairment, and a right ankle wound, but did not remove gloves or perform hand hygiene before cleansing the wound. In addition, clean linens were stored on open shelves in the laundry area alongside staff personal items and office supplies, and the Housekeeping Supervisor II acknowledged the items should not have been stored together.
The facility failed to timely report a suspected staff-to-resident abuse incident to the SSA for a resident with dementia who was totally dependent on staff for toileting and personal hygiene. During peri-care, a CNA placed a wipe with bowel movement to the resident’s face after the resident became combative and argumentative, and another CNA witnessed the incident and finished care. The incident was documented in the facility’s abuse investigation, but the report to the SSA was not made within the required timeframe.
Incorrect MDS Coding for Wander Guard Use: The facility failed to accurately code Section P of the MDS for a resident with dementia, depression, and exit-seeking behavior. Although the resident had physician orders for a wander guard on the left wrist and the care plan addressed elopement risk, both quarterly MDS assessments indicated no wander/elopement alarm use. The MDS Director confirmed the resident wore the bracelet and that the assessment was coded incorrectly.
The facility failed to use proper infection control practices during blood glucose monitoring for a diabetic resident, using incorrect wipes for cleaning a shared glucometer. Additionally, clean laundry carts were observed uncovered during transport, and a resident's urostomy bag was dragging on the floor without a privacy cover, contrary to protocol.
A resident with moderate cognitive impairment and a urostomy catheter was observed with the catheter bag dragging on the floor without a privacy cover, contrary to facility policy. Despite the resident's belief that the bag was properly managed, a CNA acknowledged the deficiency and the need for a privacy bag.
The facility failed to protect residents' rights by not reporting an abuse allegation in a timely manner. Two residents with severe cognitive impairments were involved in an incident of suspected sexual behavior. The initial report was submitted promptly, but the follow-up report was delayed and received by the state survey agency on the eighth business day, not within the required five days.
The facility failed to protect residents' rights by not conducting a thorough investigation of potential sexual abuse involving two cognitively impaired residents. The investigation lacked necessary documentation and interviews with involved residents and staff.
The facility failed to clean a resident's perineal area during incontinence care and did not follow proper hygiene protocols. Staff did not change gloves or perform hand hygiene after handling soiled areas and before touching other items. The resident had multiple diagnoses, including sepsis and urinary tract infection, and the catheter tubing was improperly positioned under the resident's leg.
The facility failed to provide eight hours of consecutive RN coverage for three days. The DON confirmed the lack of RN coverage and mistakenly believed her hours as DON would count towards the required RN coverage, despite not providing direct resident care.
Staff failed to follow infection control protocols during incontinence care for a resident with multiple health issues, including not changing gloves or performing hand hygiene after contamination with bowel movement before handling the resident's catheter, bed control, and CPAP equipment.
The facility failed to ensure accurate and current posting of nurse staffing information. Observations revealed discrepancies between the posted staffing and the actual nursing schedule, with the DON confirming that no RNs were scheduled on the day shift to provide direct resident care on certain days.
Hand Hygiene and Clean Linen Storage Failures
Penalty
Summary
The facility failed to ensure consistent hand hygiene and sanitation practices during wound care and between resident contacts. Review of the facility policies showed that hand hygiene was required after contact with blood, body fluids, non-intact skin, and wound dressings, and the wound care competency checklist directed staff to remove gloves, perform hand hygiene, and apply clean gloves after removing a dressing. During observation of wound care for one resident, an LPN removed and discarded the soiled dressing but did not remove her gloves or perform hand hygiene before cleansing the wound. The resident involved had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, peripheral vascular disease, atherosclerotic heart disease, congestive heart failure, and a suprapubic catheter. The resident’s MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The care plan identified risk for skin breakdown related to impaired mobility, incontinence, the suprapubic catheter, and a right ankle wound, and physician orders directed daily and PRN treatment to the right ankle wound with cleansing, skin prep, honey, and an adhesive foam bandage. The facility also failed to keep clean linens protected from contamination. In the laundry area, clean towels, washcloths, and blankets were stored on open shelves alongside staff personal items and office supplies, including cups, bottles, papers, scissors, and other miscellaneous items. The Housekeeping Supervisor II stated she was unsure what could be stored with clean linens and acknowledged that personal items likely should not be there. The Infection Preventionist stated that clean linen must not be stored on shelves with other items because this results in contamination and that such linens would need to be rew washed.
Failure to Timely Report Suspected Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report a suspected staff-to-resident physical abuse incident to the State Survey Agency within the required timeframe for one resident who was reviewed for abuse and neglect. The facility policy required notification of the SSA within 2 hours when the allegation involved abuse or serious bodily injury, and not later than 24 hours when the events did not involve abuse and did not result in serious bodily injury. The incident involved a resident with dementia with other behavioral disturbances and depression, whose BIMS was not coded because cognition could not be determined and who was totally dependent on staff for toileting hygiene and personal hygiene. The record showed that a Facility Incident Report documented staff-to-resident abuse, and the five-day follow-up described that during peri-care the resident became combative and argumentative, and a CNA put a wipe with bowel movement to the resident’s face. The incident was reported to the Unit Manager on 4/11/2025, although the event occurred on 4/7/2025. The investigation noted that another CNA witnessed the incident, told the CNA she could not do that, and finished providing care to the resident. The resident’s progress note documented that abuse allegations were made, the resident had no signs of distress at that time, and the police department, responsible party, NP, and abuse coordinator were notified.
Incorrect MDS Coding for Wander Guard Use
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident, R21, by incorrectly coding Section P related to restraints and alarms. R21’s EMR admission record listed diagnoses including dementia with other behavioral disturbances and depression. Review of the quarterly MDS assessment with an ARD of 3/27/2025 indicated that R21 did not use a wander/elopement alarm, and the quarterly MDS with an ARD of 6/21/2025 also indicated that R21 did not use a wander/elopement alarm. However, current physician orders for R21 included a wander guard placed on the left wrist with instructions to check functioning daily and check placement every shift, with a start date of 11/13/2024. The care plan, last reviewed/revised on 7/8/2025, identified risk for elopement as evidenced by exit-seeking behavior and included checking the wander guard device for proper functioning and placement. The MDS Director confirmed that R21 wore a wander guard bracelet on the left wrist and that the quarterly assessment from 6/21/2025, Section P, was coded incorrectly. The DHS stated that the MDS assessment should reflect the resident’s wander guard use, and the Administrator stated the facility did not have an MDS assessment policy and followed the RAI Manual.
Infection Control Deficiencies in Glucometer Use and Linen Transport
Penalty
Summary
The facility failed to adhere to proper infection control practices during blood glucose monitoring for one diabetic resident. An LPN was observed using a hand sanitizing wipe instead of the required EPA-approved germicidal/virucidal disinfectant wipes to clean a shared glucometer after use. The LPN was unable to specify the required kill time for the hand sanitizing wipes, and it was later confirmed by another LPN and the Director of Nursing that the correct wipes were not used. This improper cleaning practice had the potential to spread microorganisms. Additionally, the facility did not follow proper procedures for transporting clean linen. Clean laundry carts were observed uncovered both in the outdoor laundry department and while being distributed within the facility. A laundry technician confirmed that the carts were uncovered while moving room to room. Furthermore, a resident's urostomy bag was observed dragging on the floor without a privacy cover, which was acknowledged as inappropriate by a CNA. The resident expressed a preference for the bag to be in a blue privacy bag, as per usual protocol.
Failure to Maintain Resident Dignity with Urostomy Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident with a urostomy catheter by not using a catheter privacy bag, as observed by surveyors. The resident, who had moderate cognitive impairment and required extensive assistance with daily activities, was found with a urostomy bag dragging on the floor without a privacy cover. This was noted during multiple observations over two days, despite the facility's policy on Residents Rights, which emphasizes treating residents with respect and dignity. During an interview, a Certified Nursing Assistant (CNA) acknowledged that the urostomy bag should not be on the floor and should be placed in a blue privacy bag. The resident was unaware that the bag was not covered, believing it had been properly managed the previous day. The CNA confirmed understanding that not covering the catheter bag was a deficient practice, highlighting a lapse in adhering to the facility's protocol for maintaining resident dignity.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse by not reporting an abuse allegation in a timely manner for two residents. Specifically, the facility did not ensure that a final investigation report was submitted to the state survey agency within five business days. The incident involved a resident with severe cognitive impairment who was found holding another resident's hand on his private area. The initial report was submitted promptly, but the follow-up report was delayed and received by the state survey agency on the eighth business day, not within the required five days. The residents involved had significant cognitive impairments. One resident had a BIMS score indicating severe cognitive impairment and was independent with mobility, while the other had a BIMS score of zero and required moderate assistance with mobility. The facility's policies required that a written investigation report be submitted within five working days, but the facility failed to comply with this requirement. The Administrator and DON were aware of the reporting requirements but could not provide documentation that the follow-up report was submitted on time. The state survey agency confirmed the delay in receiving the report.
Failure to Conduct Thorough Investigation of Potential Sexual Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse by another resident by not conducting a thorough investigation for an incident of potential sexual abuse behavior involving two residents. Resident R2, who had severe cognitive impairment and used a wheelchair, was found by a nurse holding the hand of Resident R3, who also had severe cognitive impairment and required assistance with mobility, on his groin area. The incident was reported, but the investigation lacked thorough documentation, including interviews with the involved residents and staff members who witnessed the event. The facility's policy on investigating patient abuse, neglect, exploitation, mistreatment, and misappropriation of property was not followed. The policy required detailed documentation of the investigation, including names of the accused and witnesses, details of the incident, signed statements from pertinent parties, and any other relevant documentation. However, the investigation report did not include statements from the residents or staff, and there was no documentation of interviews with the residents involved or the staff who witnessed the incident. Interviews with the facility's staff, including the Administrator, Director of Nursing (DON), and nurses involved, revealed that the incident was documented in the progress notes but not thoroughly investigated. The Administrator and DON acknowledged that no interviews were conducted with the residents due to their cognitive impairments, and there were no documented statements from staff members who witnessed the incident. This lack of a thorough investigation led to the deficiency in protecting the residents' rights to be free from sexual abuse.
Failure to Perform Proper Perineal and Catheter Care
Penalty
Summary
The facility failed to clean the perineal area of bowel movement during incontinence care for a resident (R12) who was dependent on staff for hygiene. During an observation, it was noted that the resident had a large amount of bowel movement on the pad between her legs, and the indwelling foley catheter tube was underneath her left leg. The staff, including two Training Nurse Aides (TNA) and a Certified Nurse Aide (CNA), did not follow proper procedures for perineal care. They removed the bowel movement from the resident's buttocks and pad but did not clean the perineal area. Additionally, the staff did not change their gloves or perform hand hygiene after handling the soiled areas and before touching other items such as the bed control and the CPAP device, which is against the facility's policy for infection control. The catheter tubing remained improperly positioned under the resident's leg throughout the process. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had multiple diagnoses including sepsis, urinary tract infection, paraplegia, morbid obesity, bed confinement status, and diarrhea. The staff's failure to follow proper hygiene and catheter care procedures was confirmed through interviews with the involved TNAs and an LPN. The TNAs admitted to not changing gloves or performing hand hygiene as required, and they also acknowledged that the catheter tubing should not have been under the resident's leg. This deficient practice had the potential to cause infection for the resident.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight hours of consecutive Registered Nurse (RN) coverage for three of 14 days on the nursing schedule. Review of the Staffing Sheets provided by the Director of Nursing (DON) indicated that there was no RN coverage for 4/10/2024, 4/17/2024, and 4/18/2024. During an interview, the DON confirmed the lack of RN coverage on these dates and stated that she believed her hours working as the DON would count as the required RN coverage, even though she was not providing direct resident care on the unit.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
The facility failed to follow standard and transmission-based precautions during incontinence care for a resident who was dependent on nursing staff. Specifically, staff did not perform hand hygiene or change gloves after contamination with bowel movement before proceeding to clean the resident's indwelling urinary catheter, touch the bed control, and handle the CPAP humidifier and mask. This failure was observed during an incontinence care procedure involving three staff members, who did not adhere to the facility's policies on perineal care and glove use. The resident involved had a history of sepsis, urinary tract infection, paraplegia, morbid obesity, bed confinement status, and diarrhea. The resident was cognitively intact and dependent on staff for hygiene. During the observed procedure, staff members were seen handling contaminated items and performing tasks without changing gloves or performing hand hygiene, despite being trained to do so. This practice had the potential to spread infection within the facility.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that posted staffing information was accurate and current on the daily nurse staffing document. Observations on multiple days revealed discrepancies between the posted staffing information and the actual nursing schedule. Specifically, the daily nurse staff posting document indicated that three RNs were working eight hours each on certain days, while the nursing schedule provided by the Director of Nursing (DON) showed that no RNs were scheduled on the day shift for those days. This discrepancy presented staffing levels higher than the actual staffing levels to residents and visitors reviewing the posted staffing documents. During interviews, the DON clarified that the three RNs listed on the day shift were the Infection Preventionist (IP), the Clinical Care Competency (CCC) person, and herself. However, the DON later confirmed that her hours could not be counted on the daily nurse staff posting document, which led to a correction indicating only two RNs on the day shift. The DON confirmed that there were no RNs scheduled on the day shift to provide direct resident care for the days in question, highlighting a failure to accurately reflect the staffing levels responsible for resident care per shift.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 50 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Fayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Lafayette | 2 mi | ★★★★★ | 3 | 0 |
| Oakview Health And Rehabilitation | 14.8 mi | ★★★★★ | 0 | 0 |
| Center For Advanced Rehab At Parkside, The | 16.9 mi | ★★★★★ | 10 | 0 |
| Ridgewood Manor Health And Rehabilitation | 17 mi | ★★★★★ | 2 | 0 |
| Regency Park Health And Rehabilitation | 17.1 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth - Shepherd Hills.
100% money-back within 48 hours.
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.