Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Acadia St. Landry Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and prior stroke sequelae fell from bed and later developed swelling and pain in the left leg. Imaging showed a mildly displaced avulsion fx of the tibial tuberosity, but the NP was not notified of the fracture until several days later. Staff interviews showed the LPN knew the knee was fractured, while the DON stated the provider should have been notified when the change in condition and lack of interventions were identified.
Failure to Provide Quarterly Personal Funds Statements: The facility did not provide quarterly statements for residents' personal funds accounts to 3 residents reviewed. A resident with moderate cognitive impairment, another resident with moderate cognitive impairment, and a cognitively intact resident each stated they had not received the required statements, and the RT confirmed there was no evidence the statements were given to the residents or mailed to responsible parties.
Bathroom Call Systems Not Accessible: Surveyors found that multiple residents had bathroom pull cords that were disconnected, on the floor, in a box, or wrapped around grab bars, making them inaccessible or nonfunctional at the toilet. Residents included individuals with impaired cognition, mobility limitations, and conditions such as COPD, CKD, dementia, heart failure, cerebral palsy, and recent fractures. Staff, including a CNA, LPN, and DON, confirmed the residents used the toilet in their bathrooms and that the pull cords should be accessible.
Insufficient dining space left residents who required feeding assistance waiting in the adjoining TV activity area while others ate. Staff reported that the feeding table could not seat all 16 residents needing help at once, so residents were rotated in as seats became available. Observations showed a large round table and a small square table with no room for additional seating or extra tables, and residents were seen waiting there on multiple occasions.
Failure to implement ordered suprapubic catheter care for a resident with a suprapubic catheter and moderately impaired cognition. The care plan and MD orders required topical clotrimazole to the catheter site, irrigation with 60 cc NS BID, and output documentation q shift, but the TARs showed numerous missed or undocumented entries across several months for the cream application, catheter irrigation, and output recording.
A resident with moderate cognitive impairment was given multiple meds, but the nurse left before confirming he swallowed them, and tablets were later found dissolved in a cup at the bedside after the resident said he choked and spit them out. In a separate event, a resident receiving continuous enteral feeding had a tube feeding bottle that was infusing without the required date, time, or nurse initials on the label; both the LPN and DON stated it should have been labeled.
Missed Skin Assessments and Wound Rounds for a Resident With a Heel Pressure Ulcer: A resident with spina bifida, DM2, and paraplegia had a right heel stage 2 pressure ulcer with wound care orders, but weekly skin audits did not identify the ulcer and wound rounds were not completed/documented for the wound. The LPN stated she did not identify or record the ulcer on the skin assessments and had not conducted wound rounds for the heel until the interview, and the DON confirmed the ulcer should have been included.
A resident with COPD and moderate cognitive impairment was care planned for smoking-related injury, with cigarettes and a lighter to be kept at the nurse’s desk. Surveyors observed the resident smoking without staff present and later found an open pack of cigarettes and a lighter in her room; staff confirmed the items should not have been there, and the charge nurse removed additional cigarettes and lighters from the room.
Failure to Monitor Anticoagulant Therapy: A resident receiving Rivaroxaban for CAD was identified as at risk for bleeding, but the MAR and physician orders showed no anticoagulant monitoring. The care plan called for observation for bruising or signs of bleeding, and an LPN and the DON confirmed there was no evidence the resident had been adequately monitored for anticoagulant side effects.
Failure to Wear Hair Covering in Kitchen: The facility failed to maintain sanitary kitchen conditions when an employee entered the kitchen without a hair covering and stood near an uncovered pot of simmering meat. The kitchen policy required hair nets or caps and/or beard restraints to prevent hair from contacting exposed food, equipment, utensils, and linens. The kitchen manager stated that all staff, including maintenance, were aware they were not supposed to enter the kitchen without hair covering.
A CNA in an LTC facility failed to follow a resident's care plan requiring a mechanical lift and two-person assistance for transfers. The CNA attempted to transfer the resident alone, resulting in the resident falling and sustaining injuries that required stitches. The resident had a history of dementia, anxiety, and repeated falls, and was dependent on assistance for transfers due to limited mobility.
The facility did not ensure residents received mail on Saturdays, affecting 121 residents. During a resident council meeting, three residents with different cognitive statuses reported not receiving mail on Saturdays. The staff responsible for mail delivery confirmed that mail was only delivered Monday through Friday, with Saturday's mail held until Monday.
The facility failed to store and label drugs properly, with loose and expired medications found in two medication carts and improper storage of refrigerated medications. LPNs confirmed the presence of loose tablets and expired medications in the carts, and the Director of Nursing acknowledged the improper storage practices.
The facility's kitchen was found to be unsanitary, with expired food items, poor pest control, and inadequate cleaning practices. Equipment and preparation areas had dried food debris and dust, and food was served at unsafe temperatures. The Dietary Manager confirmed the lack of cleaning schedules and policies, posing a risk of foodborne illnesses to residents.
The facility failed to maintain effective oversight of the kitchen's cleanliness and food service practices, leading to accumulated dirt, debris, and expired food items. Meals were served at inappropriate temperatures, and repeated violations were noted by the State of Louisiana Department of Health. The administrator was unaware of recent inspections, indicating a communication breakdown with the Dietary Manager responsible for kitchen activities.
A resident on contact precautions due to ESBL in urine was improperly handled by staff, who failed to wear necessary PPE and allowed the resident to attend therapy sessions. Staff confusion and lack of communication contributed to the oversight, as therapy staff were unaware of the resident's precautionary status.
The facility failed to report changes in condition for two residents. One resident's bilateral lower extremity edema was not communicated to the physician, despite being observed by an LPN. Another resident's consult for left shoulder pain was not completed, and the physician was not informed of the failed attempt. These lapses in communication highlight deficiencies in the facility's reporting processes.
The facility failed to refer two residents with new mental disorder diagnoses for Level II PASARR evaluation. One resident was diagnosed with Unspecified Psychosis and prescribed Olanzapine, while another was diagnosed with Psychosis and prescribed Quetiapine Fumarate. Interviews with staff confirmed the absence of Level II reviews and a PASARR policy.
A facility failed to implement a care plan for a resident by not completing weekly weight measurements as ordered by the physician. The resident, with moderately impaired cognition and medical conditions including gastrostomy status and acute kidney failure, did not have weights recorded from October 2024 to February 2025. Staff interviews revealed a lack of communication and adherence to procedures for documenting weights.
A facility failed to provide a NOMNC form to a resident discharged from Medicare Part A services before exhausting benefit days. The discharge was facility-initiated, and an LPN confirmed the form was not given, resulting in a deficiency in SNF Beneficiary Notification compliance.
A facility failed to provide necessary communication aids for a Spanish-speaking resident with heart failure and other conditions. Despite a care plan indicating potential communication difficulties, no communication board was available, and staff relied on a Spanish-speaking LPN who was only present during certain hours. The absence of a communication aid and lack of a policy for translation services contributed to the resident's communication challenges.
A facility failed to ensure proper communication and documentation for a resident receiving dialysis services. Missing dialysis communication forms were identified, which are crucial for collaboration between the facility and the dialysis agency. Staff interviews confirmed the absence of these forms in the resident's medical records, with some forms found in the resident's backpack instead.
A resident with no upper extremity impairments was found unable to reach her call bell, which was placed on a nightstand at the foot of her bed. The resident was unaware of its location, and an LPN confirmed it should have been accessible.
A facility failed to create a comprehensive care plan for a diabetic resident with cognitive impairment and neuropathy, leading to severe foot issues. The resident was admitted without preventative foot care orders, resulting in blackened toes and a fungal infection. A subsequent evaluation revealed the need for an amputation. The facility's records lacked evidence of necessary foot care measures, including podiatrist consultations and routine preventive care.
A resident with diabetes and neuropathy experienced harm due to the facility's failure to timely identify skin changes. Despite weekly evaluations showing no issues, significant discoloration was noted, leading to a severe infection and the need for toe amputation. The LPN initially reported no issues, but upon further examination, the NP found a foul-smelling wound with exposed bone, indicating a long-standing condition.
A resident with diabetes and neuropathy suffered severe foot complications due to the facility's failure to provide preventative foot care. The resident was admitted without foot care orders, leading to blackened toes and a deep tissue injury. Staff were unaware of the resident's foot care needs, and the condition worsened over time, resulting in the need for an amputation.
A resident's responsible party was not informed of changes in the resident's skin condition, as required by the facility's policy. An LPN identified discoloration on the resident's toes but failed to notify the responsible party. The oversight was confirmed by both the LPN and the DON.
The facility's kitchen staff failed to follow the menu and serve the correct portion sizes, using incorrect serving utensils for various foods. This deficiency was observed over two days and confirmed by the Dietary Manager and cook, potentially affecting the nutritional needs and dining experience of 111 residents.
The facility failed to ensure that a resident's bed alarm was monitored every shift as ordered, resulting in multiple instances where the alarm was not checked and was found to be non-functional. Staff interviews and record reviews confirmed the deficiency.
Failure to promptly notify provider of resident’s fracture
Penalty
Summary
The facility failed to immediately notify the resident’s physician or nurse practitioner of a major change in condition after the resident fell from bed and later developed swelling and pain in the left leg. The resident had diagnoses including a displaced fracture of the left tibial tuberosity, dementia, anxiety disorder, and sequelae of cerebral infarction. Nursing documentation showed the resident was found sitting on the floor mat after the fall, and later that day the left leg was noted to be swollen and painful below the knee, with the resident complaining of bilateral leg pain to touch and movement. The resident was sent to the hospital for evaluation, and imaging later showed a mildly displaced avulsion fracture of the tibial tuberosity with joint effusion and degenerative changes. The record did not show evidence that the nurse practitioner or physician was immediately notified when the fracture was discovered on 05/22/2026. The provider on call stated she was not notified of the fracture until she made rounds at the facility on 05/26/2026, and she confirmed she was the weekend provider on call. Interviews with facility staff showed conflicting recollections about notification of the fracture. The LPN stated she was told by the ER nurse that the knee was fractured and that she notified the administrative nurse on call, but she did not recall notifying the nurse practitioner. The DON stated the LPN knew the resident had a fracture and should have notified the nurse practitioner, physician, or herself when it was discovered that no interventions such as pain medication, a knee immobilizer, or further instructions were in place. The resident’s plan of care and physician orders did not include interventions for the left knee fracture until 05/26/2026.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly statements for residents' personal funds accounts for 3 of 4 residents reviewed for personal funds. The facility policy titled Resident Trust Fund Policy and Procedure stated that residents have the right to receive quarterly statements of their account. Interviews with staff confirmed that S7RT was responsible for providing written quarterly statements to residents, but she had no evidence that the statements were provided to residents or responsible parties. Resident #83 had an admission date of 12/02/2024 and diagnoses including hypertensive heart disease with heart failure, peripheral vascular disease, and chronic kidney disease; her MDS showed a BIMS score of 11, indicating moderate cognitive impairment. She stated that she had not received any quarterly statements for money kept at the facility. Resident #89 had diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified atrial fibrillation, and cerebral ischemia, and her MDS showed a BIMS score of 11; she stated she had a personal funds account but had not been receiving quarterly statements. Resident #88 had diagnoses including occlusion and stenosis of an unspecified carotid artery, unsteadiness on feet, hypertension, and unilateral primary osteoarthritis of the left knee; her MDS showed a BIMS score of 15, indicating she was cognitively intact, and she stated she had not received statements for the money in her account and had received only one statement since admission. S7RT stated she was responsible for the residents' trust funds and confirmed she had no evidence that quarterly statements were handed to Resident #88 or mailed to her responsible party, and no evidence that Resident #89 received a quarterly statement or that one was mailed to her responsible party.
Bathroom Call Systems Not Accessible
Penalty
Summary
The facility failed to ensure that bathroom call systems were functional and accessible to residents at all times for 7 residents out of a final sample of 48. The facility policy stated that it would maintain an effective call-light system that allows residents to summon staff assistance at any time. During observations, surveyors found that the bathroom pull cords for Residents #4, #23, #75, #112, #130, #132, and #133 were disconnected from the wall units, lying on the floor, in a box on a sink counter, or wrapped around the metal grab bar next to the toilet. Resident #4 had diagnoses including COPD, acute kidney failure, and diabetes with neuropathy, and her MDS showed moderately impaired cognition and partial/moderate assistance needed for toilet transfer. Her bathroom pull cord was disconnected from the wall unit and wrapped around the grab bar, and she stated she had to constantly place it back because it disconnected every time she pulled it. Resident #23 had diagnoses including hemiplegia/hemiparesis after cerebral infarction, CKD stage 3B, and dementia; her bathroom pull cord was found disconnected and placed in a box on the sink counter. Resident #75 had a recent femur fracture and moderately impaired cognition, and her pull cord was disconnected and on the floor near the toilet. Resident #112 had heart failure and cerebral palsy, with moderately impaired cognition and supervision/touching assistance needed for toilet transfer; her pull cord was disconnected and wrapped around the grab bar, and she stated it had been that way since returning from the hospital. Resident #130 was alert and oriented x3, continent of urine, and voided via toilet; her pull cord was connected to the wall unit but wrapped around the bar next to the toilet. Resident #132 was continent of bowel and urine and voided via toilet; her pull cord was disconnected and wrapped around the grab bar. Resident #133 was alert and oriented x3, continent of bowel and urine, and voided via toilet; her pull cord was disconnected and on the floor near the toilet. The tour with S6MD confirmed the observations and that the cords were not accessible if on the floor, disconnected, or wrapped around the grab bar. S14CNA, S15LPN, and S1DON confirmed these residents used the toilet in their bathrooms and that the bathroom pull cords should be accessible to residents.
Insufficient Dining Space for Residents Requiring Feeding Assistance
Penalty
Summary
The facility failed to ensure there was sufficient space in the dining room to accommodate residents who required assistance with feeding. During observations on 03/09/2026, Resident #3 and Resident #35 were seen sitting in the adjoining TV activity section of the dining room while other residents were eating lunch. A CNA told S10TN that these residents were waiting to eat at the feeding table because space was not available. Later that morning, Resident #3 and Resident #35 were moved to the feeding table when space became available. On 03/10/2026, Resident #35 was again observed waiting in the adjoining TV activity section of the dining room to eat because there were no available seats at the feeding table. S10TN stated the facility did not have enough space to seat all residents who required feeding at once, so staff rotated residents out of the table as others finished eating. An observation of the feeding area showed a large round table and a small square table with no space for additional residents, staff, or extra tables. On 03/11/2026, Resident #121 was also observed waiting in the TV activity section to eat. S1DON stated there were 16 residents who had to be fed and it was not feasible for all of them to sit at the table at one time, so CNAs brought all of the residents needing feeding to the dining room and seated them in the TV activity section while waiting for space at the feeding table.
Failure to Implement Suprapubic Catheter Care Orders
Penalty
Summary
The facility failed to ensure the plan of care and physician orders were implemented for Resident #2, who was admitted on 08/27/2024 with diagnoses including calculus in the bladder and benign prostatic hyperplasia with lower urinary tract symptoms. The resident’s annual MDS showed a BIMS score of 11, indicating moderately impaired cognition. The care plan included interventions to document suprapubic catheter output every shift, irrigate the suprapubic catheter with 60 cc normal saline twice daily, and administer medications as ordered. Review of the resident’s physician orders showed clotrimazole external cream 1% to be applied to the suprapubic catheter site twice daily for candidiasis of the skin and nail, irrigation of the suprapubic catheter with 60 cc normal saline twice daily, and documentation of suprapubic catheter output every shift. Review of the TARs for November 2025 through March 2026 showed multiple instances where nurses’ initials or evidence of completion were missing for the ordered topical cream application, suprapubic catheter irrigation, and catheter output documentation on numerous dates across those months.
Failure to Observe Medication Swallowing and Label Tube Feeding
Penalty
Summary
Services were not provided in accordance with professional standards of quality for Resident #7 when the nurse did not remain present to ensure all medications were swallowed. Resident #7 had diagnoses including arteriosclerotic heart disease, chronic pain syndrome, and hypokalemia, and his MDS showed a BIMS score of 9, indicating moderate cognitive impairment. During an observation, tablets and capsules were found clumped together and partially dissolved in a medicine cup on the resident’s bedside table, with no nurse present. The resident stated he tried to swallow the medications, they got wet, he choked on them, and had to spit them out. He also stated the nurse placed the medications in the cup and left without watching him take them. The nurse confirmed she administered the morning medications and exited the room, and the MAR showed multiple medications documented as given that morning. Services were also not provided to professional standards for Resident #54 when the tube feeding bottle was left unlabeled. The resident had diagnoses including encounter for attention to gastrostomy and dysphagia, and had an order for continuous Jevity 1.2 enteral feeding at 70 cc per hour with hourly water flushes. During observations, the tube feeding bottle was infusing but had no label identifying the date and time it was started or the nurse’s initials. An LPN stated the bottle should have been labeled with the date and time hung and the nurse’s initials, and the DON also stated it should have been labeled accordingly.
Missed Skin Assessments and Wound Rounds for a Resident With a Heel Pressure Ulcer
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for one resident with a history of spina bifida, type 2 diabetes mellitus without complications, and paraplegia. The resident was admitted with impaired skin integrity to the right foot and had a care plan that included monitoring and measuring wounds weekly. A physician progress note documented a right heel wound with orders for Aquacel and Mepilex border dressing every other day and as needed. Weekly skin assessment audits for February and March 2026 did not identify a pressure ulcer on the resident’s right heel, and the wound rounds for those months also failed to identify the wound. During interview, the LPN responsible for skin assessment audits stated she had assessed the resident on those dates but had not identified the stage 2 pressure ulcer and had not placed it on the weekly skin assessments. She also stated that she had not conducted wound rounds for the right heel until the day of the interview. The DON confirmed that the resident had a stage 2 pressure ulcer that was not placed on the skin assessment audits or weekly wound rounds and should have been.
Smoking Supplies Left in Resident Room Despite Care Plan
Penalty
Summary
The facility failed to implement care plan interventions to keep a resident’s environment free from smoking-related hazards. Resident #66 was admitted with diagnoses including COPD, cerebral infarction, and muscle wasting/atrophy of both hands, and her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Her care plan identified that she smoked and had a potential for injury related to smoking, with an intervention stating that cigarettes and a lighter were to be kept at the nurse’s desk. During observations, the resident was seen smoking in the designated smoke room without staff present. She told staff she kept her cigarettes and lighter in her room. A later observation found an open pack of cigarettes on the side of her bed and a lighter on her nightstand while she was in her room eating breakfast. Staff interviews confirmed the cigarettes and lighter should not have been in her room, and the charge nurse retrieved a pack of cigarettes and two lighters from the room, stating the resident should not have had them there.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not adequately monitoring for anticoagulant side effects for one resident. The facility policy titled, Anticoagulation-Clinical Protocol, stated that staff would monitor for possible complications in individuals receiving anticoagulation therapy and would manage related problems, including discussing signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding with the physician before the next scheduled dose. Resident #5 was admitted with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, type 2 diabetes mellitus without complications, and hyperlipidemia. The resident's MDS indicated use of an anticoagulant, and the care plan identified the resident as at risk for bleeding related to anticoagulant use with interventions to observe for bruising or signs of bleeding and notify the MD. The order summary showed Rivaroxaban 2.5 mg twice daily, but there was no order for anticoagulant monitoring. The MAR from January 2026 through March 10, 2026 documented administration of Rivaroxaban, but it did not show evidence of anticoagulant monitoring. An LPN confirmed there was no evidence of monitoring on the MAR and no physician order for it, and the DON confirmed the resident had not been adequately monitored for anticoagulant side effects.
Failure to Wear Hair Covering in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen by not ensuring all staff wore a hair covering when entering the kitchen. A review of the facility policy titled, "Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices," stated that hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. During an observation, S6MD entered the kitchen and stood at the stove near an uncovered pot of bite-sized meat simmering while not wearing any hair covering, despite having a full head of hair. When asked, S6MD stated he usually wore a hat but did not have one on that day. In an interview, S5DM, who was responsible for the kitchen and kitchen staff, stated that everyone, including maintenance, was aware they were not supposed to enter the kitchen without hair covering and that S6MD should not have entered the kitchen without one.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in actual harm. A Certified Nursing Assistant (CNA) attempted to transfer a resident from a lying position to a sitting position without the assistance of a second person or a mechanical lift, as required by the resident's care plan. The resident, who had diagnoses including unspecified dementia, psychotic disturbance, anxiety, and a history of repeated falls, was dependent on assistance for transfers due to limited mobility and contractures. The CNA turned away from the resident to retrieve a chair, during which time the resident fell to the floor, sustaining a laceration to the right eyebrow and cheek that required stitches. The resident's care plan specified the need for a mechanical lift and two-person assistance for transfers, which the CNA did not follow. The CNA admitted to not checking the resident's transfer needs and attempted the transfer alone because another CNA was unavailable. The Director of Nursing (DON) and Infection Preventionist (IP) confirmed that the CNA should not have attempted the transfer alone, given the resident's condition and the care plan requirements. The incident was documented in the facility's investigative report, and the resident was treated at the emergency department for the injuries sustained during the fall.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, which affected the communication access for 121 residents. During a resident council meeting, three residents with varying levels of cognitive function expressed that they did not receive or were unsure if they received mail on Saturdays. The Transportation/Social Services Assistant, responsible for delivering mail, confirmed that mail delivery occurred only from Monday to Friday, and mail received on Saturdays was held until Monday for delivery. This practice resulted in a delay in residents receiving their mail on Saturdays.
Improper Storage and Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in accordance with accepted professional principles. During an inspection, it was observed that two medication carts, Cart A and Cart B, contained loose and unidentified pills, as well as expired medications. Specifically, Cart A had three loose tablets and expired bottles of Folic Acid and Vitamin B6, while Cart B contained four loose tablets and expired bottles of Nasal Moisturizing Spray, Lutein, and Vitamin E. These findings were confirmed by the LPNs overseeing the carts, who acknowledged that such medications should not have been present. Additionally, the facility did not maintain proper storage temperatures for certain medications. In Medication Storage Room A, two boxes of Latanoprost eye drops, which require refrigeration, were found in an unrefrigerated drawer. This was confirmed by the LPN overseeing the storage room. The Director of Nursing also confirmed that loose tablets, expired medications, and improperly stored refrigerated medications should not have been present in the facility.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which is essential to prevent foodborne illnesses. During an inspection, several expired food items were found in the refrigerated and dry storage areas, including lemon juice, barbecue sauce, whipped topping, sour cream, cabbage, and cookies. Additionally, there were signs of poor pest control, as evidenced by a dead cockroach found under a shelf. The storage areas were also noted to have crumbs, dirt, and dried substances on various surfaces, indicating a lack of regular cleaning and maintenance. The food preparation and equipment areas were observed to be in unsanitary conditions. There was dried food debris on various surfaces, including drawers, walls, and equipment such as the microwave oven, waffle maker, and fryer. Dust and crumbs were found on several kitchen appliances and storage containers, and a black substance resembling mold was noted in the dishwashing area. The lack of documented cleaning schedules and specific cleaning duties contributed to these unsanitary conditions, as confirmed by the Dietary Manager during interviews. Furthermore, the facility failed to serve food at appropriate temperatures, which is critical for food safety. During the inspection, food temperatures were recorded below the required levels, with rice with sausage at 129 degrees, black-eyed peas at 108 degrees, collard greens at 109 degrees, and milk at 51 degrees. These temperatures are not suitable for safe consumption, as confirmed by the Dietary Manager. The absence of policies related to kitchen cleanliness and food safety practices was evident, leading to the potential risk of foodborne illnesses for the 118 residents consuming meals from the facility's kitchen.
Deficient Kitchen Oversight and Sanitation
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, particularly in the oversight of the kitchen's cleanliness, sanitation, and food service practices. During a tour of the facility's kitchen, it was observed that surfaces had accumulated dust, dirt, food residue, and other debris. Additionally, expired food items were found, and meals were served at inappropriate temperatures during tray distribution. These findings were corroborated by a review of the facility's Retail Food Notice of Violations from the State of Louisiana Department of Health, which highlighted repeated issues with non-food contact surfaces, unclean food carts, and dirty floors in various areas of the kitchen. Interviews conducted with the facility's administrator (S1ADM) revealed a lack of awareness regarding inspections performed by the Office of Public Health since 2023. The administrator confirmed the findings in the kitchen and stated that the Dietary Manager (S17DM) was responsible for kitchen activities, including cleanliness. However, the administrator acknowledged having total oversight of the kitchen, indicating a breakdown in communication and responsibility between the administrator and the dietary manager, which contributed to the deficiency.
Failure to Adhere to Contact Precautions for Resident
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a resident on contact precautions. Resident #74, who was diagnosed with a urinary tract infection and had an indwelling catheter, was placed on contact precautions due to ESBL in his urine. Despite this, staff members did not adhere to the required protocols. Observations revealed that a Physical Therapy Tech and a Certified Nursing Assistant interacted with the resident without wearing the necessary personal protective equipment (PPE), such as gowns and gloves. Additionally, the resident was taken to therapy sessions, which was against the infection control guidelines for someone on contact precautions. Interviews with staff members, including the Infection Preventionist and the Restorative Certified Nursing Assistant, highlighted a lack of communication and awareness regarding the resident's contact precaution status. The Restorative CNA admitted to confusing the contact precautions with enhanced barrier precautions, leading to the resident being taken out of his room. The Occupational Therapist confirmed that therapy staff were not informed about the resident's precautionary status, as the Infection Preventionist typically communicated such information but failed to do so in this instance.
Failure to Report Changes in Resident Conditions
Penalty
Summary
The facility failed to ensure immediate reporting of a change in condition for two residents. For one resident, staff did not report the presence of 2+ pitting edema in the bilateral lower extremities to the attending physician. Despite the observation of edema by an LPN, the physician was not informed, and subsequent medical notes indicated the absence of edema, highlighting a communication lapse. The resident had a history of atherosclerotic heart disease and coronary artery issues, which could be relevant to the edema condition. For another resident, the facility failed to notify the physician about the inability to complete a consult for left shoulder pain. The resident, who had a history of peripheral vascular disease, neuropathy, and shoulder pain due to a fall, was supposed to have a consult with an orthopedic physician. However, the appointment could not be arranged because the resident was in rehab, and the transportation/social services assistant did not follow up adequately to inform the nurse or the physician about the failed consult. This lack of communication resulted in the physician being unaware of the situation, preventing alternative arrangements from being made.
Failure to Conduct Level II PASARR for Residents with New Mental Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed mental disorders or significant changes in their mental condition to the appropriate state-designated authority for Level II PASARR evaluation. Resident #22 was admitted with diagnoses of Insomnia and Anxiety Disorder, and later diagnosed with Unspecified Psychosis. Despite this new diagnosis, there was no evidence in the Electronic Health Record (EHR) that the facility referred the resident for a Level II PASARR. An interview with an LPN revealed a lack of awareness regarding the need for a Level II review following a new diagnosis of a serious mental disorder. Similarly, Resident #74 was admitted with a diagnosis of Psychosis, and a PASARR Level I indicated no mental illness. However, the resident was later prescribed Quetiapine Fumarate for Unspecified Mood Disorder, yet no Level II PASARR referral was made. Interviews with facility staff confirmed the absence of a Level II review for this resident as well. Additionally, it was confirmed that the facility did not have a PASARR policy in place, contributing to the oversight.
Failure to Implement Weekly Weight Monitoring
Penalty
Summary
The facility failed to implement a care plan for a resident, specifically neglecting to complete weekly weight measurements as ordered by the physician. The resident, who was admitted with diagnoses including gastrostomy status and acute kidney failure, had a moderately impaired cognitive status as indicated by a BIMS score of 8. Despite a physician's order for weekly weights every Friday evening, the facility did not record these weights from October 2024 to February 2025. Interviews with facility staff revealed a breakdown in communication and procedure. The Restorative Certified Nursing Assistant was unaware of the weekly weight requirement, and the Director of Nursing confirmed that the weights were not completed as ordered. The process for documenting weights involved recording them in a book, entering them into a kiosk, and then into the EHR, but this process was not followed for the resident in question.
Failure to Provide NOMNC Form to Resident
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non Coverage (NOMNC) form to a resident, leading to a deficiency in compliance with SNF Beneficiary Notification requirements. The resident was discharged from Medicare Part A services before exhausting their benefit days, and the facility initiated this discharge. A review of the resident's electronic health record did not show evidence that the NOMNC form was provided or signed by the resident. During an interview, an LPN confirmed that the discharge was facility-initiated and acknowledged that the NOMNC form was not given to the resident, resulting in a failure to notify the resident of their Medicare coverage status and potential liability for services not covered.
Failure to Provide Communication Aids for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide necessary communication aids for a resident who was admitted with diagnoses including heart failure, hypertension, and atrial fibrillation. The resident, who was cognitively intact with a BIMS score of 13, primarily spoke Spanish and had a care plan indicating potential communication difficulties. Despite this, the facility did not provide a communication board or chart as outlined in the care plan. Observations and interviews revealed that the resident attempted to communicate by pointing to items, but staff often did not understand him due to the language barrier. Staff interviews confirmed that communication with the resident relied heavily on a Spanish-speaking LPN who was only available during specific hours. When this LPN was not present, staff resorted to using hand gestures, as there was no communication aid available in the resident's room. The Director of Nursing acknowledged the absence of a communication aid and confirmed that there was no policy or procedure in place for communication or translation services, further contributing to the communication deficiency experienced by the resident.
Failure in Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility for a resident requiring dialysis services. The deficiency was identified through a review of the facility's agreement with the contracted dialysis agency, which mandates documented evidence of collaboration and communication between the nursing facility and the dialysis unit. The review of a resident's records revealed missing dialysis communication forms on specific dates, indicating a lack of proper documentation and communication regarding the resident's dialysis care. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed the absence of dialysis communication forms in the resident's medical records for several dates. The LPN explained that these forms are essential for communication between the facility and the dialysis agency, detailing vital signs, fluid removal, and any changes in labs or medications. The Director of Nursing verified the missing forms and acknowledged that they should have been present in the resident's records. Further investigation revealed that some forms were found in the resident's backpack, not in the medical records, highlighting a lapse in proper documentation procedures.
Resident Unable to Reach Call Bell
Penalty
Summary
The facility failed to ensure that a resident who was capable of using a call bell had access to it. Resident #60, who was admitted with diagnoses including major depressive disorder and repeated falls, was observed in her room with the call bell placed on the nightstand at the foot of her bed, out of her reach. The resident, who had no upper extremity impairments as per her quarterly MDS, was unaware of the call bell's location. During an interview, an LPN confirmed that the call bell was out of reach and acknowledged that it should have been pinned to the resident's bed for accessibility.
Failure to Develop Comprehensive Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a diabetic resident, resulting in actual harm. The resident, who was cognitively impaired and had neuropathy in the lower extremities, was admitted without preventative foot care orders. On a subsequent skin evaluation, it was discovered that the resident's toes were black, and further assessment revealed a fungal infection and suspected deep tissue injuries. The resident was transferred to another center for treatment, where it was determined that an amputation would be necessary. The review of the resident's medical records showed a lack of orders for podiatrist consultations, nail care, and proper shoe fitting assessments. Additionally, there was no evidence of routine preventive foot care or a care plan addressing the prevention of complications from diabetes. Interviews with the Director of Nursing confirmed the absence of necessary foot care measures in the resident's records, highlighting the facility's failure to provide essential care for the diabetic resident.
Failure to Timely Identify Skin Changes Leads to Harm
Penalty
Summary
The facility failed to ensure that nursing staff identified skin changes in a timely manner for a resident with diabetes and neuropathy, leading to actual harm. The resident, who had severe cognitive impairment, was admitted with diagnoses including Type 2 Diabetes Mellitus and neuropathy. Despite weekly skin evaluations indicating no issues, a significant change was noted on November 19, 2024, when the resident's toes were found to be discolored and black. The Licensed Practical Nurse (LPN) responsible for the resident's weekly assessments reported no skin issues on November 18, 2024, but was informed by a shower aide the following day to examine the resident's foot. Upon examination, the LPN observed black discoloration on the toes and notified the Nurse Practitioner (NP). The NP's evaluation on November 22, 2024, revealed a foul-smelling wound with exposed bone on the second toe, indicating a severe infection that required immediate medical attention. The resident was transferred to a hospital for further evaluation, where it was determined that the condition had likely developed over weeks or months. The resident was diagnosed with osteomyelitis and required an amputation of the affected toe. The facility's failure to identify and address the resident's skin condition in a timely manner resulted in significant harm and necessitated surgical intervention.
Failure to Provide Preventative Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate preventative foot care for a resident with diabetes and neuropathy, leading to significant harm. The resident, who was cognitively impaired, was admitted without any preventative foot care orders. Over time, the resident developed severe foot issues, including blackened toes and a suspected deep tissue injury, which were not addressed until they became critical. The lack of routine foot care assessments, nail care, and proper shoe fitting contributed to the deterioration of the resident's foot condition. On November 19, 2024, a Licensed Practical Nurse was informed by a shower aide about the resident's discolored right foot. Upon evaluation, the nurse observed black skin on the right second toe. A Nurse Practitioner later assessed the resident and found a fungal infection, foul odor, and exposed bone on the second toe, indicating a severe infection. The resident was transferred to a medical center for further evaluation and treatment, where it was determined that an amputation would be necessary. Interviews with facility staff revealed a lack of documentation and awareness regarding the resident's foot care needs. The Director of Nursing and other staff members were unable to confirm when the resident last received toenail trimming or proper shoe fitting. The Medical Doctor involved in the resident's care noted that the condition could have developed over weeks or months, suggesting a prolonged period of inadequate care. The facility's failure to implement a care plan for diabetic foot care and to conduct regular assessments led to the resident's severe foot complications.
Failure to Notify Responsible Party of Skin Condition Change
Penalty
Summary
The facility failed to notify the responsible party (RP) of a change in skin condition for one resident. The facility's policy on Diabetic Skin and Foot Care requires notifying the medical doctor and responsible party of any changes in skin integrity. On November 19, 2024, a Licensed Practical Nurse (LPN) identified skin issues on the resident's toes, noting discoloration. However, there was no evidence in the nurse's progress notes that the RP was informed of these changes. The resident's RP expressed dissatisfaction on November 25, 2024, for not being informed in a timely manner about the discoloration and changes in skin integrity. Interviews conducted with the LPN and the Director of Nursing (DON) confirmed that the RP was not notified of the findings. The LPN acknowledged the oversight, and the DON confirmed that notification was warranted but not executed.
Failure to Follow Menu and Serve Correct Portion Sizes
Penalty
Summary
The facility's kitchen staff failed to follow the menu to ensure residents were served the appropriate portion sizes of food during meals. This was evidenced by the kitchen staff using incorrect serving utensils for pureed, mechanically soft, and non-mechanically altered foods. Specifically, on two separate days, the staff used a #12 scoop (1/3 cup) instead of the required 1/2 cup for carrot souffle, mashed potatoes, pureed potato salad, and steamed rice. Additionally, chopped chicken and pureed fried chicken were served in incorrect portions, and bite-sized chicken was not measured but served using tongs. These actions were observed during meal service on 05/28/2024 and 05/29/2024, and the discrepancies were confirmed by the Dietary Manager (S2DM) and the cook (S4COOK) during interviews. The cook admitted to relying on memory for determining serving utensils and was unable to state the correct portion sizes or the capacity of the utensils used. The Dietary Manager acknowledged that the staff should use a chart on the kitchen wall to determine the correct serving utensils but verified that incorrect utensils were used during the observed meals. This deficiency had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 111 residents who consumed meals from the facility's kitchen. The facility's policy on dietary serving sizes was not adhered to, as the staff did not use the dietary menus provided by the food supply company to ensure the appropriate portion sizes were served. The failure to follow the menu and use the correct serving utensils was confirmed through observations, interviews, and menu reviews conducted by the surveyors.
Failure to Monitor Bed Alarm as Ordered
Penalty
Summary
The facility failed to ensure that physician orders and the plan of care were implemented as ordered for monitoring a bed alarm for proper functioning every shift for one resident. The resident, who had severe cognitive impairment due to Alzheimer's disease, Depression, Schizoaffective Disorder, and Insomnia, had a physician's order and a comprehensive care plan that required the bed alarm to be monitored every shift. However, the electronic Treatment Administration Records (eTARs) for March, April, and May 2024 revealed multiple instances where the monitoring was not documented, indicating that the bed alarm was not checked as required. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), confirmed that the bed alarm was not functioning properly when tested. The Director of Nursing (DON) also verified that the eTARs contained multiple blanks where staff signatures should have indicated that the bed alarm was monitored. This failure to monitor the bed alarm as ordered led to the deficiency identified by the surveyors.
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 127 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 Church Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Senior Village Nursing & Rehabilitation Center | 9.4 mi | ★★★★★ | 6 | 0 |
| Evangeline Oaks Guest House | 11.8 mi | ★★★★★ | 14 | 0 |
| Eunice Manor | 12 mi | ★★★★★ | 2 | 0 |
| Heritage Manor Of Opelousas | 12.1 mi | ★★★★★ | 6 | 0 |
| The Ellington | 12.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.