Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Lacombe Nursing Centre during CMS and state inspections, most recent first.
Improperly Stored and Undated Food Items in Kitchen Areas: Food items were found open and undated in the food prep area, dry storage area, and walk-in cooler, including bread, dinner rolls, instant mashed potatoes, macaroni noodles, instant sliced potatoes, red punch, and chicken salad. The dietary staff member confirmed that items should be labeled with the open date once opened, consistent with the facility policy requiring proper labeling and storage.
Incomplete MAR and TAR Documentation for Medications and Ordered Treatments: Multiple residents had blank MAR and TAR entries for ordered meds and treatments, including wound care, PEG site care, and suprapubic catheter care. An LPN confirmed she performed several of the documented tasks, and the DON confirmed the records were not accurately completed.
Inconsistent code status documentation was found for two residents. One resident’s physician orders listed Full Code while the hard chart LaPOST showed DNR, and another resident’s EMR LaPOST showed CPR/Attempt Resuscitation while the hard chart LaPOST showed DNR. An LPN and the DON stated staff checked the hard chart for code status, and the DON confirmed code status entries in different locations should match.
Failure to protect a resident from physical abuse occurred when one resident struck another resident in the face in the activity room. The injured resident, who had Parkinson’s Disease and moderate cognitive impairment, reported being punched after sitting near the other resident, and the other resident admitted she hit him and said she would do it again if needed. Video footage confirmed the assault, and staff later stated they did not consider the incident abuse because it was not willful.
Failure to report a physical abuse allegation to the State Agency: A resident with moderate cognitive impairment reported that another resident punched him in the face in the activity room, and the other resident admitted to hitting him. Staff documented the incident as physical aggression and notified the ADM, but the ADM stated he did not consider it abuse because it was not willful, so it was not reported to the State Agency as required.
A resident with Major Depressive Disorder later received additional mental health diagnoses of Adjustment Disorder and Schizophrenia, but the facility did not resubmit the resident review form to OBH for a PASRR Level II evaluation. The Level 1 PASRR listed Major Depressive Disorder, and staff confirmed the new diagnoses should have triggered resubmission but did not.
Oxygen Not Set at Ordered Rate: A resident with a diagnosis including Senile Degeneration of the Brain had a physician order for continuous oxygen at 3L via NC, but staff observed the oxygen set at 2.5L on two occasions. An LPN confirmed the order and the incorrect setting, and the ADON and DON confirmed oxygen should be administered at the ordered rate.
Missing Ombudsman Posting: The facility failed to post the name, address, and telephone numbers of the Office of the State LTC Ombudsman program in a form and manner accessible and understandable to residents and resident representatives. During observations, no required Ombudsman posting or signage was seen anywhere in the facility, and S3ADON confirmed the information was not posted. The deficiency had the potential to affect any of the 71 residents.
A facility failed to accurately code a resident's fall history in the MDS assessment. The resident, with osteoporosis and a personality disorder, suffered a femur fracture after a fall, requiring hospitalization. The MDS assessment did not reflect this fall, as confirmed by the RN and DON responsible for the assessment.
A resident with osteoporosis experienced an unwitnessed fall, and the facility failed to update the care plan with new interventions. Although bright signs were placed in the resident's room to remind her to ask for assistance, this was not documented in the care plan. The oversight was acknowledged by the responsible RN and confirmed by the DON, indicating non-compliance with the facility's fall policy.
The facility failed to label oxygen tubing and humidifier bottles for residents receiving oxygen therapy, contrary to its policy requiring weekly changes and labeling. Observations showed that residents with conditions like heart failure and COPD had unlabeled equipment, and staff confirmed the oversight.
The facility failed to store and discard expired dietary supplements properly, as observed in Med Storage Room B and the nursing station's refrigerator. Several supplements and a milk carton were found past their expiration dates and not discarded as required. Interviews with the DON and an LPN confirmed these findings, acknowledging the failure to adhere to the facility's policy on food storage and expiration.
A resident with a midline catheter did not receive appropriate site care due to the facility's failure to obtain necessary care orders. The facility's policy required dressing changes every seven days, but there was no documentation of such care, and the dressing was overdue for a change. Staff confirmed the lack of orders and acknowledged the oversight.
A resident's code status was inconsistently documented in a facility's records, with active physician orders indicating CPR LaPOST while the hard chart showed DNR LaPOST. Staff interviews confirmed the discrepancy, highlighting a failure to update the electronic health record to reflect the correct DNR status.
A facility failed to ensure proper PPE use during care for a resident on Enhanced Barrier Precautions. An LPN was observed administering a bolus tube feeding without wearing a gown, despite the requirement for direct care. The resident had diagnoses of Functional Quadriplegia and Gastrostomy Status. The LPN admitted to not wearing the gown, and the DON confirmed the need for gown and gloves during such procedures.
The facility failed to document required nurse staffing data, including the facility census and actual hours worked, on daily postings. This deficiency was confirmed through observations and interviews with staff, who were unaware of the documentation requirements.
A facility failed to complete and transmit a Discharge/Transfer MDS assessment for a resident who was transferred to the hospital and did not return. The RN responsible for MDS assessments confirmed the oversight, and the DON acknowledged that the assessment should have been completed.
A resident with hand contractures was unable to use the standard squeeze bulb call light due to his condition. Despite multiple staff members being aware of the issue, no alternative call light was provided, and the problem was not reported to higher authorities. The resident's call light log showed no usage for a month, indicating he was unable to call for assistance during this period.
A resident with a history of repeated falls experienced two falls, one resulting in skin tears, which were not accurately reflected in the Admission MDS assessment. Interviews confirmed the discrepancy, indicating a failure in the facility's process for accurate resident assessments.
A resident with Hemiplegia and hand contractures experienced multiple falls due to the facility's failure to implement effective interventions and monitor their effectiveness. Despite being unable to use the call light and requiring total assistance, the resident's bed was often found in a high position, and no alternative safety measures were put in place.
Improperly Stored and Undated Food Items in Kitchen Areas
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions by not ensuring food items in the kitchen were properly stored and labeled. During observations, an open and undated 20-ounce package of whole wheat sliced bread and an open and undated 24-ounce package of dinner rolls were found in the food preparation area. In the dry storage area, an open and undated 26-ounce package of instant mashed potatoes, a 5-pound package of macaroni noodles, and a 5-pound package of instant sliced potatoes were observed. In the walk-in cooler, an open and undated 2-quart pitcher of red punch and a 5-pound container of chicken salad were also found. The facility policy stated that dry storage items must be in a container with a lid or in a labeled zip lock bag and must be labeled with the item, open date, and initials of the person who placed it there. The dietary staff member interviewed confirmed the items should have been labeled with the open date once opened.
Incomplete MAR and TAR Documentation for Medications and Ordered Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for 4 of 19 sampled residents by not documenting medication administration and ordered treatments in accordance with accepted professional standards. The deficiency involved Resident #3, Resident #6, Resident #19, and Resident #32, and the record review showed multiple blank entries on MARs and TARs for medications, wound care, PEG site care, and catheter care that were expected to be documented as completed. Resident #3 was admitted with diagnoses including DM, amputations of toes and limb, a chronic ulcer of the right ankle, and chronic osteomyelitis with draining sinus. The record showed wound care orders for multiple right foot and ankle wounds, but the TAR did not show those treatments as completed on several dates and times in July 2025. The MAR also showed multiple medications and monitoring tasks not initialed as completed, including insulin, sotalol, apixaban, atorvastatin, fenofibrate, pregabalin, vitamin C, protein supplement, Miralax, pain monitoring, and bleeding/bruising observation. The resident stated the nurses had not missed any wound care treatments, while an LPN confirmed she worked the evening shifts and completed the medications, and the DON confirmed the treatments and medications were not accurately documented. Resident #6 had diagnoses including gastrostomy status and mild protein-calorie malnutrition, and the physician orders required daily PEG site care. The TAR showed PEG site care was not documented as complete on four dates in July 2025. An LPN stated she performed the PEG site care on those dates and confirmed that blank TAR entries meant the treatment was not accurately documented. The DON reviewed the record and confirmed the incomplete documentation. Resident #19 had diagnoses including pain in the right knee, hypertensive emergency, ESRD, and DM. The TAR showed surgical site monitoring and cleansing of the right knee was not initialed as completed on two dates in July 2025. The MAR also showed multiple medications and treatments not initialed as completed, including insulin, midline checks, vitamin C, haloperidol, protein supplement, carvedilol, zinc sulfate, saline flush, ceftriaxone, atorvastatin, and tizanidine. An LPN stated she performed the wound care and confirmed blank TAR entries meant the treatment was not accurately documented, and another LPN stated she completed the evening medications and that blank MAR entries meant the medications were not accurately documented. The DON confirmed the wound care and medication documentation was incomplete. Resident #32 had diagnoses including acute kidney failure and neuromuscular dysfunction of bladder, and the physician orders required daily suprapubic catheter care. The TAR showed suprapubic catheter care was not documented as complete on four dates in July 2025. An LPN stated she performed the catheter care on those dates and confirmed blank TAR entries meant the care was not accurately documented. The DON reviewed the record and confirmed the incomplete documentation of suprapubic catheter care.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that all medical records consistently reflected residents’ code status wishes for 2 of 25 residents reviewed for advance directives. For Resident #4, the current physician orders listed Full Code Status, while the resident’s hard chart contained a Louisiana Physician Orders for Scope of Treatment (LaPOST) form dated [DATE] indicating the health care representative selected DNR/Do Not Attempt Resuscitation. For Resident #66, the electronic medical record contained a LaPOST dated [DATE] showing the health care representative selected CPR/Attempt Resuscitation, and no other LaPOST documents were found in the electronic record. However, the resident’s hard chart contained a LaPOST dated [DATE] indicating the resident selected DNR/Do Not Attempt Resuscitation. Staff interviews confirmed the facility’s process was to check the hard chart for code status, and the DON stated code status orders had been deleted from the electronic record to eliminate confusion; she also confirmed that if code status was found in two places, the statuses should match.
Failure to Protect a Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse when one resident struck another resident in the face. Resident #4 had diagnoses including Parkinson’s Disease, Depression, and Mild Intellectual Disabilities, and his quarterly MDS showed a BIMS of 11, indicating moderate cognitive impairment. Resident #50 had diagnoses including Depression and Anxiety, and her annual MDS showed a BIMS of 10, also indicating moderate cognitive impairment. On 07/13/2025, Resident #4 reported to nursing staff that Resident #50 had punched him in the face after he sat next to her in the activity room and did not leave when she told him to go away. Nursing staff assessed Resident #4 and then asked Resident #50 about the incident. Resident #50 admitted that she hit Resident #4 and stated, “Yeah, I sure did. But I didn’t hit him hard.” The facility’s incident log and incident report documented the event as physical aggression received by Resident #4 and physical aggression initiated by Resident #50. Video footage reviewed with the administrator showed Resident #4 and Resident #50 seated together in the activity room, and Resident #50 hitting Resident #4 in the head with her hand. In interviews, Resident #50 stated she punched Resident #4 with a closed fist and would do it again if he bothered her. Resident #4 also confirmed that Resident #50 punched him in the face. Staff interviews reflected that the incident was reported to management, but the administrator and the director of nursing stated they did not believe the incident was abuse because it was not willful.
Failure to Report Physical Abuse Allegation to State Agency
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported to the State Agency within the required timeframe for 1 of 24 sampled residents reviewed for abuse. The facility policy dated 02/2025 stated that abuse incidents must be reported to the state agency as required and that abuse must be reported immediately. Resident #4 had diagnoses including Parkinson's Disease, Depression, and Mild Intellectual Disabilities, and his quarterly MDS showed a BIMS of 11, indicating moderate cognitive impairment. Resident #50 had diagnoses including Depression and Anxiety, and her annual MDS showed a BIMS of 10, also indicating moderate cognitive impairment. On 07/13/2025, Resident #4 reported that Resident #50 punched him in the face in the activity room, and Resident #50 admitted that she had hit him, stating, "Yeah, I sure did. But I didn't hit him hard." The incident was documented in the facility's incident log and incident report as physical aggression initiated by Resident #50 and received by Resident #4. Staff interviews confirmed that S9RN notified S10WS, who notified S1ADM, and both residents later stated that Resident #50 punched Resident #4 in the face. S1ADM stated he did not believe the incident was abuse because it was not willful, and therefore it was not reported to the state agency.
Failure to Refer Resident for PASRR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with a mental health diagnosis was referred for a PASRR Level II evaluation after new psychiatric diagnoses were identified. Resident #2 was admitted with Major Depressive Disorder, and the record later showed diagnoses of Adjustment Disorder and Schizophrenia. The resident’s Level 1 PASRR dated 09/24/2019 listed Major Depressive Disorder in Section III: Mental Illness, but did not include Adjustment Disorder or Schizophrenia. During interview, S7SSD stated she was responsible for resubmitting resident review forms to the Office of Behavioral Health when a new mental health diagnosis was acquired, and she confirmed that a resident review form should have been resubmitted for Level II evaluation after the new diagnoses were added, but it was not.
Oxygen Not Set at Ordered Rate
Penalty
Summary
The facility failed to provide necessary respiratory care by not ensuring a resident's oxygen was administered at the physician-ordered rate. Resident #10 was admitted with diagnoses including Senile Degeneration of the Brain, and the current physician order directed oxygen at 3L per nasal cannula continuously every shift. During observations, the resident was seen wearing oxygen at 2.5L on 07/28/2025 at 12:02 p.m. and again on 07/29/2025 at 9:00 a.m. An LPN confirmed the resident had an order for oxygen at 3L continuous and acknowledged the oxygen was set at 2.5L instead of the ordered rate. The ADON and DON also confirmed that all residents' oxygen should be administered at the ordered rate.
Missing Ombudsman Posting
Penalty
Summary
The facility failed to post the name, address, and telephone numbers of the Office of the State Long-Term Care Ombudsman program in a form and manner accessible and understandable to residents and resident representatives. During an observation on 07/28/2025 at 9:45 a.m., no posting or signage of the required Office of the State Long-Term Care Ombudsman Program information was seen in the facility. A later observation throughout the facility at 9:50 a.m. with S3ADON confirmed that there was no information regarding the Office of the State Long-Term Care Ombudsman Program posted in the facility. The deficiency was identified as affecting any of the 71 residents residing in the facility.
Inaccurate MDS Assessment for Fall History
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically in the coding of falls in the Minimum Data Set (MDS) assessment. A resident, who was admitted with diagnoses including age-related osteoporosis and an unspecified disorder of adult personality and behavior, suffered a displaced intertrochanteric fracture of the right femur. This incident occurred after a fall, leading to hospitalization and subsequent return to the facility. However, the resident's Quarterly MDS, with an Assessment Reference Date of December 23, 2024, did not reflect this fall in Section J1700: Fall History, which was left blank. Interviews with the responsible RN and the Director of Nursing confirmed the oversight in coding the fall history, acknowledging that the MDS assessment should have included this information.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised following a fall incident. Specifically, the care plan for a resident with age-related osteoporosis was not updated with new interventions after the resident experienced an unwitnessed fall in the day room. The incident report and nurse's notes from the date of the fall indicated that the resident was found lying on her left side and was unable to explain how the fall occurred. Despite this, the only intervention added to the care plan was to send the resident to the local hospital for evaluation, which did not address the need for preventive measures to mitigate future falls. Interviews with facility staff revealed that the responsibility for updating the care plan lay with a registered nurse, who acknowledged that the care plan was not revised to include new interventions after the fall. The Director of Nursing confirmed that although bright signs were placed in the resident's room to remind her to ask for assistance, this intervention was not documented in the care plan. This oversight indicates a failure to adhere to the facility's policy, which requires the fall care plan to be updated with interventions after each fall to prevent subsequent incidents and reduce the risk of serious injuries.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards by not properly labeling oxygen tubing and humidifier bottles for four residents receiving oxygen therapy. The facility's policy required that oxygen tubing, humidifiers, and nebulizer sets be changed every Sunday night by the night shift nursing staff and labeled with the date of change. However, observations revealed that the oxygen tubing and humidifier bottles for all four residents were not labeled with the date they were last changed. Resident #11, who had a diagnosis of heart failure, was observed wearing oxygen via nasal cannula without a date on the tubing. Similarly, Resident #43, with chronic obstructive pulmonary disease and acute respiratory failure, and Resident #62, with chronic obstructive pulmonary disease and congestive heart failure, were both observed with unlabeled oxygen tubing and humidifier bottles. Resident #64, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, also had unlabeled oxygen tubing. Interviews with nursing staff confirmed the lack of labeling and the failure to adhere to the facility's policy.
Failure to Store and Discard Expired Dietary Supplements
Penalty
Summary
The facility failed to store, prepare, and distribute food and dietary supplements under sanitary conditions, as observed during a survey. The facility's policy requires that all foods stored in the refrigerator or freezer be covered, labeled, and dated with a use-by date. Additionally, food items and snacks kept on nursing units must be maintained at or below 41 degrees Fahrenheit and labeled with a use-by date. Beverages must be dated when opened and discarded after 24 hours. However, during an observation of Med Storage Room B and the nursing station's refrigerator, it was found that several dietary supplements and a milk carton were past their expiration dates and had not been discarded as required. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed the observations. The DON acknowledged that the facility failed to store food and dietary supplements properly, and confirmed that all food products and supplements should be used by the expiration date and discarded within 24 hours of opening. The LPN also confirmed the presence of an expired supplement on Med Cart C, which should have been discarded. The facility administrator was informed of these findings and confirmed that the expired items should have been discarded prior to their expiration dates or within 24 hours after opening.
Failure to Obtain Midline Catheter Care Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not obtaining device site care orders for a midline catheter. The facility's policy required routine care and dressing changes for peripherally inserted central catheter lines every seven days to prevent infection. However, for one resident, there was no documentation of site monitoring or dressing changes for the midline catheter, and no physician's orders were obtained for these necessary procedures. The resident, who was admitted with diagnoses including Dementia, Severe Sepsis without Septic Shock, Bacteremia, and Urinary Tract Infection, had a midline catheter placed. Observations revealed that the dressing on the catheter was overdue for a change, and the date on the dressing was illegible. Interviews with staff confirmed that the necessary orders for site monitoring and care were not obtained, and the responsibility to do so was acknowledged by the Director of Nursing and a Licensed Practical Nurse who was present when the catheter was placed.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently maintained and accurately reflected throughout the clinical record. This deficiency was identified for one resident during an initial screening of 25 residents. The resident in question had conflicting code status orders in their medical records. The active physician orders indicated CPR LaPOST, while the hard chart contained a DNR LaPOST. This discrepancy was confirmed during interviews with facility staff, including an LPN, a social worker, and the Director of Nursing (DON). The LPN and DON both stated that the protocol for verifying a resident's code status involved checking the hard chart or the electronic health record, depending on the resident's location within the facility. However, the electronic health record incorrectly listed the resident's code status as CPR LaPOST, which did not match the DNR LaPOST in the hard chart. The social worker, responsible for updating code statuses in the electronic health record, confirmed that the resident's status should have been updated to DNR but was not. This inconsistency in the resident's code status documentation could lead to inappropriate medical interventions.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff. Specifically, a Licensed Practical Nurse (LPN) was observed administering a bolus tube feeding to a resident without wearing the required gown, despite the resident being on Enhanced Barrier Precautions (EBP). The EBP sign on the resident's door clearly indicated that a gown was necessary for direct, hands-on care. The resident in question was admitted with diagnoses of Functional Quadriplegia and Gastrostomy Status. During an interview, the LPN acknowledged the failure to wear a gown and recognized the requirement to do so. The Director of Nursing (DON) confirmed the necessity of wearing both a gown and gloves for such procedures and expressed the expectation that all staff adhere to these precautions.
Failure to Document Nurse Staffing Data
Penalty
Summary
The facility failed to ensure compliance with nurse staffing data requirements on daily postings, which had the potential to affect any of the 71 residents residing in the facility. On 08/19/2024, an observation of the staffing data sheet revealed that it lacked documentation of the facility census. Further review of staffing data sheets from 08/16/2024 to 08/18/2024 showed no documentation of the facility census or the actual hours worked by nursing staff. Interviews conducted on 08/19/2024 with S8ADON and S1ADM confirmed the absence of required information on the staffing data sheets. S8ADON stated she was unaware that the staffing data sheet required the facility census and actual hours worked for nursing staff, and both she and S1ADM confirmed these details were not documented.
Failure to Complete and Transmit Discharge/Transfer MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion and transmission of a Discharge/Transfer MDS assessment for a resident who was sent to the hospital and did not return. The resident was admitted to the facility and later transferred to the hospital on March 21, 2024. However, the required MDS assessment was not electronically transmitted as mandated. During an interview, the RN responsible for completing and transmitting MDS assessments confirmed that the assessment for the resident was not completed. Additionally, the Director of Nursing also confirmed the oversight, acknowledging that the assessment should have been completed and transmitted.
Failure to Provide Appropriate Call Light for Resident with Hand Contractures
Penalty
Summary
The facility failed to ensure that a resident with hand contractures had an appropriate call light to notify staff for assistance. Resident #2, who was moderately cognitively impaired and had mild bilateral hand contractures, was observed to be unable to use the standard squeeze bulb call light due to his condition. Despite multiple staff members being aware of the resident's inability to activate the call light, no alternative call light was provided, and the issue was not reported to higher authorities for resolution. Interviews with various staff members, including CNAs and LPNs, confirmed that they were aware of the resident's difficulty but did not take appropriate action to address the problem. The resident's call light log showed no usage from April 1, 2024, to May 1, 2024, further indicating that the resident was unable to call for assistance during this period. Observations and interviews conducted on May 1 and May 2, 2024, revealed that Resident #2's hands were contracted to the extent that he could not squeeze or press the bulb call light. Staff members, including CNAs, LPNs, and the ADON, confirmed the resident's inability to use the call light due to his hand contractures. The DON stated that she expected staff to report when a resident was unable to activate their call light and confirmed that other call lights were available to accommodate residents' needs. However, no action was taken to provide an appropriate call light for Resident #2, resulting in a failure to reasonably accommodate his needs and preferences.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status. Specifically, Resident #1, who was admitted with a diagnosis of repeated falls, experienced two falls on 03/10/2024. The Admission MDS assessment for Resident #1, with an ARD of 03/11/2024, did not accurately reflect these falls. The MDS assessment indicated only one fall without injury, despite the resident having two falls, one of which resulted in skin tears, as documented in the nurse's notes and the facility's incident log. Interviews with the LPN and MDS coordinator confirmed that the resident had two falls on 03/10/2024, and the second fall resulted in skin tears, which should have been coded as an injury on the MDS assessment. The Director of Nursing also verified that the resident's MDS assessment was not accurately coded to reflect the fall with injury. This discrepancy indicates a failure in the facility's process for ensuring accurate resident assessments.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement appropriate interventions, monitor the effectiveness of interventions, and modify interventions following a fall for one resident. The resident, who had a history of Hemiplegia following a Cerebral Infarct and mild contractures to bilateral hands, experienced multiple falls. Despite being instructed to call for assistance, the resident was unable to use the call light due to his condition, and his bed was often found in a high position, contrary to the care plan's instructions to keep it in a low position. Staff interviews confirmed that the resident required total assistance for all activities of daily living (ADLs) and was unable to use the call light effectively, yet no alternative interventions were implemented to address these issues. The resident's care plan included instructions to keep personal items within reach, keep the bed in a low, locked position, and ensure the call button was accessible. However, incident reports revealed that the resident fell multiple times while attempting to reach for items or move without assistance. Immediate actions taken after each fall included educating the resident on the importance of calling for assistance, but these measures were ineffective due to the resident's inability to use the call light. Observations and interviews with staff confirmed that the resident's bed was often in a high position, and the call light was not usable by the resident due to his hand contractures. Interviews with various staff members, including CNAs, LPNs, and the ADON, revealed a lack of communication and failure to implement effective fall prevention measures. The staff were aware of the resident's inability to use the call light and the need for total assistance, yet no alternative safety measures were put in place. The ADON and DON confirmed that they were not notified of the resident's inability to use the call light and acknowledged that the current fall prevention interventions were ineffective. The facility's failure to address these issues resulted in repeated falls and potential injury to the resident.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 64 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lacombe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor Of Mandeville | 8.4 mi | ★★★★★ | 5 | 0 |
| Trinity Trace Community Care Center | 10.5 mi | ★★★★★ | 4 | 0 |
| Pontchartrain Health Care Center | 10.7 mi | ★★★★★ | 3 | 0 |
| Greenbriar Community Care Center | 10.8 mi | ★★★★★ | 3 | 0 |
| Lakeshore Manor Nursing & Rehab | 11.2 mi | ★★★★★ | 10 | 2 |
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