Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Lady Of The Oaks Retirement Manor during CMS and state inspections, most recent first.
Failure to Provide Required Grooming and Hygiene Assistance: Four residents who required staff help with ADLs were observed without needed grooming care. One resident had dirty fingernails with caked debris, two residents had greasy, uncombed or matted hair, and one resident had excessive facial hair that had not been shaved after a shower. Staff and the DON confirmed the grooming care had not been provided as expected under the residents’ care plans and AM care policy.
Food service practices were not followed when an S8DA served residents with exposed facial hair, food in the cooler and freezer was left unlabeled, undated, and improperly sealed, and the kitchen had visible lint, residue, and debris in multiple areas. The fryer contained food particles in grease, the steam table had missing knobs while food was being served, and hot menu items were observed at 130 degrees F instead of the required holding temperature.
Infection control failures were observed when a dirty trash can was placed on a resident’s bed, an LPN did not perform hand hygiene between medication passes and after touching her face and equipment, and staff did not follow EBP for two residents during transfers, bathing, and feeding. Staff and leadership confirmed the missed hand hygiene and PPE use, and one resident’s care plan and diagnoses indicated the need for EBP.
Failure to Document Resident Grievance for Missing Clothing: A cognitively intact resident with DM, PVD, and COPD reported missing pants, shirts, and underwear, but no grievance was filed in the complaint log. Staff confirmed the resident told housekeeping about the missing clothing, yet the complaint was not documented or escalated to the supervisor, and the ADM confirmed a grievance should have been filed the same day.
A resident with bipolar disorder and major depressive disorder was not referred for a PASARR Level II evaluation. The Level I PASARR and psychiatric note listed major depressive disorder and stated a Level II decision was not required, but bipolar disorder was not included on the form, and there was no evidence a Level II was completed. An S5SSD confirmed the Level II PASARR was not completed.
A resident with ESRD, CHF, a left forearm laceration, and left arm edema was found in bed with the arm swollen and not elevated, despite an order to elevate the arm every shift. The resident’s left forearm dressing was also not changed as ordered daily, and staff interviews showed the CNA was not informed of the elevation need and an LPN did not elevate the arm during morning medication administration.
Medication administration failed to meet professional standards when an LPN left morning meds at the bedside for two residents and did not observe them swallow the medications. Both residents had intact cognition but had not been assessed or approved for self-administration, and the DON confirmed the nurse should have remained with them to ensure the meds were taken.
Incomplete and inaccurate daily staffing posting: Surveyors observed that the staffing board was outdated and the daily staffing log was incomplete, missing the census number and hours of service. An CNA was listed on the day shift assignment but was not on the hall, and an RN stated she was unaware the CNA had called in. A WC confirmed the daily staffing had not been posted and said the night shift was supposed to post it.
Staff did not follow care plans and physician orders for three residents, including not providing a prescribed thickened diet to a resident with dysphagia, failing to assist another resident with meal setup and serving inappropriate fluids for a renal diet, and not maintaining required ear cushions on a nasal cannula for a resident with respiratory conditions. Multiple staff confirmed these lapses during interviews and observations.
Surveyors found that kitchen staff did not label or date opened food items in the walk-in cooler, and expired or spoiled foods were not discarded as required by facility policy. The Dietary Supervisor confirmed these lapses, which included unlabeled cheese, milk, and lettuce, as well as expired taco shells, red liquid, hash browns, and cut okra.
Two residents who were unable to perform their own ADLs did not receive timely incontinence care as required by their care plans and facility policy. One resident was left in a wet brief from the previous night until the following morning, despite requesting assistance, and another was found in a wet brief late in the morning after not being checked or changed since early morning. Staff interviews confirmed that required checks and changes were not performed.
A resident with impaired cognition and multiple health conditions was found with an exposed black wire hanging from the ceiling over her bed for several weeks. Staff were aware of the issue but failed to report or address it, and the Maintenance Supervisor only responded to logged requests, resulting in an unsafe and non-homelike environment.
A resident with hemiplegia and aphasia, requiring two-person assistance for toileting, was neglected when a CNA failed to provide timely incontinence care. The CNA did not perform scheduled rounds or seek help from available staff, leaving the resident in distress. Despite a grievance being filed, the resident reported no improvement in care.
The facility failed to accurately complete the MDS for a resident with multiple diagnoses, including Cerebral Infarction and Hemiplegia. Despite a physician order to maintain a bed alarm every shift, the Quarterly MDS assessment incorrectly indicated that no bed alarm was in use. This was confirmed by the MDS Lead Coordinator.
The facility failed to implement person-centered care plans for three residents, leading to deficiencies such as not repositioning a resident at high risk for skin breakdown, not including a hand roll intervention in a care plan, and not ensuring a bed alarm was functioning correctly.
The facility failed to ensure that a resident's enteral feeding bag was changed within the required 24-hour period. An LPN and the DON confirmed that the bag, dated 04/07 at 8:00 a.m., should have been changed before 8:00 a.m. the following day, but it was not.
A resident with a known allergy to morphine received the medication multiple times due to the nursing staff's failure to review allergies before administration. Despite clear documentation of the allergy, LPNs administered morphine from February to April 2024, and the DON confirmed that proper procedures were not followed.
The facility failed to ensure an RN provided services for 8 consecutive hours on a weekend for two days. Review of the PBJ Data time sheet revealed no RN staffing hours, and the DON confirmed the absence of RN coverage for those dates.
The facility failed to coordinate care for a resident by not obtaining necessary hospice documentation, including a hospice election form, a hospice plan of care, and a physician's certification of terminal illness.
The facility failed to maintain the cleanliness of a medication cart. The left two lower drawers of the cart contained bottles of medication in plastic bags, which were stuck to the bottom of the drawers with a thick, sticky substance. The DON confirmed the drawers were not clean and needed to be cleaned.
Failure to Provide Required Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure residents who were unable to perform activities of daily living received the necessary assistance to maintain good grooming and personal hygiene. The deficiency involved four residents reviewed for ADL care, all of whom had care plans directing staff to assist with hygiene and grooming tasks, and facility policy stated that AM care would be provided daily and as needed, including shaving when applicable and assisting with combing and brushing hair. Resident #3 had diagnoses including other intervertebral disc degeneration, obstructive and reflux uropathy, and venous insufficiency. His MDS showed moderate cognitive impairment and dependence on staff for personal hygiene. During observations on two consecutive days, his fingernails were dirty with a dark brown caked substance underneath the outgrown nails, and he stated he could not remember the last time his fingernails were cleaned and that staff did not clean them. The DON confirmed the nails were dirty and should have been cleaned. Resident #86 had dementia and severe cognitive impairment, and was observed with greasy, disheveled, uncombed hair in the dining room and later in her room with the hair still uncombed and greasy. Resident #91 had dementia, anxiety, muscle weakness, and contractures, with severe cognitive impairment, and was observed on two days with uncombed, matted hair that remained unchanged. Staff confirmed both residents’ hair was uncombed and stated residents were supposed to have their hair combed after being dressed for the day. Resident #104 had cerebral infarction with hemiplegia, dysarthria, anxiety, depression, and cognitive communication deficit, and was cognitively intact but dependent for shaving. She was observed with long facial hair on her neck, cheeks, chin, and around her mouth; she indicated she knew about the facial hair, wanted staff to shave her face, and that staff had not shaved her after her shower. An LPN and the DON both confirmed she should have been shaved and needed to be shaved.
Food Storage, Kitchen Cleanliness, and Temperature Control Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the facility kitchen and serving areas. During breakfast service, S8DA was observed serving residents with his mustache and facial hair exposed, and S7DA and S8DA confirmed the facial hair needed to be covered. In the kitchen cooler and freezer, food items were found unlabeled, undated, opened, and not sealed, including shredded lettuce that was wilted with brown areas and frozen diced chicken in opened bags. The cooler fan also had visible lint on its exterior surface. The kitchen environment and equipment were also observed to be in poor condition. The fryer had visible particles in grease, and the stainless steel wall behind the stove and fryer had visible lint and residue. Behind ice machine #2, lint remained on the wall and floor across multiple observations, and two plastic resident pitchers were on the floor behind the machine. The steam table in the communal dining room had three missing turn knobs while food was being served from it, and during lunch meal monitoring, pureed chicken, mashed potatoes, and pureed vegetables were held at 130 degrees F.
Infection Control Failures During Resident Care and Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. One event involved Resident #115, whose room was observed with a yellow wet floor sign at the entrance and a black trash can with a white plastic bag liner placed on the resident’s bed while the resident was not in the room. Staff confirmed the trash can should not have been on the bed, and the ADON/IP stated that germs could have been transferred from the dirty trash can to the bed. During medication administration, an LPN was observed touching a resident’s door knob, returning to the medication cart, and dispensing medications without performing hand hygiene. The LPN also touched her nose and the computer screen without sanitizing her hands, then administered medications to another resident and returned to the cart without sanitizing her hands. She was later observed entering another resident’s room to give medications and again returned to prepare the next resident’s medications without sanitizing her hands. The LPN confirmed she had not performed hand hygiene between residents and stated she should have. The ADON/IP also confirmed nursing staff should perform hand hygiene between residents during medication administration. The facility also failed to follow Enhanced Barrier Precautions for residents identified as requiring them. One resident had diagnoses including anemia with chronic kidney disease, type 2 diabetes mellitus with chronic kidney disease, and Alzheimer’s disease, and his care plan indicated a condition warranting EBP. Staff transferred him from bed to wheelchair without gowns, and another observation showed a CNA feeding him without hand hygiene before the meal. A second resident had diagnoses including ileostomy status, encephalopathy, conjunctivitis, and urinary tract infection, and his care plan also indicated a condition or device warranting EBP. Staff provided bathing care and transfers without gowns, and one staff member did not wear gloves during transfer. Staff and the ADON/IP confirmed that gowns and gloves should have been used for the resident’s high-contact care.
Failure to Document Resident Grievance for Missing Clothing
Penalty
Summary
The facility failed to file a grievance for a complaint of missing clothing for one resident. Resident #96, who was cognitively intact with a BIMS score of 14 and had diagnoses including type 2 diabetes mellitus with diabetic nephropathy, peripheral vascular disease, and chronic obstructive pulmonary disease, reported that he could not find 3 pairs of pants, 2 shirts, and 1 pair of underwear. He stated he told someone in laundry about the missing clothes, but could not remember who he told. The resident grievance/complaint log for May 2026 showed no grievance filed for him. Interviews confirmed the complaint was known to staff but was not documented as a grievance. A housekeeping staff member confirmed the resident told her he was missing clothes and stated she did not document the complaint or tell her supervisor, even though the supervisor was at work that day. Housekeeping and supervisory staff confirmed the clothing was being looked for, and the administrator confirmed a grievance should have been filed the same day the complaint was made and that housekeeping should have filed it the same day.
Failure to Complete PASARR Level II Evaluation for Qualifying Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with qualifying diagnosed mental disorders was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. Resident #29 was admitted with diagnoses including bipolar disorder and major depressive disorder. Review of the resident’s PASARR Level I evaluation dated 06/22/2020 showed a psychiatric progress note from 02/03/2020 listing the current diagnostic impression as major depressive disorder and stating that a Level II decision was not required, but the bipolar disorder diagnosis was not included on the form. The resident’s clinical record contained no evidence that a PASARR Level II was completed for the bipolar disorder diagnosis. During interview, S5SSD stated that the Level II PASARR was not completed because the Level I evaluation did not include bipolar disorder and confirmed that a Level II evaluation was not completed.
Failure to Follow Wound Care and Edema Orders
Penalty
Summary
The facility failed to implement Resident #18’s plan of care and physician’s orders by not changing the left forearm dressing daily and by not elevating the resident’s swollen left arm while she was in bed. The resident was admitted with diagnoses including end stage renal disease, chronic diastolic congestive heart failure, a laceration of the left forearm, localized swelling of the left upper limb, and dependence on renal dialysis. Current orders directed staff to elevate the left arm in bed every shift for edema and to cleanse the left forearm wound, apply triple antibiotic ointment, and cover it with a dressing once daily. Observations showed the resident lying in bed with the left arm swollen and not elevated on two separate occasions. During the first observation, the left forearm had a white dressing with a transparent border dated 5/15 and initialed DA. The wound nurse confirmed she changed the dressing on 5/15 and stated it should have been changed on 5/16 and again on 5/17 by the weekend treatment nurse because it was ordered daily. Staff interviews confirmed the swelling and that the arm was not elevated, and a CNA stated she had not been informed by the nurse that the arm needed to be elevated. An LPN stated the swelling was ongoing and that she had gone into the room to give morning medications but did not elevate the arm.
Medication Left at Bedside Without Observation
Penalty
Summary
The facility failed to ensure medication administration met professional standards of quality when medications were left at the bedside for two residents who had not been assessed and approved for self-administration. Resident #40 was admitted with diagnoses including radiculopathy, COPD, type 2 diabetes mellitus without complications, paroxysmal atrial fibrillation, anxiety disorder, and cardiomyopathy, and her most recent BIMS score was 14, indicating intact cognition. During observation, S14LPN administered the resident’s morning medications, left a medication cup on the bedside table, and exited the room without observing the resident swallow the medications. Review of the electronic health record showed the resident had not been assessed and approved for self-administration of medication. Resident #61 was admitted with diagnoses including unilateral primary osteoarthritis of the left knee, hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, generalized anxiety disorder, and dysphagia following cerebral infarction, and her most recent BIMS score was 13, indicating intact cognition. During observation, S14LPN administered the resident’s morning medications, left a medication cup on the bedside table, and exited the room without observing the resident swallow the medications. The resident’s record also showed she had not been assessed and approved for self-administration. In interview, S14LPN stated she left both residents’ medications with them because she did not have to watch them take their medications and was not aware of a facility policy prohibiting this practice. The DON confirmed the nurse should not have left the medications with the residents and should have remained with them to ensure they took all of their medications.
Incomplete and inaccurate daily staffing posting
Penalty
Summary
The facility failed to ensure that nurse staffing information was complete, accurate, and posted daily when its census was 105. On 05/17/2026 at 8:43 a.m., surveyors observed that the staffing information posted on the bulletin board was dated Wednesday, 05/13/2026, while the Daily Nursing Assignment log was dated 05/17/2026. The posted information was not complete or accurate and did not include a census number or the hours of services to be provided. Staff member S27CNA was listed on the day shift Daily Nursing Assignment log dated 05/17/2026 but was not present on the hall. During interviews, S9RNS stated she was not aware that S27CNA was not present at the facility, then later stated that S27CNA had called in but this was not reported to her. S9RNS also stated that an overall accurate daily staffing posting had not been posted and she had not seen one. S10WC confirmed that the daily staffing had not been posted and stated that the night shift was supposed to post it, but it was not posted.
Failure to Follow Care Plans and Physician Orders for Diet, Oxygen, and Equipment
Penalty
Summary
Facility staff failed to follow physician orders and care plan interventions for three residents, resulting in deficiencies related to diet, oxygen therapy, and assistance with meals. One resident with diagnoses including encephalopathy, dementia, Alzheimer's disease, and dysphagia was observed receiving milk that was not thickened as required by her prescribed pureed, nectar-thickened diet. Staff interviews confirmed that the milk should have been thickened, and the dietary manager stated that CNAs were responsible for ensuring correct diets and fluids were provided. Another resident with alcoholic cirrhosis, dyspnea, and chronic kidney disease was not assisted with meal tray setup as required by her care plan, and was served orange juice despite being on a renal diet, which was confirmed by both the CNA and dietary manager. Additionally, this resident was observed multiple times without her prescribed oxygen therapy, with her oxygen concentrator turned off and her oxygen saturation levels dropping to 84% before staff reapplied oxygen as ordered. A third resident with chronic obstructive pulmonary disease and acute respiratory failure had a physician's order and care plan intervention for maintaining bilateral ear cushions on her nasal cannula. Multiple observations throughout the day revealed that the resident was wearing a nasal cannula without the required ear cushions, and this was confirmed by an LPN during interview and record review.
Failure to Properly Store and Discard Food Items
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards and did not maintain sanitary conditions in the kitchen. During a tour of the kitchen, several opened food items in the walk-in cooler, including mayonnaise, sliced cheddar cheese, shredded cheddar cheese, whole milk, and shredded lettuce, were found without labels indicating the date and time they were opened. The shredded lettuce was visibly spoiled, and additional items such as taco shells and a tray of red liquid were found to be expired or undated. The facility's own policies require all opened foods to be labeled with the name and date stored, and for expired foods to be discarded, but these procedures were not followed. Further inspection of the walk-in freezer revealed an opened bag of hash browns and a large, unsealed bag of cut okra, both of which were past their expiration dates. The Dietary Supervisor confirmed that these items were expired and should have been discarded. The failure to properly label, date, and discard expired or spoiled food items demonstrates non-compliance with both facility policy and professional food safety standards.
Failure to Provide Timely Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically incontinence care, for two residents who were unable to perform these tasks independently. One resident, with diagnoses including atherosclerosis, type 2 diabetes, and overactive bladder, was found to have not been changed since the previous night despite being frequently incontinent of urine and always incontinent of bowel. The resident reported asking for assistance in the morning, but no staff responded. The assigned CNA confirmed she had not checked or changed the resident since starting her shift and had not been informed of the need. Facility policy required incontinence care to be performed as needed and residents to be checked at least every two hours, but this was not followed. Another resident, dependent on staff for toileting hygiene due to Parkinson's disease and other conditions, was observed in a wet brief late in the morning, having last been changed around 5 A.M. The resident confirmed he had not been checked or changed since then. An LPN checked the resident's brief, found it wet, but did not change it, instead stating she would get the CNA to do so. The LPN later acknowledged she should have changed the resident at that time. Both residents had care plans indicating the need for regular assistance and checks for incontinence, which were not adhered to by staff.
Failure to Maintain Safe and Homelike Resident Environment Due to Exposed Electrical Wire
Penalty
Summary
A deficiency was identified when a resident with impaired cognition, muscle weakness, and Chronic Obstructive Pulmonary Disease was found to have a black wire hanging from the ceiling over her bed, with the connector exposed and within close proximity to her while she was lying down. The resident reported that the wire had been present since she moved into the room several weeks prior, and that it sometimes touched her while she was in bed. Observations on two separate days confirmed the presence of the exposed wire in the resident's environment. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) was aware of the wire but did not report it to the nurse or log it in the maintenance system, as required by facility protocol. The Maintenance Supervisor confirmed responsibility for environmental repairs but stated he only addressed issues listed in the maintenance log and did not conduct regular rounds in resident rooms. Both the CNA and Maintenance Supervisor acknowledged that the exposed wire created an environment that was not homelike and should not have been present near the resident.
Neglect in Incontinence Care for a Resident
Penalty
Summary
The facility failed to protect a resident from neglect by not providing timely incontinence care. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, and aphasia, was cognitively intact and required assistance from two or more staff for toileting. Despite being always incontinent of bowel and bladder, the resident did not receive the necessary care, leading to emotional distress. On the day of the incident, the CNA responsible for the resident did not perform the required two-hour rounds. The CNA acknowledged that she was aware of the resident's need for assistance but failed to seek help from available staff, including other CNAs, the nurse, or the ADON. Instead, she turned off the call light without completing the task and did not return to change the resident before the end of her shift. Interviews with the ADON and DON confirmed that the CNA did not follow protocol, which required leaving the call light on until the task was completed. The resident confirmed through nonverbal communication that she was left wet for extended periods and was upset by the lack of care. Despite the grievance filed, the resident indicated that there had been no improvement in the care provided.
Inaccurate MDS Assessment for Bed Alarm Usage
Penalty
Summary
The facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for one resident. The resident, who was admitted with multiple diagnoses including Cerebral Infarction, Hemiplegia, Restlessness, Generalized Anxiety Disorder, and Muscle Weakness, had a physician order to maintain a bed alarm every shift. However, the Quarterly MDS assessment inaccurately indicated that no bed alarm was in use. This discrepancy was confirmed during an interview and record review with the MDS Lead Coordinator.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for three residents, leading to deficiencies in their care. Resident #47, who was at high risk for skin breakdown due to conditions such as diabetes and dementia, was not repositioned every two hours as required. Despite the care plan indicating the need for staff assistance with bed mobility, observations showed the resident remained on her back for extended periods, and interviews with CNAs confirmed that the resident was not turned as needed during their shifts. The Director of Nursing verified that the resident required assistance with turning and repositioning, which was not provided by the staff. Resident #72, diagnosed with dementia, epilepsy, and muscle weakness, had a physician's order for the use of a hand roll to prevent contractures. However, the care plan did not include this intervention. The Minimum Data Set Nurse confirmed that the care plan was incomplete and should have included the hand roll intervention. This oversight meant that the resident's specific needs were not fully addressed in the care plan. Resident #77, who had a history of stroke and was at risk for falls, had a physician's order for a bed alarm to be checked every shift. Observations revealed that the bed alarm was not functioning correctly, with a frayed wire and no bed alarm mat present under the resident. Interviews with the CNA and the Director of Nursing confirmed that the bed alarm was not in proper working condition and should have been monitored by the nurses every shift. This failure to ensure the bed alarm was operational compromised the resident's safety and risk management plan.
Failure to Change Enteral Feeding Bag as Required
Penalty
Summary
The facility failed to ensure that a resident's enteral feeding was properly changed. Resident #61, who was admitted with multiple diagnoses including Traumatic Subdural Hematoma, Alzheimer's Disease, and Gastrostomy status, had a physician's order for Isosource 1.5 at 45 ml/hr continuously. On 04/08/2024, observations revealed that the resident's tube feeding bag, dated 04/07/2024 at 8:00 a.m., had not been changed within the required 24-hour period. An LPN confirmed that the bag should have been changed before 8:00 a.m. on 04/08/2024, and the Director of Nursing corroborated this requirement. The failure to change the feeding bag as per protocol was identified during the survey.
Failure to Ensure Nursing Staff Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that the nursing staff were competent in administering medications, resulting in a resident with a known allergy to morphine receiving the medication. The resident, who was on hospice care with a diagnosis of End Stage Parkinson's disease, had her allergy to morphine clearly documented on her face sheet, care plan, and Medication Administration Record (MAR). Despite this, Licensed Practical Nurses (LPNs) administered morphine to the resident on various occasions from February to April 2024. The nurses did not review the resident's allergies before administering the medication, and the hospice nurse had instructed them to give morphine to keep the resident comfortable as needed. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the nurses were aware of the resident's allergy but failed to follow proper procedures. The DON stated that the procedure for administering medications should have included reviewing the resident's allergies listed at the top of the MAR and contacting the physician for clarification if there was an order for a medication to which the resident was allergic. The failure to adhere to these procedures led to the administration of morphine to a resident with a documented allergy to the medication.
Failure to Ensure RN Coverage for 8 Consecutive Hours on a Weekend
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day on a weekend for two days. Review of the facility's Payroll Based Journal (PBJ) Data time sheet for the dates of 10/21/2023 and 10/22/2023 revealed that there were no staffing hours recorded for an RN. An interview with the Director of Nursing (S1DON) confirmed the absence of RN staffing hours for those dates, and no evidence was provided to show that an RN worked the required hours on those days.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to coordinate care for a resident by not obtaining pertinent information from the hospice agency. Specifically, the clinical record for a resident admitted with diagnoses of Cerebral Infarction and Pneumonitis due to Inhalation of Food and Vomit lacked a hospice election form, a hospice plan of care, and a physician's certification of the resident's terminal illness. This deficiency was confirmed by the Assistant Director of Nursing during a review of the resident's clinical record.
Unclean Medication Cart
Penalty
Summary
The facility failed to maintain the cleanliness of a medication cart (MC1) as observed on 04/09/2024 at 9:59 a.m. The left two lower drawers of MC1 contained bottles of medication in plastic bags, which were stuck to the bottom of the drawers. The second to last drawer had four bottles of medication in plastic bags, with the bottom of the drawer covered in a reddish gold sticky substance. When the bottles and plastic bags were picked up, the thick, sticky liquid adhered to the surveyor's fingers. The bottom drawer had three bottles of medication in plastic bags, similarly stuck to the bottom of the drawer with a thick reddish sticky substance. The Director of Nursing (S1DON) confirmed that the drawers were not clean and sanitary and needed to be cleaned.
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Illustrative
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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
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Nursing homes near Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Louisiana Extended Care Hospital Of Lafayette | 1.2 mi | ★★★★★ | 8 | 0 |
| Camelot Rehabilitation At Magnolia Park | 1.6 mi | ★★★★★ | 4 | 0 |
| River Oaks Retirement Manor | 3.8 mi | ★★★★★ | 3 | 0 |
| Amelia Manor Nursing Home | 3.8 mi | ★★★★★ | 5 | 0 |
| Cornerstone At The Ranch | 4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.