Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lagniappe Healthcare during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep medications secured and properly ordered, as required. One resident had three bottles of discontinued miconazole powder stored in the room despite no current physician order or MAR documentation. Another resident, with COPD, cardiac disease, hypertension, hyperlipidemia, dorsalgia, depression, GERD, and moderate cognitive impairment (BIMS 12), had ferrous sulfate tablets, Ofloxacin otic solution, and two inhalers (Albuterol sulfate and Ventolin HFA) on the bedside table, all containing available doses, even though there were no physician orders for these drugs or for them to be kept at bedside. An LPN confirmed the lack of orders, and the DON was notified of the unsecured, unordered medications.
The facility failed to obtain and document informed consent for psychotropic medications for two residents receiving Zoloft and Abilify. One resident with moderate cognitive impairment and multiple complex conditions, including respiratory failure, CKD, dysphagia, hemiplegia, malignancy, and cardiomyopathy, received Zoloft 25 mg daily via PEG for major depressive disorder per physician order, with MARs showing routine administration but no documented consent. Another resident with severe cognitive impairment, post-CVA hemiplegia, T2DM, coronary artery disease, bipolar disorder, and other comorbidities received Abilify 2.5 mg PO daily for bipolar disorder, again with MAR documentation of administration but no record of consent. Nursing staff confirmed during surveyor interviews that there was no documentation supporting that consent for these psychotropic medications had been obtained, indicating residents were not fully informed of their treatment in advance.
Two residents at high risk for falls did not receive care-planned safety interventions. One resident with dementia, Alzheimer’s disease, muscle weakness, and moderate cognitive impairment had a care plan requiring a stand-alone bathroom motion sensor to alert staff when the resident entered the bathroom; surveyors found the sensor on the floor, turned off, and not alarming while the resident was in the room. Another resident with hemiplegia after a cerebral infarction, severe cognitive impairment, and multiple comorbidities had a care plan requiring wheelchair brake extenders after a fall, but was observed seated in a manual wheelchair in the dining area without brake extenders, which was confirmed by an LPN and the DON.
Staff failed to follow the facility’s Enhanced Barrier Precautions policy requiring gown and glove use during high-contact care involving medical devices. A resident on EBP due to a PEG tube received a bolus feeding from an LPN who did not wear a gown, and another resident with an indwelling Foley catheter received catheter care from an LPN who wore gloves but not a gown. The DON later confirmed that gowns should have been used for these high-contact activities, showing that EBP was not consistently implemented during device care.
A resident with multiple medical conditions was improperly restrained with a lap tray on her wheelchair without a physician's order or pre-restraint assessment. The lap tray was not secured correctly, allowing the resident to move it, and staff failed to monitor and document its use as required by facility policy. Observations and staff interviews confirmed these deficiencies.
The facility failed to conduct timely and accurate assessments for residents, leading to deficiencies in care. A resident with an inhaler was not reassessed for self-medication capability, another with a pressure ulcer had inaccurate skin assessments, and a resident with loose dentures was not properly evaluated, affecting her ability to eat. Additionally, records inaccurately showed continued antibiotic treatment for a resident after it was discontinued.
A facility failed to monitor a resident for bleeding risks while on the anticoagulant Xarelto. The resident, diagnosed with atrial fibrillation and bradycardia, had no documented evidence of bleeding risk monitoring. This was confirmed by a nurse during an interview.
A facility failed to follow infection control standards by not using a gown during wound care for a resident under Enhanced Barrier Precaution (EBP). The EBP policy requires gowns and gloves for high-contact activities to prevent the spread of multi-drug resistant organisms. A Wound Care Nurse admitted to forgetting to don a gown during the procedure, contrary to the facility's policy.
Unsecured and Unordered Medications Found in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments and that discontinued medications were not kept in resident rooms. For one resident, review of February 2026 physician orders and the medication administration record showed no current order or documentation for miconazole powder, yet surveyors observed three bottles of miconazole powder in the resident’s room. The DON confirmed that the miconazole powder had been discontinued and acknowledged that the medication should not have been stored in the resident’s room. For another resident, admitted with multiple diagnoses including COPD, Takotsubo syndrome, atherosclerotic heart disease, hypertension, hyperlipidemia, dorsalgia, depression, and GERD, the admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment with daily decision-making. Review of physician orders revealed no orders for ferrous sulfate 325 mg tablets, Ofloxacin otic solution 0.3%, Albuterol sulfate inhalation aerosol, or Ventolin HFA 90 mcg/actuation. However, observations of the resident’s room with an LPN showed a labeled bottle of ferrous sulfate tablets on the side table on one day, and Ofloxacin otic solution, Albuterol sulfate inhalation aerosol, and Ventolin HFA inhaler on the side table on another day, all with doses available. The LPN confirmed there were no orders for these medications or for them to be kept at bedside, and the DON was informed of these findings.
Failure to Obtain and Document Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were fully informed about and consented to psychotropic medication treatment. For one resident admitted with multiple complex conditions including acute and chronic respiratory failure, diabetes with chronic kidney disease, dysphagia and hemiplegia following cerebral infarction, secondary malignant neoplasm of the large intestine and rectum, peripheral vascular disease, ischemic cardiomyopathy, and hypertension, the admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment with daily decision-making ability. This resident was receiving the psychotropic medication Zoloft 25 mg daily via PEG tube for major depressive disorder, initiated by physician order on 12/08/2025 and administered daily in January 2026 as documented on the MAR. On 02/11/2026, an LPN confirmed there was no documentation in the medical record to support that consent for Zoloft had been obtained. The facility also failed to obtain documented consent for psychotropic medication for another resident admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus without complications, atherosclerotic heart disease of native coronary artery without angina pectoris, bipolar disorder, hyperlipidemia, and anemia. The annual MDS showed a BIMS score of 6, indicating severe cognitive impairment with daily decision-making. This resident was receiving Abilify 2.5 mg by mouth daily for bipolar disorder, initiated by physician order on 07/21/2025 and administered daily in January 2026, except during hospitalization, as shown on the MAR. On 02/11/2026, an RN confirmed there was no documentation in the medical record to support that consent for Abilify had been obtained. These findings show the facility did not address the residents’ right to be informed in advance of the risks and benefits of psychotropic medication treatment and to provide consent.
Failure to Implement Care-Planned Fall Prevention Devices for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement person-centered care plan interventions for two residents identified as high fall risks. One resident with dementia, Alzheimer’s disease, muscle weakness, lack of coordination, and moderate cognitive impairment used a manual wheelchair and required assistance with ADLs. The resident’s care plan, updated after a fall, specified that therapy would screen the resident and that a stand-alone motion sensor would be placed in the bathroom to notify staff when the resident entered. During an observation, the resident was seated in a wheelchair in the room while the bathroom motion sensor was found lying on the floor and not alarming when someone walked in front of it. A subsequent observation with an LPN confirmed the motion sensor in the bathroom was not turned on while the resident was in the room. The second resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes, atherosclerotic heart disease, bipolar disorder, hyperlipidemia, and anemia, and used a manual wheelchair for mobility. This resident’s fall risk assessments identified a high risk for falls, and the care plan documented risk factors including weakness, history of falls, cognitive impairment, polypharmacy, psychotropic medication use, lack of safety awareness, and loss of mobility with hemiplegia. An approach added to the care plan after a fall required wheelchair brake extenders to be placed on the wheelchair. During observations in the main dining area, the resident was seen seated upright in the wheelchair without brake extenders in place, and both an LPN and the DON confirmed that the wheelchair brake extenders were not present as required by the care plan.
Failure to Implement Enhanced Barrier Precautions During High-Contact Device Care
Penalty
Summary
Facility staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring gown and glove use during high-contact resident care activities for residents on EBP. The policy specified that high-contact activities, including device care or use such as feeding tubes and urinary catheters, required the use of gown and gloves to prevent the spread of multi-drug resistant organisms. Resident #7 had an order placing the resident under EBP due to a percutaneous endoscopic gastrostomy (PEG) tube, and the care plan identified EBP for high-contact activities, including feeding tube care. During an observation of a bolus feeding via PEG tube at the bedside, an LPN administered the bolus without wearing a gown, despite later confirming that the resident was on EBP precautions due to the PEG. Resident #15 had diagnoses including urinary tract infections and hemiplegia and an order for an indwelling Foley catheter with catheter care to be provided each shift. During an observed catheter care episode, an LPN wore gloves but did not don a gown before performing the catheter care. In a subsequent interview, the DON confirmed that the LPN should have worn a gown prior to performing catheter care. These observations demonstrated that staff did not consistently implement the required EBP measures, specifically the use of gowns during high-contact care involving a PEG tube and an indwelling Foley catheter.
Improper Use of Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for discipline or convenience. The resident, who was admitted with multiple diagnoses including epilepsy, mild vascular dementia, and chronic kidney disease, was observed with a lap tray on her wheelchair that was not properly secured. The lap tray was intended to be used as a restraint but lacked a physician's order, a pre-restraint assessment, and specific interventions in the care plan. The facility's policy required these steps to ensure restraints were used appropriately and only for medical symptoms. Observations revealed that the lap tray was not fitted securely to the resident's wheelchair, with Velcro straps tied improperly to the wheelchair handles. The resident was able to move the lap tray, indicating it was not functioning as intended. Despite the presence of CNAs and an LPN, the issue was not addressed, and the lap tray remained improperly secured. The facility's policy required that restraints be monitored and released every two hours, but there was no documentation to confirm this was done. Interviews with facility staff, including the Director of Nursing and the MDS Nurse Coordinator, confirmed the lack of a physician's order, pre-restraint assessment, and proper documentation of monitoring and releasing the restraint. The staff acknowledged that the lap tray was not working effectively for the resident, and the necessary procedures outlined in the facility's restraint policy were not followed, leading to the deficiency.
Inaccurate and Untimely Resident Assessments
Penalty
Summary
The facility failed to ensure timely and accurate assessments for several residents, leading to deficiencies in care. One resident, who had an albuterol inhaler at her bedside, had not been reassessed for her ability to self-administer medications since July 2023, despite having chronic obstructive pulmonary disease and anxiety. This oversight was confirmed by the RN/MDS Coordinator, indicating a lapse in the regular evaluation of the resident's capability to manage her medications independently. Another resident, who was at high risk for pressure ulcers, had inaccurate weekly skin assessments documented by an LPN. Despite having a pressure ulcer that was being treated, the LPN's records repeatedly noted the resident's skin as intact, failing to acknowledge the existing condition. This discrepancy was confirmed by the DON, highlighting a significant gap in the monitoring and documentation of the resident's skin condition. Additionally, a resident with loose dentures was not accurately assessed upon admission, as the initial nursing evaluation and subsequent assessments failed to document the poor fit of her dentures. This oversight led to difficulties in chewing and sore gums, which were not addressed in the dietary assessment or communicated to the social services director. The DON later discovered that the dietary manager was aware of the issue but had not acted on it. Furthermore, another resident's records inaccurately reflected the continuation of an antibiotic treatment after it had been discontinued, due to nurses copying and pasting previous notes, as confirmed by the DON.
Failure to Monitor Anticoagulant Risks
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for bleeding risks. Resident #16, who had diagnoses of atrial fibrillation and bradycardia, was prescribed the anticoagulant medication Xarelto at a dosage of 15 milligrams daily. Upon review of the resident's medical record, there was no documented evidence that the facility was monitoring the resident for bleeding risks associated with the anticoagulant. This deficiency was confirmed during an interview with S3Registered Nurse/Minimum Data Set Coordinator, who acknowledged that nurses had not been monitoring resident #16 for bleeding risks.
Failure to Follow Enhanced Barrier Precaution During Wound Care
Penalty
Summary
The facility failed to adhere to infection control prevention standards by not following the Enhanced Barrier Precaution (EBP) policy during wound care for a resident. The EBP policy, dated August 2022, mandates the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the spread of multi-drug resistant organisms. On December 11, 2024, during an observation of wound care, the Wound Care Nurse did not don a gown before performing the procedure on a resident. After completing the wound care, the nurse confirmed in an interview that she had forgotten to wear the gown, acknowledging the oversight in following the EBP policy.
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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.
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Nursing homes near Bastrop
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherry Ridge | 0.6 mi | ★★★★★ | 0 | 0 |
| Legrand Healthcare And Rehabilitation Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Oak Woods Home For The Elderly | 5.4 mi | ★★★★★ | 0 | 0 |
| Avalon Place | 17.7 mi | ★★★★★ | 9 | 0 |
| St Joseph Skilled Nursing And Rehabilitation | 20.1 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.