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 Landmark Of Rayne during CMS and state inspections, most recent first.
Accurate medical records were not maintained when an LPN failed to sign out controlled medications on the narcotics record at the time they were given to five residents. During a narcotic count, the recorded tablet counts did not match the tablets observed for residents receiving meds such as acetaminophen with codeine, alprazolam/Xanax, and lacosamide, and the DON and RNS confirmed the documentation should have been completed at the time of administration.
Inaccurate Dental Assessment on Admission MDS: A resident with schizophrenia, depression, bipolar disorder, type 2 DM, COPD, and obesity was inaccurately assessed on the admission MDS for dental status. The resident had decayed and broken teeth with gum-level decay, and the dental eval documented broken natural teeth and inflamed or bleeding gums, but the MDS marked none of those conditions as present. The RN/AN responsible for the MDS confirmed the assessment was inaccurate.
Failure to follow a resident’s person-centered care plan for perineal skin sensitivity. A resident with dementia, severe cognitive impairment, and incontinence had a care plan stating staff were not to use perineal wash due to sensitivity, yet she was observed grimacing and reporting irritation in her private area, with red, irritated, raised skin noted on the groin and inner thigh. The daughter said the cleanser caused severe irritation, and staff confirmed an agency CNA had left perineal wash in the room after care.
Unsafe smoker left unsupervised while smoking: A resident with severely impaired cognition, hemiplegia, and substance-related diagnoses was identified as needing 1:1 supervision for smoking. Staff wheeled him to the smoking patio and left him there without supervision, and he was later observed with a lit cigarette. An ADON confirmed he was smoking unsupervised, and the RN confirmed he had left the resident alone despite knowing supervision was required.
Medication administration errors exceeded the allowed rate, with 2 errors in 25 observed opportunities. One resident with COPD and bipolar disorder did not receive Budesonide-Formoterol inhaler administration per manufacturer instructions when an LPN gave the inhaler without proper instruction and the resident used it without shaking between puffs or holding the breath as directed. Another resident with dementia and low vitamin D received only 1 Cholecalciferol tablet instead of the ordered 2 tablets, and the LPN confirmed the dose was incomplete.
Failure to perform hand hygiene and change gloves during wound care for a resident with stage 2 pressure injuries to both buttocks. An RN cleansed the wound, then applied collagen and a dressing without removing gloves or sanitizing hands between steps. The RN acknowledged the lapse, and the DON stated gloves should have been removed, hand hygiene performed, and new gloves donned before applying the dressing.
A resident with Alzheimer's disease and other neurological conditions had a documented DNR status in physician orders and advance directives, but the care plan continued to state 'Full Code.' Both MDS staff and the DON confirmed the care plan was inaccurate and had not been revised to reflect the resident's DNR status as required by facility policy.
The facility did not complete required MDS assessments, including quarterly, annual, admission, discharge, and death assessments, within the mandated 14-day timeframe for multiple residents. A review confirmed that these assessments remained incomplete and in progress past the regulatory deadline, as acknowledged by the staff member responsible for MDS.
The facility did not transmit completed MDS assessments to the State within the required 14-day timeframe for several residents. Completed assessments were delayed in submission, as confirmed by the MDS Nurse and CMS transmittal validation reports, resulting in noncompliance with mandated reporting timelines.
Dietary staff did not use the correct serving sizes for ham and beans and greens as specified in the diet spreadsheet, resulting in residents receiving less food than required. The dietary manager confirmed the use of incorrect scoop sizes, and the trays were not corrected before being served to residents on the secured unit.
Staff failed to follow Enhanced Barrier Precautions by not wearing required gowns during wound care and oral assessments for two residents on EBP. A treatment nurse did not don a gown or properly discard soiled PPE after wound care for a resident with arterial ulcers, and a CNA did not wear a gown while providing oral care to another resident. These lapses were acknowledged by staff and confirmed by the infection preventionist.
A resident's MDS assessment was inaccurately coded to indicate the use of a trunk restraint, despite no physician order or documentation supporting restraint use. Staff confirmed the error during record review and interview.
A resident with a serious mental illness and a Level II PASRR determination was admitted and approved for nursing home care, but the facility did not include the required PASRR considerations in the resident's comprehensive care plan. This omission was confirmed by the staff member responsible for care planning.
A resident with multiple chronic conditions and intact cognition was not invited to participate in care plan meetings, and there was no documentation of invitation or attendance. Staff interviews revealed that residents and their representatives were not consistently invited to care plan meetings, particularly following significant change assessments, contrary to facility policy.
The QAPI program did not document monitoring or performance tracking after implementing a corrective action plan to address task scheduling errors following a shift change. Despite auditing and staff in-servicing, there was no evidence of data collection or analysis to measure the plan's effectiveness.
Facility staff failed to conduct required weekly body audits for one resident at risk for pressure ulcers, resulting in an unrecognized Stage 2 ulcer that was only identified upon hospital admission. Additionally, another resident with a facility-acquired Stage II heel ulcer did not consistently receive ordered wound care treatments, with multiple missed applications documented over several weeks. The DON confirmed awareness of these missed treatments.
Narcotic Documentation and Count Discrepancies
Penalty
Summary
Accurate medical records were not maintained in accordance with accepted professional standards when controlled medications were not signed out on the Individual Resident Narcotics Record at the time they were administered for five residents. The facility policy stated that controlled medications are to be signed out on the narcotics record form when administered, but an LPN acknowledged that she had not yet signed out the narcotics she had given on the day shift. The DON and RNS also confirmed that controlled medications should have been documented at the time of administration. During the narcotic reconciliation, the counts on the Individual Resident Narcotics Records did not match the tablets observed for each of the five residents. One resident had acetaminophen with codeine ordered for chronic pain and another had alprazolam ordered for anxiety disorder; additional residents had lacosamide for epilepsy and alprazolam/Xanax for anxiety. The records showed last documented doses from the prior evening, while the medications had been administered earlier that day, and the observed tablet counts were lower than the recorded counts for all five residents.
Inaccurate Dental Assessment on Admission MDS
Penalty
Summary
The facility failed to accurately assess one resident’s dental status on the admission MDS assessment. Resident #27 was admitted with diagnoses including schizophrenia, depression, bipolar disorder, type 2 diabetes, COPD, and obesity, and her BIMS score was 15, indicating she was cognitively intact. During an observation on 05/11/2026, the resident’s oral cavity showed one decayed tooth on the top front and one decayed tooth on the bottom front, with the rest of her teeth broken and decayed at the gums. The resident stated her teeth were in this condition when she was admitted. Record review showed the admission MDS section for dental status did not check boxes for obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, or mouth/facial pain, discomfort, or difficulty chewing, and instead checked that none of those conditions were present. However, the resident’s dental evaluation dated 01/22/2026 documented that obvious or likely cavity or broken natural teeth and inflamed or bleeding gums or loose natural teeth were present. On 05/12/2026, the resident’s oral cavity was again assessed and the broken and decayed teeth were confirmed, and the RN/AN responsible for the MDS confirmed the admission assessment was inaccurate and that the resident had broken and decayed natural teeth on admission.
Failure to Follow Care Plan for Perineal Skin Sensitivity
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident with dementia, traumatic subdural hemorrhage, encephalopathy, chronic kidney disease stage 3, dysphagia, depression, and bowel and bladder incontinence. The resident’s mental status score was 5, indicating severely impaired cognition, and her daughter was identified as the responsible party. The care plan dated 08/01/2024 stated the resident had bladder incontinence and that staff were not to use perineal wash on her due to sensitivity. During observation, the resident was found lying in bed grimacing and holding her perineal area and stated that her private area was irritated and aggravated to the point she could not tolerate it. Signs posted in the room instructed staff not to use perineal wash on the resident. The resident’s daughter stated the perineal area was severely irritated and uncomfortable, and that she had posted the signs after realizing the cleanser irritated her mother. Further observation showed the left groin and inner thigh were red, irritated, and raised. Staff confirmed that perineal wash was not to be used because it caused skin irritation, and an agency CNA had left a bottle of perineal wash in the room after providing care.
Unsafe smoker left unsupervised while smoking
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed as an unsafe smoker. Resident #24 had diagnoses including hemiplegia and hemiparesis following a non traumatic intracerebral hemorrhage affecting the right dominant side, alcohol abuse with unspecified alcohol induced disorder, other psychoactive substance abuse with psychoactive substance induced psychotic disorder with delusions, and cognitive communication deficit. His modified significant change MDS showed a BIMS score of 3, indicating severely impaired cognition, and he was coded for current tobacco use. His care plan identified him as a smoker who required supervision by one staff member at all times, and his smoking screening stated he could not get to the designated smoking areas independently, was not able to follow smoking policies, and required 1:1 supervision while smoking. On 05/12/2026, S3RNS wheeled Resident #24 from the dining room to the smoking patio and left him there while re-entering the dining room. Observations showed no staff or visitors on the smoking patio when Resident #24 was later seen there with a lit cigarette in his left hand. S2ADON was summoned, removed the cigarette from his hand, and confirmed that he was smoking unsupervised and should have been supervised by staff. During interview, S3RNS confirmed he had left Resident #24 unsupervised on the smoking patio while other residents smoked and stated he was aware the resident required supervision.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 2 medication errors identified during 25 observed opportunities for an error rate of 8.00%. One error involved a resident with COPD and bipolar disorder who had an order for Budesonide-Formoterol Fumarate inhalation aerosol, 2 puffs in the morning. During observation, an LPN handed the inhaler to the resident and confirmed the dose when the resident asked if it was two puffs, but no instruction was given on the inhaler’s use. The resident took two puffs one after the other without pausing, without shaking the inhaler between puffs, and medication fumes were seen exiting the resident’s mouth after each puff. The LPN later confirmed the inhaler had not been administered per the manufacturer’s instructions. The second error involved a resident with unspecified dementia and low vitamin D who had a physician order for Cholecalciferol 1000 unit tablets, 2 tablets by mouth daily. During medication administration observation, an LPN gave only 1 tablet. The LPN later confirmed that only 1 tablet had been administered and that 2 tablets should have been given per the physician’s order. The DON also reviewed the records and confirmed the resident should have received 2 tablets daily and that the inhaler administration for the other resident did not follow standard practice.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed and gloves were changed during wound care treatment for one resident with pressure injuries to both buttocks. Resident #17 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction and pressure ulcers of the left and right buttocks, stage 2. Physician orders directed daily cleansing of the pressure injuries with wound cleanser, application of collagen, skin prep to the periwound on the right buttock wound, and dry dressings. During an observation of wound care, the RN performed hand hygiene and donned a gown and gloves before entering the room, then cleansed the resident’s sacral wound with gauze sprayed with wound cleanser. After cleansing, the RN did not remove gloves or perform hand hygiene before opening and applying collagen and then placing the dressing over the wound. The RN did not perform hand hygiene or change gloves at any point during the procedure. In interview, the RN stated he did not take off his gloves or sanitize his hands between cleaning the wound and applying the dressing, and the DON stated the RN should have removed his gloves, performed hand hygiene, and donned new gloves before applying the collagen and dressing.
Failure to Update Care Plan with Accurate DNR Status
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to accurately reflect the resident's advance directive code status. Specifically, the care plan for one resident continued to indicate 'Full Code' despite multiple sources in the resident's medical record, including physician orders, an Advance Directive Consent, and a Louisiana Physician Order for Scope of Treatment (LaPOST), all documenting a Do Not Resuscitate (DNR) status. This discrepancy was identified through interviews and record reviews, where both the Minimum Data Set (MDS) staff member and the Director of Nursing (DON) confirmed that the care plan was inaccurate and should have been updated to reflect the resident's DNR status. The resident involved had a medical history that included Alzheimer's disease, cerebral vascular disease, and cerebral infarction. The facility's own policies require that care plans be reviewed and revised periodically to ensure consistency with the resident's written plan of care and advance directives. Despite these requirements, the care plan was not updated to match the documented DNR status, resulting in an inaccurate representation of the resident's wishes and physician orders.
Failure to Complete MDS Assessments Within Regulatory Timeframes
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed within the required regulatory timeframes for 17 out of 24 residents reviewed for assessments. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines, MDS assessments must be completed no later than the 14th calendar day after the Assessment Reference Date (ARD). The survey found that multiple types of MDS assessments, including quarterly, annual, admission, discharge, and death assessments, remained incomplete and in progress beyond the required 14-day period. Record reviews revealed that for each of the identified residents, the MDS assessments had ARDs set and corresponding required completion dates, but the assessments were not finalized within the mandated timeframe. The types of assessments affected included quarterly, annual, admission, discharge, and death assessments. For example, one resident had both quarterly and discharge assessments that were not completed on time, while another had both annual and death assessments outstanding. This pattern was consistent across all 17 residents cited in the deficiency. During an interview and records review with the staff member responsible for MDS (S5MDS), it was confirmed that each of the cited assessments remained open and incomplete past the 14-day requirement. The staff member acknowledged that the assessments should have been completed within the specified timeframe, as required by regulation, but this was not done for the residents identified in the survey.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit completed Minimum Data Set (MDS) assessments to the State within the required 14-day period for seven residents. For each of these residents, quarterly or significant change MDS assessments were completed, but the transmission to the Centers for Medicare & Medicaid Services (CMS) was delayed well beyond the 14-day window. Specific examples include assessments with Assessment Reference Dates (ARDs) and completion dates in January and February, but transmissions not occurring until April, resulting in delays of more than 14 days for each case. During a concurrent interview and record review, the MDS Nurse confirmed that the assessments for these residents were submitted late, as evidenced by the facility's CMS transmittal validation report. The deficiency was identified through a review of both the electronic clinical records and the transmittal validation reports, which consistently showed late submission for the affected residents. No information was provided regarding the residents' medical histories or conditions at the time of the deficiency.
Failure to Provide Correct Food Serving Sizes as Indicated by Diet Spreadsheet
Penalty
Summary
Dietary staff failed to provide residents with the correct serving sizes of food as specified in the facility's diet spreadsheet. On the observed date, staff used a 1/3 cup scoop for greens instead of the required 1/2 cup, and a 6 oz scoop for regular ham and beans instead of the required 7 oz. For residents on pureed diets, staff used a 6 oz scoop for pureed ham and beans instead of the specified 2 #8 scoops. These errors were confirmed by the dietary manager, and the incorrect serving sizes were not corrected before the meals were distributed to the secured unit. This practice had the potential to affect all 21 residents residing on the secured unit. No information was provided regarding the specific medical history or condition of the residents at the time of the deficiency.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) protocols during resident care. Specifically, a treatment nurse provided wound care to a resident with peripheral vascular disease, diabetes mellitus, and bilateral lower extremity arterial ulcers without donning the required gown, despite an EBP sign being posted in the room. After completing the wound care, the nurse exited the resident's room carrying soiled PPE on a tray and disposed of it in the hallway, rather than removing and discarding the PPE inside the resident's room as required by policy. The nurse acknowledged both lapses when questioned. Additionally, a certified nursing assistant was observed assisting with an oral assessment for another resident who was on EBP, but did not wear a gown while placing gloved hands in the resident's mouth. The CNA stated she believed a gown was not required for this care activity, despite the EBP sign on the resident's door. The infection preventionist later confirmed that the resident was on EBP and that a gown should have been worn for direct care involving the mouth. These failures were observed to have the potential to affect the facility's entire census of 96 residents.
Inaccurate MDS Coding for Restraint Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident regarding restraint use. Record review showed that the resident was admitted with diagnoses including diabetes mellitus and lower limb amputations. The resident's December 2024 physician's orders did not include any order for a restraint. However, the annual MDS assessment for the resident indicated the use of a trunk restraint in a chair or out of bed. During an interview and record review, the staff member responsible for MDS confirmed that there was no order for a restraint and acknowledged that the assessment was incorrectly coded to indicate restraint use.
Failure to Include Level II PASRR in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident with a Level II PASRR determination. Record review showed that the resident was admitted with diagnoses including Schizoaffective Disorder, Depressive Type, and had been approved for admission by the Level II Authority for a specified period. The resident's OBH-PASRR Evaluation Summary and Determination Notice indicated the presence of a serious mental illness and recommended nursing home admission. However, review of the resident's care plan revealed that it did not address the Level II PASRR requirements. During an interview, the staff member responsible for Minimum Data Set (MDS) confirmed that the resident was a Level II PASRR and acknowledged that this should have been included in the comprehensive care plan but was not.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident was invited to participate in their care planning meetings, as required by policy and regulation. Specifically, a resident with chronic kidney disease, heart failure, and major depressive disorder, who was cognitively intact as indicated by a BIMS score of 15, was not invited to any care plan meetings during their stay. The resident reported never having attended or been informed about care plan meetings. Review of the medical record confirmed there was no documentation of the resident or their representative being invited or participating in care plan meetings, including those following significant change and quarterly MDS assessments. Interviews with facility staff revealed that the process for inviting residents or their representatives to care plan meetings was not consistently followed. MDS staff stated that invitations were only extended for quarterly and annual assessments, not for significant change assessments, and there was no documentation of invitations or attendance for the resident in question. The Social Service Director also confirmed not having been instructed to invite residents to care plan meetings and had not done so for this resident. This practice was inconsistent with the facility's own policy, which requires resident and/or representative participation or documentation if participation is not practicable.
Failure to Monitor Effectiveness of QAPI Corrective Action Plan
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Program failed to measure its success and track performance after identifying an area of improvement related to task scheduling errors. Specifically, after the facility transitioned from 12-hour to 8-hour shifts, tasks continued to be scheduled according to the old 12-hour format, resulting in time code discrepancies and necessitating a facility-wide audit to correct these errors. The corrective action plan included auditing and correcting task time codes for each resident and in-servicing nursing staff on the new schedule requirements. Despite these identified issues and the implementation of a corrective action plan, there was no documented evidence that the effectiveness of these actions was monitored or that performance tracking occurred during the specified period. The section of the corrective action plan designated for follow-up and effectiveness remained blank, and interviews with facility leadership confirmed the absence of data collection, analysis, or documentation of monitoring activities from the time the plan was initiated through the review date.
Failure to Provide Pressure Ulcer Prevention and Treatment
Penalty
Summary
Facility staff failed to provide necessary pressure ulcer care and prevention for two residents, resulting in deficiencies related to both the identification and treatment of pressure ulcers. For one resident with multiple comorbidities including COPD, diabetes with neuropathy, and malnutrition, the facility did not conduct weekly body audits as required by policy for several weeks. This resident was assessed as being at risk for pressure ulcers, and the lack of documented audits coincided with the development of a Stage 2 pressure ulcer, which was only identified upon the resident's admission to the hospital. Interviews with facility staff confirmed the absence of required documentation and the failure to identify the pressure ulcer prior to hospitalization. Another resident, admitted with diagnoses including a femur fracture, malnutrition, and muscle weakness, developed a facility-acquired Stage II pressure ulcer on the left heel. The resident's treatment administration records revealed multiple missed wound care treatments over several weeks, despite physician orders specifying daily care. The DON acknowledged awareness of these missed treatments during an interview, confirming that the prescribed wound care was not consistently provided as ordered.
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What surveyors actually found near you
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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 Rayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southwind Nursing & Rehabilitation Center | 1.6 mi | ★★★★★ | 9 | 0 |
| The Ellington | 4.3 mi | ★★★★★ | 0 | 0 |
| The Encore Healthcare And Rehabilitation Center | 6.1 mi | ★★★★★ | 0 | 0 |
| Acadia St. Landry Nursing & Rehabilitation Center | 13.6 mi | ★★★★★ | 10 | 0 |
| Kaplan Healthcare Center | 15.6 mi | ★★★★★ | 14 | 0 |
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