Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Legacy Nursing And Rehabilitation Of Lafourche during CMS and state inspections, most recent first.
Walk-In Cooler Not Maintained in a Sanitary Manner: The kitchen walk-in cooler contained 3 decomposing tomatoes, a brown decomposing lemon-like fruit, a discolored milk carton lying in an unknown white curdled substance, and an unknown brown liquid on the floor under the storage racks. The Dietary Manager confirmed the tomatoes were rotten with mold growth, the lemon was decomposing, and the milk carton was leaking and disintegrating, and stated the cooler floors were not kept in a sanitary manner.
A resident’s hand was injured during a mechanical lift transfer when it got caught in the wheelchair, but the CNA did not report the incident to the nurse or administration until the next day. The resident later had an x-ray showing an acute fracture of the fifth proximal phalanx, and there was no documentation that the physician was consulted when the change in condition occurred.
A resident with a suprapubic catheter, obstructive uropathy, and BPH had the catheter bag hanging on the back of a wheelchair where it touched the floor, and the privacy bag was observed soiled with an unknown black/gray substance on two occasions. The care plan and MD order required the catheter to be secured and hung freely off the floor, and an LPN, DON, and Administrator confirmed the bag was not maintained as ordered.
Staff failed to follow EBP for two residents with indwelling catheters when a CNA provided catheter and incontinence care without wearing a gown. For one resident, the CNA also changed gloves multiple times during perineal care without performing hand hygiene between glove changes or before touching items in the resident’s environment; the CNA and DON confirmed the missed gown use and hand hygiene.
A resident with osteoporosis, dementia, and a traumatic brain injury fell in a shower room after being left unattended by a CNA, resulting in a C7 fracture and increased pain and depression. The resident, who was at high risk for falls, required supervision during showers, but the CNA left the door propped open, allowing the resident to enter unsupervised. This incident led to decreased mobility and independence for the resident.
A resident with moderate cognitive impairment experienced a fall, but the facility failed to update the care plan with new interventions. Despite being at risk for falls, the resident's care plan was not revised after the incident, as confirmed by an LPN and the DON.
A resident experienced a fall and was found on the floor without visible injuries. The facility's staff failed to immediately notify the resident's responsible party, as required. Although attempts were made to contact the responsible party, they were unsuccessful, and the responsible party was not informed until weeks later. The Director of Nursing and the Administrator confirmed the lapse in communication.
Walk-In Cooler Not Maintained in a Sanitary Manner
Penalty
Summary
The facility failed to ensure the kitchen's walk-in cooler was maintained in a sanitary manner. Review of the facility's Food Safety and Sanitization policy and procedure stated that stored food was to be protected from contamination and growth of pathogenic organisms, and the Dietary Manager job description included keeping the kitchen maintained as required by state and federal regulations, keeping the kitchen clean and organized, and keeping work areas clean. The February 2026 Dietary Cleaning Schedule also indicated the cooler floors should be checked for food and/or spills and mopped. Observation of the walk-in cooler on 02/23/2026 at 8:45 AM revealed 3 decomposing tomatoes, one brown decomposing lemon-like fruit, a discolored milk carton laying on its side in an unknown white curdled substance, and an unknown brown liquid on the floor underneath the raised storage racks. A second observation on 02/24/2026 at 11:10 AM with the Dietary Manager found the same conditions still present. During interview on 02/24/2026 at 11:15 AM, the Dietary Manager stated the lemon was brown and decomposing, the tomatoes were rotten with mold growth, the milk carton was leaking and disintegrating, and the cooler floors were not kept in a sanitary manner and should have been.
Failure to Report Resident Injury and Notify Physician
Penalty
Summary
The facility failed to ensure staff immediately consulted a physician regarding a resident’s change of condition after an incident involving Resident #52. On 02/18/2026, the resident’s right 4th and 5th digits were bruised during a transfer from the bed to the wheelchair, and the resident stated his pinky finger was bruised. The facility’s incident report documented the injury, but the record contained no documentation that the physician was consulted the morning the incident occurred. Resident #52’s right hand x-ray on 02/19/2026 showed an acute appearing fracture of the base of the fifth proximal phalanx with mild displacement of the distal fragment. During interviews, the assigned LPN stated the resident’s right hand got caught in the wheelchair during a mechanical lift transfer, but the CNA did not report the incident until the following day. The CNA acknowledged she did not report the incident to the nurse or administration when it occurred and should have. The DON confirmed the incident was not reported until the next day, and the Administrator stated she was unaware the CNA had not notified the nurse or completed an incident report when it occurred.
Suprapubic Catheter Bag Touched Floor and Was Soiled
Penalty
Summary
The facility failed to ensure a resident’s suprapubic catheter was maintained in a sanitary condition. Resident #8 was admitted with diagnoses including obstructive uropathy and benign prostatic hyperplasia, and the resident’s MDS indicated a BIMS score of 15, showing the resident was cognitively intact. The care plan identified that the resident had a suprapubic catheter and that staff were to ensure the catheter was secured appropriately. A physician’s order also directed that the suprapubic catheter be hung freely off the floor. During observations, the resident’s catheter bag, placed inside a privacy bag, was seen hanging on the back of the wheelchair and touching the floor. The bottom of the privacy bag was observed to be soiled with an unknown black/gray substance on two separate occasions. An LPN confirmed the catheter bag should hang freely off the floor and should not be touching the floor, the DON stated the bag was touching the floor and should have been freely hanging off the floor as ordered, and the Administrator confirmed the deficient practice.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Catheter Care
Penalty
Summary
Staff failed to follow enhanced barrier precautions during catheter care for two residents with indwelling catheters. Resident #8 had a suprapubic catheter and was ordered to have enhanced barrier precautions in place. During observation, a CNA provided catheter care to Resident #8 without wearing a gown. The CNA stated Resident #8 was on enhanced barrier precautions and that she should have worn a gown. The DON and Administrator later confirmed the gown was required and was not worn. Resident #65 also had an indwelling catheter and was ordered to have enhanced barrier precautions during catheter and incontinence care. During observation, a CNA provided incontinence care and catheter care to Resident #65 without wearing a gown. The CNA acknowledged that a gown and gloves were required. In the same observation, the CNA changed gloves multiple times while cleaning the resident’s perineal area but did not perform hand hygiene between glove changes or before touching items in the resident’s environment. The CNA stated hand hygiene should have been performed between each glove change and after contact with items in the resident’s environment, and the DON confirmed the hand hygiene was not performed as observed.
Resident Fall Due to Inadequate Supervision in Shower Room
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who required supervision with showers and had diagnoses including osteoporosis, dementia, and a traumatic brain injury. The incident occurred when a CNA left the door to the shower room propped open, allowing the resident to enter unattended. The resident was found on the floor after an unwitnessed fall, resulting in a C7 displaced fracture, increased neck pain, depression, decreased mobility, and decreased independence. The resident's medical record indicated a high risk for falls, requiring staff supervision during showers. Despite this, the resident was left unattended in the shower room, leading to the fall. The resident's condition worsened post-fall, with increased assistance needed for activities of daily living and multiple instances of pain requiring medication. The resident also experienced depression related to the fall and expressed fear of ambulating independently. Interviews with staff confirmed the resident was left unsupervised in the shower room, contrary to the facility's policy. The CNA admitted to leaving the door propped open, which allowed the resident to enter the room unsupervised. The incident highlighted a failure in adhering to the facility's policy of ensuring residents are not left unattended in the shower room, contributing to the resident's fall and subsequent injuries.
Removal Plan
- All residents involved in a major incident would be assessed for psychosocial wellbeing post incident.
- Acute charting on Resident #65 continued for 72 hours upon return from the ER.
- All Shower Aides and CNAs on shift were in-serviced on revisions to the Policy and Procedure related to changes on showers/whirlpools' doors.
- Resident #65 was seen by the Psychiatric Nurse Practitioner.
- A behavioral health facility was contacted to conduct a follow-up visit regarding information.
- An Activity Assessment was completed for Resident #65 with alternative options for in-room activities.
- All shower/whirlpool room doors were evaluated for proper function.
- The facility revised a Policy and Procedure on Resident Bathing/Shower as it related to shower room doors.
- Door audits were initiated by S1ADM or a designee at least 5 times per week for four weeks.
- An in-service was initiated by the facility leadership to ensure that all staff were educated on the Policy and Procedure on Resident Bathing/Shower.
- S12Maintenance Supervisor visually inspected all shower/whirlpool doors to assure that all doors were functioning properly.
- The Incident/Accident policy and procedure were revised to include the psychosocial aspect of residents post incident.
- A post-incident QA initiated related to psychosocial monitoring was created, and education was provided to staff on recognizing psychosocial changes.
- In-services were initiated on Identifying Residents with Psychosocial Status Changes with staff.
- All data and findings will be reviewed by the QAPI committee as necessary.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop a plan of care after a fall for Resident #55, who was one of the three residents investigated for falls. Resident #55 had a moderate cognitive impairment, as indicated by a Brief Interview for Mental Status assessment score of 11, and had experienced recent falls. On 01/10/2025, a CNA reported finding Resident #55 lying on the floor near his recliner. Despite the fall, Resident #55's plan of care, which identified him as at risk for falls due to various factors including weakness and cognitive impairments, was not updated with a new intervention for the fall that occurred on 01/10/2025. Interviews with the S4Minimum Data Set/LPN and the S2Director of Nursing confirmed that the plan of care should have been updated but was not.
Failure to Notify Responsible Party of Resident Fall
Penalty
Summary
The facility failed to immediately notify the responsible party of a resident after the resident sustained a fall. On 10/27/2024, a resident was found sitting on the floor next to her bed with no visible injuries. The facility's incident log noted that the resident's responsible party was notified several hours later, at 6:00 AM. However, the responsible party reported not being informed of the fall until 11/15/2024. Interviews revealed that the Director of Nursing and an agency LPN attempted to contact the responsible party but were unsuccessful. The Director of Nursing and the Administrator acknowledged that the responsible party was not verbally notified of the fall as required.
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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 Thibodaux
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Audubon Health And Rehab | 1.8 mi | ★★★★★ | 2 | 0 |
| Thibodaux Healthcare And Rehabilitation Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Heritage Manor Of Houma | 13 mi | ★★★★★ | 0 | 0 |
| Chateau Terrebonne Health Care Center | 14.1 mi | ★★★★★ | 3 | 0 |
| Terrebonne General Med Ctr Snf | 15 mi | ★★★★★ | 2 | 0 |
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