Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Plaquemine during CMS and state inspections, most recent first.
Failure to Provide ADL Assistance and Personal Hygiene: A resident who was totally dependent on staff for ADLs, including personal hygiene, was observed multiple times with oily hair and small, dried, white flakes on the head. The resident’s care plan required a bed bath and help with personal hygiene, but the EHR had no documentation confirming ADL care was provided. A CNA said hair care had last been done several days earlier, and the ADON and DON confirmed the resident should not have had the flakes.
A CNA did not pull the privacy curtain while providing incontinence care to a resident with severe cognitive impairment, resulting in the resident's exposed genitalia being visible to her roommate. Facility policy requires privacy during personal care, but this was not followed during the incident.
A CNA did not perform hand hygiene or change gloves after cleaning a resident's perineal area and before applying a clean brief. The CNA also used soiled gloves to obtain additional wipes from a multi-use package, contrary to infection control policy, as confirmed by interviews with the DON and Administrator.
The facility failed to maintain food safety and hygiene standards, with staff not fully containing hair in hairnets, uncovered food items, and improperly labeled and stored food. Personal food items were stored with residents' food, and expired food was available for use. These deficiencies were confirmed by staff interviews.
Two residents were unable to reach their call bells, which were improperly placed, leading to a deficiency in care. An LPN confirmed the issue, and the facility administrator acknowledged that call bells should be accessible.
A resident with severe cognitive impairment was not provided adequate privacy during personal care activities. Staff failed to pull the privacy curtain and fully close the window blinds, exposing the resident's nude body to the outside. Interviews with facility staff confirmed that privacy should have been maintained.
A facility failed to implement a care plan intervention for a resident at risk of falls due to hemiplegia. The care plan required a self-release lap tray while the resident was in a wheelchair, but observations showed the resident without the tray on multiple occasions. Interviews with an LPN and the ADON confirmed the oversight.
A resident with a suprapubic catheter experienced improper care when their catheter bag was repeatedly placed in bed rather than below the bladder, contrary to CDC guidelines. This oversight, acknowledged by a CNA and confirmed by an LPN and the ADON/Infection Preventionist, contributed to the resident's history of UTIs and cystitis.
A facility failed to follow its policy for maintaining respiratory care equipment for a resident. The policy required storing respiratory tubing, mouthpieces, and masks in a plastic bag when not in use. However, observations showed the resident's nasal cannula, nebulizer mask, and oxygen tubing were repeatedly found uncontained and improperly stored on the floor, on the resident's chest, and on the bedside table. The DON confirmed the equipment should have been stored in a clean, labeled plastic bag.
The facility failed to maintain a sanitary environment for two residents, as dried tube feeding formula was observed on their enteral feeding equipment and floors over two days. The administrator confirmed the oversight, acknowledging that the areas should have been cleaned by staff.
The facility failed to accurately complete the MDS for two residents. One resident with bilateral amputations was incorrectly assessed as needing assistance with footwear, while another resident with serious mental illnesses was inaccurately marked as not having such conditions. Staff interviews confirmed these inaccuracies.
The facility failed to designate a licensed nurse as a charge nurse for each shift, as required by regulations. A review of schedules from early December 2024 showed no designated charge nurse for both day and night shifts. Interviews with LPNs confirmed the absence of a charge nurse on the night shift. The DON admitted to not designating a charge nurse, and the administrator confirmed the lack of documentation.
A facility failed to communicate necessary resident information to a receiving facility during a transfer. An LPN did not call the emergency department to provide a report when a resident was transferred, as required by the facility's procedures. Interviews with the LPN, DON, and Administrator confirmed the lapse, and there was no documentation to show that the receiving facility received all required information.
A resident with a history of COVID-19 and displaying symptoms requested a test after developing a fever. Despite the facility's policy for immediate testing, the resident was not tested until the following day, resulting in a positive COVID-19 result. An LPN administered Tylenol and noted the need for testing the next day, leading to a deficiency in infection control.
The facility failed to prevent an altercation between two residents, resulting in physical harm. Both residents had shown increased agitation and aggressive behaviors, but the facility did not increase supervision or take preventive measures. Staff observed one resident pacing with a belt and making delusional statements, but no additional interventions were implemented.
The facility failed to report an altercation between two residents, one of whom sustained injuries, to the State Survey Agency within the required 5 working days. The incident involved residents with mental health diagnoses, and the facility's administrator acknowledged the reporting failure.
The facility failed to develop a crisis intervention plan for a resident with delusional disorder, anxiety disorder, and paranoid personality disorder, as required by the PASRR program. Despite the resident's cognitive intactness and additional diagnoses, no documented evidence of the plan was found, and interviews confirmed its absence.
The facility failed to address signs of pain in a nonverbal resident with a left shoulder fracture. Despite multiple high pain levels documented in the resident's EMAR and standing orders for pain medication, there was no evidence of pain medication being administered. Observations and interviews confirmed the resident's pain and the lack of appropriate pain management.
Failure to Provide ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for all activities of daily living received assistance to maintain personal hygiene. Resident #102 had diagnoses of traumatic brain injury and quadriplegia, was not capable of being interviewed, had bilateral impairment to the upper and lower extremities, and was dependent on staff for all ADLs, including personal hygiene. The care plan stated the resident was totally dependent on staff for all ADLs and required a bed bath and assistance with personal hygiene, but the electronic health record contained no documentation confirming that ADL assistance, including personal hygiene, was provided. Observations showed Resident #102 lying in bed with hair that appeared oily and had small, dried, white flakes throughout the left side of the head on multiple occasions. A CNA stated the last time she washed the resident’s hair was several days earlier and acknowledged that ADLs included hair care and that the resident should not have had the flakes. The ADON and DON both confirmed the resident had small, dried, white flakes throughout the left side of the head and should not have, and the DON stated the resident did not have a diagnosis related to skin conditions that would explain the flakes.
Failure to Ensure Resident Privacy During Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide privacy for a resident with severe cognitive impairment during incontinence care. The CNA did not pull the privacy curtain between the resident and her roommate, resulting in the resident's exposed genitalia being visible to the roommate. This action was observed during incontinence care, and both the CNA and facility leadership acknowledged that the privacy curtain should have been used to ensure the resident's privacy. The resident was dependent on staff for toileting hygiene and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment at the time of the incident. Facility policy states that residents have the right to privacy during treatment and care of personal needs, but this was not followed during the observed event.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow proper hand hygiene protocols during incontinence care for a resident. Specifically, after cleaning the resident's perineal area and removing a soiled brief, the CNA did not sanitize her hands or apply clean gloves before proceeding to put on a clean brief. Additionally, the CNA used soiled gloves to obtain more disposable wipes from a multi-use package multiple times during the care process, and placed the package of wipes on the resident's bed. Interviews with the CNA, the Director of Nursing (DON), and the Administrator confirmed that the CNA should have removed soiled gloves, performed hand hygiene, and donned clean gloves before applying a clean brief. They also acknowledged that obtaining wipes from a multi-use package with soiled gloves was not in accordance with facility policy and infection prevention procedures.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards in food procurement, storage, preparation, and service, as observed during a kitchen inspection. Staff members, identified as S8Dietary Helper and S9Dietary Helper, were found with hair not fully contained in hairnets while in the food preparation area, contrary to the facility's policy. Additionally, individual cups of vanilla pudding were left uncovered on the preparation table. The facility's refrigerator contained several unlabeled and undated food items, including a zip lock bag of cooked cubed chicken, a Styrofoam cup with a pudding-like substance, and a cream cheese Danish, which was later identified as a personal food item belonging to S8Dietary Helper. Furthermore, a bag of chopped cabbage was found with a grayish-black unknown substance, indicating spoilage. The facility's freezer also contained undated and unlabeled food items, such as a half-full bag of frozen fries and an opened package of an unspecified item. Interviews with S8Dietary Helper and S7Dietary Manager confirmed these observations, with S7Dietary Manager acknowledging that all kitchen staff should wear hairnets properly, food items should be labeled and dated, and personal food items should not be stored with residents' food. The presence of expired and improperly stored food items, along with the lack of adherence to hairnet policies, highlights deficiencies in the facility's food safety and hygiene practices.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, leading to a deficiency in resident care. Resident #2 reported being unable to reach his call bell, which was observed to be tangled and located under his bed on multiple occasions. Despite being capable of using the call bell, Resident #2 was unable to access it due to its improper placement. This was confirmed by an LPN who acknowledged that the call bell was not within reach. Similarly, Resident #95 was observed multiple times lying in bed with the call bell placed on top of a dorm-size refrigerator on a nightstand, making it inaccessible. Resident #95 expressed a need for assistance but was unable to call staff due to the call bell's location. An LPN confirmed that Resident #95 was capable of using the call bell and that it should have been within reach. The facility administrator also acknowledged that call bells should be accessible to residents.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to maintain a resident's right to privacy during care for one resident. The resident, who had severe cognitive impairment and was dependent on staff for various personal care tasks, was observed receiving a bed bath and having their bedsheets changed without adequate privacy measures in place. Specifically, the privacy curtain in the room was not pulled, and the window blinds were only halfway down, exposing the resident's nude body to the outside parking lot. Interviews with facility staff, including a CNA Supervisor, the Assistant Director of Nursing, and the Director of Nursing, confirmed that privacy should have been provided during the resident's care. The staff acknowledged that the privacy curtain should have been pulled and the blinds fully closed to ensure the resident's privacy during these personal care activities.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care plan interventions to decrease the risk of falls for Resident #84, who was identified as being at risk for falls due to an unsteady gait related to hemiplegia. The care plan for Resident #84 included an intervention to apply a self-release lap tray while the resident was up in his wheelchair, with a start date of 10/19/2024. However, multiple observations on 01/27/2025 and 01/28/2025 revealed that Resident #84 was sitting in his wheelchair without the self-release lap tray. Interviews with an LPN and the Assistant Director of Nursing confirmed that the resident was supposed to have the lap tray while in the wheelchair, indicating a failure to implement the care plan intervention as required.
Improper Positioning of Catheter Bag Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper positioning of a urinary catheter bag for a resident with a suprapubic catheter, leading to a deficiency in care. Observations revealed that the catheter bag was placed in the resident's bed near their feet, rather than below the level of the bladder, as required by the CDC's guidelines for preventing catheter-associated urinary tract infections. This improper positioning was noted during catheter care provided by a Certified Nursing Assistant (CNA), who acknowledged the mistake in an interview. The resident in question had a history of urinary tract infections (UTIs) and cystitis, with multiple diagnoses recorded over several months. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing/Infection Preventionist, confirmed that the catheter bag should have been maintained below the bladder level to prevent such infections. The repeated failure to adhere to this guideline contributed to the resident's ongoing issues with UTIs and cystitis.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to adhere to its policy and procedure for maintaining respiratory care equipment for a resident. The facility's policy required that respiratory tubing, mouthpieces, and masks be stored in a plastic bag when not in use. However, observations revealed that a resident's nasal cannula, nebulizer mask, and oxygen tubing were repeatedly found uncontained and improperly stored. On multiple occasions, the nebulizer mask was observed lying on the floor, on the resident's chest, and on the bedside table. During an interview, the Director of Nursing confirmed that the nebulizer mask should have been contained in a clean, labeled plastic bag, which was not the case.
Failure to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to maintain a sanitary environment for two residents, leading to a deficiency in providing a safe, clean, and comfortable living space. Observations revealed that a dried light brown unknown substance was present on the enteral feeding pump poles and floors of two residents' rooms. These observations were made multiple times over two days, indicating a lack of timely cleaning and maintenance by the facility staff. Interviews with the facility's administrator confirmed the presence of the dried substance, which was identified as dried tube feeding formula. The administrator acknowledged that the enteral feeding equipment and floors should have been cleaned by the staff but were not. This oversight in maintaining cleanliness and sanitation in the residents' environment contributed to the deficiency noted in the report.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately for two residents. Resident #42, who was admitted with bilateral above-the-knee amputations, had inaccuracies in his MDS assessments. The assessments incorrectly indicated that he was dependent on staff for putting on or taking off footwear, despite his condition making it impossible for him to perform these actions. Interviews with the Director of Rehabilitation and the MDS Nurse confirmed that the MDS assessments for Resident #42 were not completed accurately due to his amputations. Resident #51, who was admitted with diagnoses including Schizophrenia, Bipolar Disorder, and Post Traumatic Stress Disorder, also had an inaccurate MDS assessment. The significant change MDS assessment incorrectly marked that Resident #51 did not have a serious mental illness, despite his documented diagnoses. An interview with the MDS nurse confirmed that the MDS question regarding serious mental illness was not marked correctly, leading to an inaccurate assessment.
Failure to Designate Charge Nurse for Each Shift
Penalty
Summary
The facility failed to ensure a licensed nurse was designated as a charge nurse for each shift, as required by nursing staff regulations. A review of the facility's Nursing Daily Work Schedules from December 2, 2024, through December 11, 2024, revealed the absence of a designated charge nurse for both the 6:00 AM to 6:00 PM shift and the 6:00 PM to 6:00 AM shift. Additionally, the November and December 2024 Nurse Schedules lacked a designated charge nurse for each shift. Interviews with several Licensed Practical Nurses (LPNs) confirmed the absence of a designated charge nurse on the night shift. The Director of Nursing (DON) acknowledged the oversight, admitting that she did not designate a charge nurse on the nursing schedule for each shift, which was a requirement. The facility administrator also confirmed the lack of documented evidence of a designated charge nurse for each shift.
Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to communicate appropriate resident information to a receiving facility during a transfer, resulting in a deficiency. Specifically, a Licensed Practical Nurse (LPN) was responsible for transferring a resident to the emergency department but did not call the receiving facility to provide a report, as required by the facility's procedures. The resident was discharged to the emergency department without documented evidence that the necessary information was conveyed. Interviews with the LPN, the Director of Nursing (DON), and the Administrator confirmed that the report was not given, and there was no documentation to support that the receiving facility received all required information for the transfer.
Delayed COVID-19 Testing for Symptomatic Resident
Penalty
Summary
The facility failed to test a resident displaying signs and symptoms of COVID-19 in a timely manner, as required by their COVID-19 testing policy. The policy mandates that any resident showing symptoms should be tested as soon as possible. Resident #2, who had a history of COVID-19, requested a temperature check on August 22, 2024, and was found to have a fever of 101.2°F. Despite expressing that he felt similar to when he previously had COVID-19 and requesting a test, the resident was not tested until the following day, August 23, 2024, when he tested positive for COVID-19. Interviews revealed that the delay in testing was due to the actions of an LPN who, upon discovering the resident's fever, administered Tylenol and documented the need for testing in a nurse's note for the following day. This delay in testing did not align with the facility's policy of immediate testing for symptomatic residents, resulting in a deficiency in infection prevention and control.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that residents remained free from physical abuse, resulting in an altercation between two residents. Resident #4, who had a history of delusional disorder, anxiety disorder, and paranoid personality disorder, attacked Resident #5 with a belt, causing scratches that required daily wound care. Both residents had shown increased agitation and behaviors prior to the incident, but the facility did not increase supervision or take preventive measures despite these warning signs. Staff had observed Resident #4 pacing and making delusional statements, but no additional interventions were implemented to address his escalating behavior. Resident #4 had previously exhibited delusional behavior, including an incident in August 2023 where he believed Resident #5 was trying to kill him. Despite this history, the facility did not separate the two residents or increase supervision. On the day of the incident, Resident #4 was seen walking around with a belt and a lock in his hand, and staff noted his increased agitation. However, no measures were taken to monitor him more closely or to prevent potential harm. Resident #5, who had diagnoses including bipolar disorder and major depressive disorder, also displayed aggressive behavior and had a history of making racial slurs and threats. Despite these behaviors, the facility did not increase supervision or implement new interventions. The staff and administration were not adequately informed about the residents' escalating behaviors, and no actions were taken to prevent the altercation. The facility's failure to address these issues resulted in physical harm to Resident #5.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency within the required 5 working days. Resident #4, who has diagnoses including delusional disorder, anxiety disorder, and paranoid personality disorder, was involved in an altercation with Resident #5. Resident #4's care plan indicated a potential for verbal aggression due to his mental and emotional illnesses. On the day of the incident, Resident #4 was found walking around with a belt and a lock, claiming his roommate, Resident #5, had attacked him. Resident #5, who has diagnoses including bipolar disorder and major depressive disorder, confirmed the altercation, stating that Resident #4 had become aggressive and they had wrestled. Resident #5 sustained scratches to his neck and thumb during the incident, which were documented and treated by the facility's staff. Despite the altercation and the injuries sustained by Resident #5, the facility did not report the incident to the state agency. The administrator acknowledged that the incident should have been reported but was not. The failure to report this incident within the required timeframe constitutes a deficiency in the facility's compliance with regulations regarding the reporting of abuse and neglect.
Failure to Develop Crisis Intervention Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident had a crisis intervention plan developed as required by the pre-admission screening and resident review (PASRR) program. Resident #4, who was admitted with diagnoses including delusional disorder, anxiety disorder, and paranoid personality disorder, did not have a documented crisis intervention plan despite the PASRR Level II Evaluation Summary and Determination Notice specifying the need for such a plan. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 14, showing cognitive intactness, and additional diagnoses of non-traumatic brain dysfunction and paranoid schizophrenia. Upon review, there was no documented evidence of a crisis intervention plan for Resident #4, and the facility was unable to provide such documentation. Interviews with the resident's psychiatric counselor and the Director of Nursing confirmed that no crisis intervention plan had been developed. The psychiatric counselor indicated that the contracted psychiatric services company had not developed or assisted in the development of the plan, and the Director of Nursing acknowledged the facility's inability to present the required evidence to the surveyor.
Failure to Address Pain in Nonverbal Resident
Penalty
Summary
The facility failed to address signs of pain in a nonverbal resident with a left shoulder fracture. The resident's care plan, initiated on 04/02/2024, included goals for minimal to no discomfort and interventions such as administering medications as prescribed and reporting unrelieved pain to the physician. However, a review of the resident's March and April 2024 Electronic Medication Administration Records (EMAR) revealed multiple instances of high pain levels (ranging from 4 to 8) without any documented evidence of pain medication being administered. The facility's standing physician orders included administering 650 milligrams of acetaminophen for mild to moderate pain, but there was no documentation that this was done for the resident's reported pain levels. Observations on 04/02/2024 and 04/04/2024 revealed the resident exhibited facial grimacing during incontinence care, indicating pain. Interviews with CNAs and LPNs confirmed the resident's pain and the lack of pain medication administration. The Director of Nursing (DON) and the resident's Nurse Practitioner also confirmed the resident's high pain ratings and the absence of documented pain medication administration. Despite the standing orders for pain management, the facility did not address the resident's pain, leading to the deficiency noted in the report.
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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 Plaquemine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Plaquemine | 0.2 mi | ★★★★★ | 0 | 0 |
| St James Place Nursing Care Center | 10.5 mi | ★★★★★ | 1 | 0 |
| Sage Rehabilitation Hospital Snf | 12.6 mi | ★★★★★ | 0 | 0 |
| Center Point Health Care And Rehab | 12.6 mi | ★★★★★ | 13 | 0 |
| Ollie Steele Burden Manor | 13 mi | ★★★★★ | 0 | 0 |
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