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 Louisiana Extended Care Hospital Of Lafayette during CMS and state inspections, most recent first.
Nurse staffing information was not posted at the beginning of the shift in a clear, readable format accessible to residents and visitors. An observation of Hall W and the nurse's station did not show the staffing information, and the ADON/IP and ADM confirmed it was not posted even though it should have been.
The facility failed to keep its facility assessment current after its licensed resident capacity changed. The assessment still listed 18 residents and 18 beds, while the DON confirmed the facility had received approval to care for 28 residents. The facility census was 12.
Late MDS Discharge Transmissions: The facility failed to transmit accurate and complete MDS discharge assessments for 5 residents within the required timeframe. An MDS staff member stated the computer system was not uploading MDSs, and the ADMIN confirmed the facility had ongoing upload issues and had not informed CMS, as it was trying to resolve the problem internally.
Improper food labeling and missing cooler temperature logs were observed in the kitchen. Opened items in the walk-in cooler, including cheeses, dressings, salsa, puree, mayonnaise, marmalade, and mustard, were not labeled with the date/time opened or use-by date, and the kitchen manager confirmed they should have been. Review of logs also showed multiple missing AM/PM temperature entries for the kitchen fridge cooler, patient cooler, and walk-in cooler, which the manager confirmed should have been recorded daily.
Staff failed to use required PPE for two residents on EBP during high-contact care. A RN/WCN removed her gown after wound care for one resident and then assisted with brief care and repositioning without putting on another gown, and later performed PEG site wound care for another resident without a gown. The RN/WCN confirmed the PPE should have been worn, and the ADON/IP confirmed the gown requirement and noted no EBP signage was posted on the second resident’s door.
Incomplete NOMNC forms were found for two residents whose Medicare Part A skilled services were ending. The forms were signed by the residents, but the effective date for when SNF services would end was left blank, and no additional NOMNC was provided before discharge. S3ADMIN confirmed the forms were completed on the residents’ admission dates and should not have been.
A resident with intact cognition reported missing lower partial dentures and said the issue had been brought to multiple nurses, but no grievance was documented or initiated. The resident and RP searched the room with staff help, and an LPN later admitted she forgot to notify administration. The ADON/IP confirmed missing items would be considered a grievance, yet she had not received any complaint about the dentures.
Improper Storage and Labeling of Nasal Cannula: A resident with orders for PRN oxygen via low-flow nasal cannula was observed multiple times with the cannula hanging over the oxygen flow meter, unlabeled, and not stored in a bag. The resident stated staff manage the cannula for her due to an upper extremity impairment, and the S2ADON/IP confirmed that when not in use, the cannula should be labeled with the change date and placed in a storage bag.
The facility failed to create person-centered baseline care plans for seven residents within 48 hours of admission, resulting in a lack of specific goals and interventions for conditions such as fractures, cardiac defibrillators, and various medications. The Chief Nursing Officer confirmed that the care plans were not tailored to individual needs, potentially impacting the quality of care.
The facility failed to maintain an effective infection prevention and control program, with key policies not reviewed annually since 2020. Additionally, a resident with a urinary tract infection and Foley catheter did not have Enhanced Barrier Precautions (EBP) implemented, as staff were unaware of EBP requirements. This oversight was confirmed by the facility's CNO and DON, indicating a lack of understanding and implementation of EBP.
The facility failed to ensure the designated Infection Preventionist (IP) had the necessary training and certification. The Chief Nursing Officer (CNO), acting as the IP, lacked specialized Infection Prevention and Control training and was unfamiliar with key procedures. Despite claims of completed training, documentation showed the required training was not completed, potentially affecting 10 residents.
A facility failed to notify the State LTC Ombudsman of a resident's hospital transfer. The resident, diagnosed with a stage 4 large cell neuroendocrine tumor, was transferred per physician orders. The DON was unaware of the notification requirement and did not provide the Emergency Transfer Log when requested. This oversight could impact 10 residents.
Nurse Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted at the beginning of each shift in a clear and readable format accessible to residents and visitors. The facility had a census of 12. On 02/24/2026 at 8:14 a.m., an observation of Hall W and Hall W's nurse's station did not reveal any posted nurse staffing information. At 8:21 a.m., a second observation of Hall W and Hall W's nurse's station was completed with S2 ADON/IP and S3 ADM, and they confirmed that the nurse staffing information pattern was not posted on 02/24/2026 and should have been.
Facility Assessment Not Updated for Increased Bed Capacity
Penalty
Summary
The facility failed to ensure its facility assessment was updated after changes were made to the resident capacity. Review of the facility assessment dated [DATE] showed the resident profile listed the number of residents the facility was licensed to provide care for as 18, and the facility had 18 beds. During a record review and interview on 02/24/2026 at 9:28 a.m., the DON stated that on 12/15/2025 the facility received its license and approval to care for 28 residents. She confirmed that the facility assessment still reflected a licensed capacity of 18 residents and acknowledged that the assessment should have been updated to reflect the new bed capacity changes. The facility census was 12.
Late MDS Discharge Transmissions
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete MDS discharge assessments to CMS within the required timeframe for 5 of 5 residents reviewed. Resident #4 was admitted on [DATE] and discharged on 09/18/2025, but the discharge assessment was not accepted until 02/23/2026, when it should have been submitted by 10/02/2025. Resident #8 was admitted on [DATE] and discharged on 09/09/2025, but the discharge assessment was accepted on 09/28/2025 instead of by 09/23/2025. Resident #11 was admitted on [DATE] and discharged on 09/12/2025, but the discharge assessment was accepted on 02/24/2026, when it should have been submitted by 09/26/2025. Resident #17 was admitted on [DATE] and discharged on 09/26/2025, but the discharge assessment was accepted on 10/24/2025, when it should have been submitted by 10/10/2025. Resident #26 was admitted on [DATE] and discharged on 09/18/2025, but the discharge assessment was accepted on 02/23/2026, when it should have been submitted by 10/02/2025. During interview, the S5 MDS staff member stated the computer systems had not been uploading the MDSs, which was why the discharge MDSs were late. The S3 ADMIN also confirmed the findings and stated the facility had been having issues uploading MDSs and had not informed CMS, as they were trying to resolve the issue internally.
Improper Food Labeling and Missing Cooler Temperature Logs
Penalty
Summary
Food items in the walk-in cooler were observed opened and not labeled with the date and time they were opened or the use-by date. During the kitchen tour, the facility’s day-to-day kitchen manager confirmed that the items should have been labeled. The items observed without required labeling included large bags of parmesan cheese and mozzarella cheese, several dressings, picante salsa, strawberry puree, mayonnaise, orange marmalade, sweet chili sauce, coleslaw dressing, and Dijon mustard. The facility also failed to maintain temperature logs for the kitchen fridge cooler, the patient cooler, and the walk-in cooler. Review of the temperature logs with the kitchen manager showed multiple missing AM and PM entries across several dates for each cooler. The kitchen manager stated that the temperatures of these coolers were to be checked and logged daily in the morning and evening, and confirmed that the temperatures were not logged on the dates identified.
Failure to Use Required PPE for Residents on EBP
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring staff used the required PPE for residents on Enhanced Barrier Precautions during high-contact care. The facility policy stated that gloves and gowns must be worn for high-contact activities such as hygiene assistance, toileting, wound care, device care, and assisting with mobility. Resident #12 was admitted with diagnoses including type 2 diabetes mellitus and morbid obesity, and her MDS indicated a stage 2 pressure ulcer. Her physician orders included Enhanced Barrier Precautions with gown and gloves required during close contact activities, and signage outside her room also indicated EBP. During observation, a RN/WCN removed her gown after completing wound care for Resident #12 and then assisted a CNA with re-applying the resident’s brief and transferring her higher in bed without putting on another gown. The RN/WCN stated she knew she should have had a gown on and confirmed she should have put on another gown. Resident #34 was admitted with diagnoses including status post craniotomy, dysphagia, and aphasia, and had orders for wound care to his PEG site and Enhanced Barrier Precautions. During observation, the RN/WCN prepared supplies outside the room, entered without a gown, and performed PEG site wound care without wearing a gown. The RN/WCN confirmed the resident required EBP and that she should have worn a gown, and the ADON/IP confirmed a gown should have been worn; the ADON/IP also confirmed there was no EBP signage on the resident’s door.
Incomplete NOMNC Forms for Two Residents
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered was not completed for 2 residents reviewed for termination of Medicare Part A services. For Resident #39, the electronic health record showed admission to the facility, and the Skilled Nursing Facility Beneficiary Notification Review, form CMS-20052, identified 10/16/2025 as the last day of Medicare Part A services. The resident’s NOMNC was signed and dated on 10/02/2025, but the effective date line for when current skilled nursing facility services would end was left blank, and no additional NOMNC was provided prior to discharge. For Resident #40, the electronic health record showed admission to the facility, and the Skilled Nursing Facility Beneficiary Notification Review, form CMS-20052, identified 09/18/2025 as the last day of Medicare Part A services. The resident’s NOMNC was signed and dated on 08/26/2025, but the effective date line for when current skilled nursing facility services would end was left blank, and no additional NOMNC was provided prior to discharge. During interview and record review on 02/25/2026, S3ADMIN confirmed both NOMNC forms were signed on the residents’ admission dates, the effective date field was left blank on both forms, and the forms should not have been completed on the dates of admission.
Failure to Initiate Grievance for Missing Dentures
Penalty
Summary
The facility failed to initiate a grievance for a resident who reported missing lower partial dentures, despite the resident having intact cognition with a BIMS score of 15 and the dentures being listed among the belongings brought to the facility on admission. The facility’s Complaint/Grievance Process policy stated that a verbal complaint about patient care should be resolved immediately by staff present, with immediately defined as within one hour. However, the grievance log contained no documented grievance related to the missing dentures, and there was no evidence that the facility initiated a grievance after the resident and her resident representative reported the dentures missing and said they had complained to multiple nurses since the prior Friday. During interviews, the resident stated it was hard to chew without her bottom dentures, and the resident representative said they had searched the room with staff help but could not find them. A nurse stated the resident told her the dentures had been missing since the prior Friday, but she forgot to notify administration and said she should have informed the ADON/IP. The ADON/IP stated she had not received any grievances or complaints about the missing dentures and confirmed that missing items would be considered a grievance.
Improper Storage and Labeling of Nasal Cannula
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who had orders for oxygen therapy via low-flow nasal cannula at 2 LPM as needed. Resident #12 was admitted with diagnoses including partial idiopathic epilepsy with seizures of localized onset, respiratory distress, obstructive sleep apnea, and morbid obesity. Her MDS showed a BIMS score of 15, indicating she was cognitively intact, and also documented an upper extremity impairment on one side and oxygen therapy as a special treatment. During observations on 02/23/2026, the resident’s nasal cannula was found not in use, hanging over the oxygen flow meter, unlabeled, and not stored in a bag. This condition was observed multiple times during the day. The resident stated that she received oxygen via nasal cannula sometimes and that staff take her nasal cannula on and off and store it for her because she is unable to do so herself. The S2ADON/IP confirmed that when the nasal cannula was not in use, it should be labeled with the date it needs to be changed and placed in a storage bag.
Failure to Develop Person-Centered Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered baseline care plans for seven residents within 48 hours of their admission. These care plans are essential for addressing the residents' immediate needs and ensuring appropriate interventions are in place. The deficiencies were identified through record reviews and interviews, revealing that the facility's computer system generated generalized care plans that were not specific to the individual needs of the residents. For instance, one resident with a left wrist splint and pelvic fractures did not have a baseline care plan that included goals and interventions for these conditions. Another resident with a cardiac defibrillator and a right great toe fracture also lacked a care plan addressing these specific medical needs. Additionally, residents requiring insulin, anticoagulants, antianxiety, antidepressant, opioid, and diuretic medications did not have corresponding goals and interventions outlined in their baseline care plans. The Chief Nursing Officer confirmed these findings, acknowledging that the care plans generated by the facility's system were not tailored to the residents' specific conditions. This lack of individualized care planning could potentially impact the quality of care provided to the residents, as their unique medical needs were not adequately addressed in the initial care plans.
Inadequate Infection Control Program and Lack of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program (IPCP) as evidenced by the lack of annual review of its policies and procedures. Key policies, including those related to pneumococcal and COVID-19 vaccinations, as well as the infection control committee and plan, had not been updated since their initial effective dates, some dating back to 2020. This oversight was confirmed by the facility's Chief Nursing Officer, who also served as the designated Infection Preventionist, acknowledging that these policies should have been reviewed annually. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a urinary tract infection who had a Foley catheter. Observations revealed that staff assisted the resident without using personal protective equipment, and there were no signs indicating the need for EBP in the resident's room. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, indicated a lack of understanding and implementation of EBP, with the Director of Nursing being unaware of what EBP entailed. This lack of knowledge and implementation of EBP had the potential to affect the facility's census of 10.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) possessed the necessary knowledge and skills for the role, as evidenced by the lack of specialized Infection Prevention and Control training. The Chief Nursing Officer (CNO), who assumed the role of IP after the previous IP resigned in April 2024, confirmed during an interview that he did not hold an Infection Preventionist certificate and had not received any specialized training from the former IP. Additionally, the CNO had not reviewed the facility's Infection Prevention and Control Program (IPCP) policies and procedures for the year and was unfamiliar with Enhanced Barrier Precautions (EBP). Although the Administrator stated that the CNO completed IP training in July 2022, a review of the Infection Control Nurse Competency Checklist revealed that the required specialized training had not been completed. This deficiency had the potential to affect a census of 10 residents.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of a facility-initiated transfer for a resident who was hospitalized. The resident, who was admitted with a diagnosis including a stage 4 large cell neuroendocrine tumor, was transferred to the hospital on December 14, 2024, as per physician orders. Despite requests made to the Director of Nursing (S2DON) on February 17, 2025, for the facility's Emergency Transfer Log sent to the Ombudsman, the documentation was not provided by the time of the survey exit. During an interview, S2DON admitted to marking hospital transfers on a paper calendar and was unaware of the requirement to notify the Ombudsman of such transfers. This oversight has the potential to affect a census of 10 residents.
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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 Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Camelot Rehabilitation At Magnolia Park | 0.6 mi | ★★★★★ | 4 | 0 |
| Lady Of The Oaks Retirement Manor | 1.2 mi | ★★★★★ | 0 | 0 |
| Cornerstone At The Ranch | 3.2 mi | ★★★★★ | 0 | 0 |
| Maison De Lafayette | 3.9 mi | ★★★★★ | 12 | 0 |
| River Oaks Retirement Manor | 4.5 mi | ★★★★★ | 3 | 0 |
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