Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Maison De Lafayette during CMS and state inspections, most recent first.
Two residents with diagnoses requiring fluid management did not have daily weights obtained and documented as ordered by their physicians. Over several months, one resident missed 33 daily weights, and another had no weights recorded on two consecutive weekends. Staff interviews revealed unclear responsibility for weekend weight checks and a lack of daily verification by nursing leadership, resulting in unaddressed gaps in monitoring.
Failure to follow physician orders and care plans affected multiple residents. A resident with ESRD did not receive ordered Nepro because the supplement was unavailable, a resident with a right-hand contracture did not have the ordered carrot stretcher applied daily, and a resident ordered IV cefazolin had missed doses documented on the MAR. In addition, a resident who required two-person assistance for toileting was changed by one CNA alone, and a resident ordered to be supervised for all meals was observed eating without staff monitoring or cueing.
Menu Not Followed for Mechanical Soft Diets: Several residents on mechanical soft diets were served whole Brussel sprouts instead of the sliced carrots listed on the meal tickets and diet spreadsheet. A dietary staff member said she served the Brussel sprouts so residents would not start their meal without a vegetable, and the DON confirmed the residents should have received sliced carrots and that the menu and meal tickets were not followed.
Resident Choice and CNA Assignment: A resident with intact cognition and diagnoses including spastic diplegic cerebral palsy, MDD, and anxiety reported that a CNA would not help when asked and did not provide ADL assistance in the way she preferred to avoid pain. The resident said she did not want that CNA assigned to her because the CNA made her uncomfortable, but the DON and ADON told her she had to get used to the CNA and did not change the assignment.
Failure to provide quarterly personal funds statements for a resident with a trust account. The resident had moderately impaired cognition and diagnoses including dementia, Parkinson’s disease, and Alzheimer’s disease, and the RP was a family member. The resident stated she had not received statements, the RP confirmed she had not received them, and the Office Director could not provide evidence that the required quarterly statement was given to the resident or mailed to the RP, despite the facility policy requiring individual financial records to be available through quarterly statements.
A resident with cerebral palsy, MDD, and anxiety reported ongoing concerns with a CNA, stating the CNA would not help when asked, did not provide care the way she preferred, and made her uncomfortable. She told the ADON and DON she did not want that CNA caring for her, but the grievance was not documented or investigated, and the grievance log showed no filed complaint for the resident. The DON said no grievance form was completed because the resident could not explain what she complained about.
A resident was discharged without a discharge MDS assessment being completed and transmitted within the required timeframe. Record review showed the EHR did not contain a discharge MDS, and an MDS staff member confirmed the assessment should have been completed within 14 days after discharge.
Inaccurate MDS coding was found for two residents. One resident receiving Aspirin for paroxysmal atrial fibrillation was coded as taking an anticoagulant instead of an antiplatelet, and another resident’s MDS incorrectly listed an unplanned discharge even though the discharge home had been planned after skilled therapy ended and the record showed no evidence of an emergent discharge.
Improper Storage and Labeling of Respiratory Equipment: A resident’s CPAP mask was found stored in a dresser drawer without a plastic bag, another resident’s O2 tubing was observed on the floor beside a garbage can, and a third resident’s O2 tubing plus nebulizer mask and tubing were found without dates. An LPN confirmed the CPAP and O2 tubing storage issues, and the DON confirmed the nebulizer and O2 equipment should have been labeled with the date changed.
Delayed Dental Consult for a Resident With Dental Pain: A resident with severe cognitive impairment, broken teeth, and suspected abscessed tooth had a dental consult order entered, but the appointment was not arranged in a timely manner. The resident was observed with missing teeth, a dark-colored tooth, difficulty chewing, and facial grimacing during meals, while the SSD and an LPN confirmed the consult was not followed up and the resident was not seen when the dental team was in the facility.
Expired and past-best-by food items were found in dry storage during a kitchen tour, including prune juice and multiple loaves of bread. The Dietary Director confirmed the items should have been discarded by the dates printed on the products, and the facility policy required dry foods to be labeled, dated, and rotated using FIFO.
Infection control lapses were observed when a CNA fed two residents and repeatedly touched their utensils and cups without hand hygiene, and two CNAs handled dirty linen and then touched clean linen carts without washing or sanitizing their hands. A treatment cart on Hall A also had an open trash can with red biohazard bags and soiled PPE gowns overflowing and hanging out of the container, and the IP confirmed the waste was not contained or discarded appropriately.
A resident was transferred to the hospital, and the facility did not provide the required written notice specifying the duration of the bed-hold policy to the resident or responsible party. Review of documentation and staff interviews confirmed that the notification was either not sent or did not include the necessary information about the bed-hold duration.
A resident with multiple neurological conditions and a pressure ulcer was receiving scheduled pain medication as ordered, but the MDS assessment was inaccurately coded to reflect that no scheduled pain medication was given. Staff confirmed the resident did receive pain medication and acknowledged the assessment error.
Staff did not conduct required two-hour rounding or provide timely peri-care for a dependent resident with dementia and incontinence, resulting in the resident being left soiled for several hours, as confirmed by family reports and video evidence.
A resident was hospitalized and readmitted on two occasions, but the facility did not complete and transmit a comprehensive MDS assessment within the required 14-day period after each readmission. The facility also did not provide a policy on MDS completion time frames when requested by surveyors, and an interview with the MDS nurse was not granted.
A resident with a history of falls, muscle weakness, and cognitive deficits experienced two falls within a short period. The care plan was not updated with individualized interventions after these incidents, and only standard measures such as keeping the bed low and call light within reach were documented, despite these already being in place.
The facility failed to maintain resident dignity by allowing a CNA to stand while feeding residents, contrary to policy, and by not providing a privacy cover for a resident's urinary catheter bag. The CNA admitted to standing for convenience, and the DON confirmed the policy violation. Additionally, the LPN acknowledged the lack of a privacy cover for the catheter bag.
The facility failed to follow recipes for pureed and chopped diets, as observed when dietary staff prepared meals with unmeasured ingredients and without using available recipes. This oversight could impact the nutritional intake and dining experience of residents on specialized diets.
The facility failed to support two residents' choices, impacting their self-determination. One resident, with intact cognition, experienced repeated neglect in removing food trays from their room, attracting pests. Another resident, also cognitively intact, was served meals containing items they disliked, despite clear documentation of these preferences. Staff confirmed awareness of these issues but did not act accordingly.
Two residents experienced deficiencies in their living environment. One resident's bathroom had scratched and peeling walls with holes in the sheetrock, which was not reported for maintenance until surveyors visited. Another resident's bathroom had a shower curtain with black spots and residue, which remained unclean over several days despite cleaning policies. The facility's staff acknowledged these issues, indicating a failure to maintain a homelike environment.
The facility failed to update PASARR screenings for two residents with newly identified mental disorders. One resident had new psychiatric diagnoses not included in their existing screening from 2006, and another resident was diagnosed with mental illnesses in 2023 without a new screening being conducted. The Social Services Directors confirmed the absence of updated screenings.
A resident with multiple diagnoses, including End Stage Renal Disease and Tobacco Use, was found with cigarettes despite being assessed as an unsafe smoker requiring supervision. The care plan required the care team to store the resident's smoking materials, but this was not followed. Additionally, the facility failed to remove the resident's dialysis dressing as per physician's orders, leaving an old dressing with blood on the site. These actions indicate non-compliance with the care plan and physician's directives.
The facility failed to update care plans for two residents. One resident refused to wear an abdominal binder due to pain, but this was not documented, and the LPN did not inform the physician. Another resident's care plan was not updated to reflect a change from Full Code to DNR, as the MDS coordinators were unaware of the change.
A resident with a urinary catheter was observed with the catheter bag improperly positioned above the bladder on the arm of a wheelchair, rather than below the bladder as required. The resident, who had a history of refusing catheter care but had not refused in recent months, was confirmed by an LPN to have the catheter bag incorrectly placed.
A resident with a PEG tube for enteral feeding did not receive appropriate care as the facility failed to change the dressing daily as ordered. The dressing was found unchanged for three days, confirmed by an LPN and the ADON, despite physician's orders for daily cleansing and dressing application.
A resident with moderate cognitive impairment was found with eye drops at her bedside, which she sometimes self-administered without a formal assessment for self-administration. The facility's policy requires such an assessment, but it was not conducted, leading to improper medication storage.
Two residents did not receive timely and adequate meals due to the facility's failure to provide breakfast before their doctor's appointments. One resident, with multiple health conditions, missed breakfast due to a lack of plates and eggs, while another resident, with pulmonary and vascular issues, experienced frequent delays and cold meals. Both residents left for their appointments without eating, highlighting a deficiency in meal service.
The facility failed to provide timely meal delivery for 57 residents due to insufficient dietary staff in Kitchen 3. Meals were consistently delivered late, with breakfast and lunch trays observed being served past scheduled times. The Dietary Manager noted issues such as poor phone reception and the need for staff to walk to another kitchen for supplies, contributing to the delays.
A housekeeping staff member failed to notify nursing staff when a resident was heard yelling for help. Despite hearing the cries, the staff member continued with her duties without investigating or alerting the nursing team. The housekeeping supervisor confirmed that staff are expected to use the resident's call button or notify the supervisor if they hear a resident in distress. The facility administrator expressed disbelief at the staff member's inaction.
A facility failed to protect a resident's confidential information by not enabling a computer's privacy screen during a treatment for another resident. An unattended treatment cart with a visible computer screen displayed private medical information. The ADON confirmed that computer screens should be locked when unattended, and the LPN admitted to not locking the screen, thus breaching confidentiality policies.
A resident with a history of Traumatic Subdural Hemorrhage, Major Depressive Disorder, and Dementia was placed on a concave mattress to prevent falls, effectively restraining them without proper assessment or physician's orders. Staff did not consider the mattress a restraint, leading to a failure to conduct a necessary evaluation.
Failure to Obtain and Document Daily Weights for Residents with Fluid Management Needs
Penalty
Summary
The facility failed to follow physician orders to obtain and document daily weights for two residents with diagnoses including congestive heart failure and fluid overload. For one resident, there were 33 instances over several months where daily weights were not recorded, despite clear physician orders and care plan interventions specifying the need for daily monitoring. The resident's responsible party reported that the facility provided various excuses for not obtaining weights, such as malfunctioning equipment or inability to locate the scale, and that the facility did not implement the physician's orders in a timely manner. There was no documentation indicating that the resident refused to be weighed on the missed days. Staff interviews revealed that the CNA/Weight Tech was responsible for obtaining weights Monday through Friday, while floor CNAs were expected to obtain weights on weekends. However, the process for ensuring weights were obtained on weekends was not effectively managed, and nurses were identified as ultimately responsible for ensuring compliance with orders. The Assistant Director of Nursing (ADON) generated weekly weight reports but did not verify daily compliance by reviewing each resident's chart, resulting in unawareness of the missed weights. The Director of Nursing (DON) and ADON both confirmed that staff should have identified and addressed the missed weights, and that the resident could have been weighed even if in a chair using a Hoyer lift. A second resident with orders for daily weights also had undocumented weights on two consecutive weekends. The ADON confirmed that daily weights were ordered and acknowledged that staff did not identify the missed documentation. Both residents had medical conditions requiring close monitoring of fluid status, and the failure to obtain and document daily weights as ordered was confirmed through record review and staff interviews.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to implement physician orders and the plan of care for multiple residents. Resident #13 had diagnoses including end stage renal disease and diabetes type 2, and her physician ordered Nepro twice daily related to ESRD. The resident stated she had not received the supplement for several days, and the nurse stated it was on back order. An observation of the nutrition room found no Nepro available, and the QA nurse stated she was responsible for ensuring supplements were ordered and available, but could not provide evidence of when Nepro was last ordered. Resident #52 had diagnoses including cerebral infarction and hemiplegia affecting the right dominant side. Her physician ordered a carrot stretcher for the right hand contracture to be applied daily and removed once per day to clean the hand. Review of the July and August MAR and TAR showed no evidence the carrot stretcher was placed in the resident’s hand daily as ordered. During observation, the resident’s right hand was contracted into her palm, she was unable to open it, and she did not have a carrot stretcher or hand roll in her hand. The DON, ADON, and QA nurse confirmed the order and confirmed there was no documentation showing the device had been applied daily. Resident #69 had diagnoses including osteomyelitis of the vertebra, lumbar region. Her physician ordered Cefazolin Sodium 2 gm IV every 8 hours related to infection and inflammatory reaction due to an internal fixation device of the spine. Review of the MAR showed no evidence the medication was administered at 0400 on two dates. Resident #120 had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, difficulty walking, generalized muscle weakness, and other impairments, and her care plan and POC required two-person assistance for toileting every shift. During observation, one CNA changed and cleaned the resident’s soiled brief alone without calling for assistance, despite another CNA being available. Resident #65 had diagnoses including cognitive communication deficit, gastrostomy, diabetes, hemiplegia, dysphagia, and adult failure to thrive, and her physician ordered that she be placed in the dining room and supervised for all meals. She was observed in the dining room without staff monitoring or cueing during meals, and an LPN confirmed she had not been supervising the resident as ordered.
Menu Not Followed for Mechanical Soft Diets
Penalty
Summary
The facility failed to ensure menus were followed for 7 residents who were prescribed mechanical soft diets. The facility policy stated that menus must meet residents’ nutritional needs, and the diet spreadsheet showed that residents on mechanical soft diets were to receive sliced carrots with the meal served on 08/11/2025. During lunch observation in Dining Hall B, residents #1, #3, #71, #89, #121, #145, and #148 were all served whole Brussel sprouts on their plates instead of the ordered sliced carrots. Residents #1 and #145 ate all of the Brussel sprouts that were served, and resident #89 attempted to eat them but stated that she could not chew them. At 11:55 a.m., dietary staff brought a covered pan to the serving kitchen for Dining Hall B, and S25Dietary confirmed the pan contained sliced carrots. S25Dietary stated that the main kitchen was responsible for sending the carrots to Dining Hall B and that the meal tickets showed the mechanical soft residents were to receive sliced carrots, not Brussel sprouts. She stated that she served Brussel sprouts anyway because she did not want the residents to start their meal without a vegetable. The Dietary Director confirmed that residents on mechanical soft diets were to have sliced carrots with their meals and stated that the Dining Hall B dietary staff should have followed the menu and meal tickets and should have notified the main kitchen before serving any resident meals if the carrots were not received.
Resident Choice and CNA Assignment
Penalty
Summary
The facility failed to ensure Resident #49’s right to make choices about aspects of her life that were significant to her. Resident #49 was admitted with diagnoses including spastic diplegic cerebral palsy, major depressive disorder, and anxiety disorder, and her quarterly MDS showed a BIMS score of 15, indicating intact cognition. During an interview, she stated that she had ongoing concerns with S15CNA, including instances where she asked for assistance and the CNA would not help her, and that the CNA did not respect how she wanted assistance with ADLs in a way that would not increase her pain related to her cerebral palsy. Resident #49 stated that she did not want S15CNA as her CNA because the CNA made her uncomfortable and she did not like the way she was cared for. She reported that she had discussed this with the former administrator, S5ADON, and S2DON, but was told she had to get used to the CNA and that CNA assignments would not be changed. S2DON and S5ADON confirmed that the resident had requested not to have S15CNA assigned to her, but S2DON stated she did not remove the CNA from the resident’s assignment because there had to be a legitimate reason and it would not be fair to the CNA. Instead, S2DON instructed that another CNA accompany S15CNA in the room, and S15CNA remained assigned to Resident #49 despite the resident’s request.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to ensure that individual financial records were provided to a resident through quarterly statements for Resident #35, who had a personal funds account at the facility. During an interview, Resident #35 stated she had not received quarterly statements for her personal funds account. Review of the resident’s MDS showed a BIMS score of 11, indicating moderately impaired cognition, and the admission record listed diagnoses including unspecified dementia, Parkinson’s disease, and Alzheimer’s disease. The record also identified a family member as the resident’s Responsible Party. Interviews with the Office Director showed the facility’s process was to give quarterly statements to residents who were their own Responsible Party and to mail statements to the Responsible Party when the resident was not. The Office Director confirmed that a resident admitted in April 2025 should have received a quarterly statement in June 2025, but could not provide evidence that Resident #35 received one or that a statement was mailed to the Responsible Party. The resident’s Responsible Party also confirmed that she had not received quarterly statements from the facility. The facility policy stated that the individual financial record shall be available through quarterly statements.
Failure to Address Resident Grievance About CNA Care
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances without discrimination or reprisal and did not establish prompt efforts to resolve her complaint. Resident #49 was admitted with diagnoses including spastic diplegic cerebral palsy, major depressive disorder, and anxiety disorder, and her MDS showed a BIMS score of 15, indicating intact cognition. She told surveyors that she had ongoing concerns with a CNA, stating the CNA would not help when she asked for assistance, did not respect how she wanted help with ADLs, and increased her pain related to her cerebral palsy. She also stated that the CNA had been fired and later rehired, and that she had told the former administrator, the ADON, and the DON that she did not want that CNA caring for her because the CNA made her uncomfortable. The resident reported that she was told she had to get used to the CNA and that room changes or CNA assignment changes were not done. Review of the grievance log from April 2025 through August 2025 did not show a grievance filed for Resident #49. During interview, the DON and ADON confirmed they had spoken with the resident about the CNA issue several weeks earlier, but the DON stated no grievance form or investigation was completed because the resident could not explain what she complained about. The facility policy stated that grievances and complaints would be considered, responded to in writing, and investigated by the grievance officer, with results maintained on file.
Late Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure a discharge MDS assessment was completed and transmitted within 14 days after Resident #111 was discharged. Record review showed the resident was admitted on 03/24/2025 and discharged on 06/13/2025, but the EHR did not reveal a discharge MDS assessment. The facility’s CMS RAI Manual policy stated that for non-admission OBRA and PPS assessments, the MDS completion date must be no later than 14 days after the ARD. During an interview and record review on 08/12/2025, S4MDS confirmed that Resident #111 did not have a discharge MDS assessment and that it should have been completed and transmitted within 14 days after discharge.
Inaccurate MDS Coding for Medication and Discharge Status
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately code the Minimum Data Set (MDS) for two residents. For one resident with diagnoses including paroxysmal atrial fibrillation, the physician ordered Aspirin 81 mg daily, and the MAR showed the medication was administered daily throughout July 2025. However, the annual MDS with an ARD of 07/09/2025 coded the resident as taking an anticoagulant and left antiplatelet use blank. During interview and record review, the MDS nurse confirmed the resident was not prescribed an anticoagulant, was prescribed Aspirin, and that the MDS was coded incorrectly. For another resident, the care plan documented a goal to return to the community after skilled therapy services, and the MDS assessment showed the resident’s overall goal was discharge to the community with a discharge plan marked yes and a referral made to the Local Contact Agency. Even so, the assessment also coded the discharge status as Home/Community, entry/discharge reporting as Discharge return not anticipated, and the type of discharge as unplanned. The record contained no evidence of an unplanned or emergent discharge, and the MDS nurse confirmed the resident was admitted for skilled services and discharged home after skilled service days ended, with the discharge having been planned.
Improper Storage and Labeling of Respiratory Equipment
Penalty
Summary
The facility failed to ensure oxygen equipment was stored appropriately when not in use for 3 of 5 sampled residents reviewed for respiratory care. The facility’s policies for Oxygen Administration and administering medications through a small volume nebulizer did not address oxygen equipment storage, while the CPAP/BiPap policy stated that masks, nasal pillows, and tubing should be placed in a zip lock bag once dry until used again. For Resident #116, who had diagnoses including obstructive sleep apnea, pulmonary hypertension, and pleural effusion, a CPAP mask was observed stored in the top drawer of the bedside dresser without a plastic bag, and an LPN confirmed it should have been stored in a bag. For Resident #89, who had diagnoses including dysphagia following cerebral infarction, type 2 diabetes mellitus, emphysema, and asthma, an oxygen concentrator was observed running with oxygen tubing on the floor beside the garbage can, and an LPN confirmed the tubing should not have been on the floor. For Resident #30, who had diagnoses including pneumonia, lung abscess with pneumonia, acute respiratory failure with hypoxia, and chronic respiratory failure with hypoxia, oxygen at 2 L NC and albuterol nebulizer treatments were ordered, but the resident’s MAR and TAR showed no evidence that the nebulizer mask and tubing or oxygen tubing were changed. During observation, the oxygen tubing had no date on it and the nebulizer mask and tubing were on the countertop without a date, and the DON confirmed they should have been labeled with the date they were changed.
Delayed Dental Consult for Resident With Dental Pain
Penalty
Summary
The facility failed to make a timely dental appointment for a resident who had an order dated 08/06/2025 for a dental consult related to dental pain in the right upper gums, broken teeth, and redness and tenderness. The resident had multiple diagnoses including cerebral infarction, diabetes mellitus, speech and language deficits following cerebral infarction, dysarthria following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and depressive disorders. The resident’s MDS admission assessment showed a BIMS score of 07, indicating severely impaired cognition, and the care plan identified a need for dental care due to dental pain and a potentially abscessed tooth. Observation on 08/11/2025 showed missing teeth and a dark-colored bottom left tooth. Later that day, the resident was observed during lunch eating white beans, rice, carrots, and cornbread, consumed 25% of the meal, had difficulty chewing, would not fully close the mouth to bite down and chew, and was observed with facial grimaces while eating. The Social Services Director stated she was responsible for arranging dental consults and that the resident was not seen when the dental team was in the facility on 08/11/2025 and 08/12/2025. An LPN confirmed she entered the dental consult order into the computer but did not follow up and assumed the order had been completed.
Expired Food Found in Dry Storage
Penalty
Summary
Food was not stored in accordance with professional standards, and expired foods were not removed from the kitchen. During an initial kitchen tour with the Dietary Director, surveyors observed 15 cups of prune juice on a dry storage shelf with an expiration date of 07/03/2025, 4 loaves of bread with a best use by date of 07/24/2025, 22 loaves of bread with a best by date of 08/06/2025, and 10 loaves of bread with a best by date of 08/08/2025. The Dietary Director confirmed that the expired and past-best-by items should have been discarded by the date printed on the food items. The facility policy stated that dry foods stored in bins are to be removed from original packaging, labeled and dated, and rotated using a first in-first-out system.
Infection Control Lapses With Hand Hygiene and Medical Waste Disposal
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. During observations in the dining room, S17CNA was feeding two residents and repeatedly touched the residents’ utensils and cups without performing hand hygiene. In interview, S17CNA confirmed she had not used hand sanitizer between feeding the two residents and stated she did not have sanitizer in her pocket at the time, though she should have had it and used it while assisting them. On Hall A, a treatment cart was observed with its trash can lid open and lined with a red biohazard bag. A yellow soiled disposable personal protective gown was hanging halfway outside the bag, along with other discarded materials and smaller biohazard bags; a later observation showed the same cart still overflowing with soiled gowns and biohazard bags not contained appropriately. On Hall W, S21CNA and S22CNA were each observed disposing of dirty linen in the hopper room and then immediately handling clean linen carts without performing hand hygiene. Both CNAs confirmed they did not wash or sanitize their hands after handling contaminated linen and before touching clean linen. The Infection Preventionist stated the CNAs should have sanitized their hands between contact with contaminated and clean surfaces.
Failure to Provide Written Bed-Hold Duration Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a resident or their responsible party with written notice specifying the duration of the bed-hold policy at the time of transfer to the hospital. Review of the facility's policy indicated that the business office is responsible for informing residents or their representatives about readmission appeal rights and bed-hold policies. However, examination of the Emergency Transfer Log for the relevant period showed that the section for written notification to the resident was left blank for the resident who was transferred and later returned. Interviews with the Social Services Director revealed a lack of awareness regarding the requirement to send written notification about the bed-hold duration or payment policy at the time of transfer. Additionally, review of the Bed Hold Agreement provided by the Administrative Assistant confirmed that it did not include information explaining the duration of the bed-hold.
Inaccurate MDS Assessment for Pain Medication Administration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident. A resident with a history of metabolic encephalopathy, cerebral infarction, memory deficit, and hemiplegia was admitted to the facility and had a physician's order for scheduled Tylenol for pain management. During an interview, the resident reported experiencing pain from a pressure ulcer and confirmed receiving pain medication, which was supported by physician orders. However, review of the resident's quarterly MDS assessment showed that it was incorrectly coded to indicate that the resident did not receive any scheduled pain medications during the look-back period. Staff responsible for completing the MDS assessment confirmed during interviews that the resident did receive pain medication and acknowledged the error in coding.
Failure to Provide Timely ADL Care and Rounding for Dependent Resident
Penalty
Summary
Facility staff failed to provide required Activities of Daily Living (ADL) care for a dependent resident who was unable to perform self-care. The resident, who had diagnoses including unspecified dementia and urinary tract infection, was always incontinent of bowel and bladder and required substantial or maximal assistance for toileting. Medical record review and interviews revealed that certified nursing assistants (CNAs) were expected to round every two hours to ensure residents were clean, provided with peri-care, and had their needs met. However, video evidence from the resident's electronic monitoring device showed that staff did not perform peri-care or rounds at the required intervals, resulting in the resident being left soiled for several hours. The deficiency was further substantiated by interviews with the resident's family member, who reported that the resident was not being rounded on every two hours and was left soiled for extended periods. The facility administrator confirmed that staff were instructed to round every two hours but could not provide video evidence to support that this was done for the resident in question. The failure to conduct timely rounds and provide necessary ADL care was observed for one resident out of three sampled, as documented by both family reports and video footage.
Failure to Complete Timely Comprehensive MDS Assessment After Readmission
Penalty
Summary
The facility failed to complete and transmit a comprehensive Minimum Data Set (MDS) assessment within the required 14-day timeframe following a resident's readmission after hospitalization. Record review showed that one resident was hospitalized and subsequently readmitted on two separate occasions, but the electronic clinical record did not contain evidence that a comprehensive MDS assessment was completed and transmitted within 14 days after each readmission. Additionally, when surveyors requested the facility's policy on MDS completion and submission time frames, no policy was provided by the time of survey exit. An interview with the MDS nurse could not be conducted as requested by surveyors, as the Regional Administrator required questions to be submitted in writing.
Failure to Develop Resident-Specific Care Plan After Multiple Falls
Penalty
Summary
The facility failed to develop and implement a complete, resident-specific care plan following two documented falls for one resident. The resident, who had a history of falls, muscle weakness, abnormal gait, cognitive deficits, dementia, and a prior femur fracture, experienced two falls within a five-day period. Nursing progress notes detailed that the resident was found on the floor on both occasions, once next to the bed and once partially under the bed, with the second incident involving incontinence and an attempt to use the bathroom independently. Review of the resident's care plan revealed that interventions such as keeping the call bell and assistive devices within reach and toileting before bed were already in place. After the second fall, the only update to the care plan was to keep the bed in the lowest position and the call light within reach, which staff acknowledged were standard interventions and not specific to the resident's needs. The quality nurse confirmed that no new, individualized interventions were added to address the resident's repeated falls.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal assistance and in the management of a urinary catheter. Observations revealed that a Certified Nursing Assistant (CNA) was standing while feeding three residents, which is against the facility's policy that requires staff to sit while assisting residents with meals to ensure their dignity. The CNA admitted to standing because it was easier for her, acknowledging that she should have been sitting. The Director of Nursing confirmed that staff should not stand over residents during meal assistance. Additionally, the facility did not maintain the dignity of a resident with a urinary catheter by failing to provide a privacy bag or covering for the urine collection bag. Observations showed the catheter drainage bag was visible and not covered while the resident was in bed and in a wheelchair, exposing the contents to others. A Licensed Practical Nurse confirmed that the catheter drainage bag should have had a privacy covering, which it did not.
Failure to Follow Recipes for Pureed and Chopped Diets
Penalty
Summary
The facility failed to ensure that recipes for pureed and chopped diets were followed, which could potentially affect the nutritional intake and dining experience of residents. During an observation, the Dietary Supervisor was seen preparing a pureed dessert without using a recipe, adding unmeasured amounts of ingredients such as chocolate peanut butter bars and milk. Similarly, a cook was observed preparing pureed black-eyed peas and rice without using recipes, adding unmeasured amounts of milk and thickener, and failing to measure the portions served to residents. The Dietary Manager confirmed that recipes were available in the kitchen and should have been used by the staff. The cook, who was filling in, was unaware of the recipes and did not use them while preparing meals for residents on pureed diets. This lack of adherence to recipes and portion control could lead to inadequate nutritional intake for the residents who rely on these specialized diets.
Failure to Support Resident Choices in Meal Preferences and Room Cleanliness
Penalty
Summary
The facility failed to promote and facilitate residents' self-determination by not supporting their choices regarding significant aspects of their lives. For Resident #25, the facility did not remove completed food trays from the resident's room, despite the resident's expressed dislike for this practice due to concerns about attracting roaches. The resident, who has intact cognition as indicated by a BIMS score of 15, reported that this issue occurred frequently. A CNA confirmed that she was responsible for picking up the trays on the specified date but failed to do so. For Resident #35, the facility did not adhere to the resident's documented food preferences. Despite having a BIMS score of 15, indicating intact cognition, and clear documentation of food dislikes such as oatmeal and bacon, these items were repeatedly served to the resident. Observations confirmed that the resident received meals containing these disliked items, and the Assistant Director of Nursing acknowledged that the meal tickets clearly indicated these preferences, which were not followed.
Failure to Maintain a Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a homelike environment for two residents, as observed during a survey. Resident #1's bathroom was found to be in disrepair, with scratched and peeling walls and four holes in the sheetrock. The Assistant Director of Nursing confirmed the condition and stated that maintenance was responsible for repairs. The Maintenance Supervisor revealed that he was only made aware of the issue when surveyors were present, despite the facility's policy of conducting Ambassador Rounds to report such issues. The Director of Nursing, who was responsible for Resident #1's room, admitted to not reporting the maintenance needs until the surveyors' visit. Resident #123's bathroom was also found to be lacking in cleanliness, with a shower curtain covered in black spots and residue. Despite the facility's policy requiring regular cleaning and disinfection, the shower curtain remained unclean over multiple days. The Housekeeping Supervisor confirmed the condition of the shower curtain and acknowledged that the housekeeping staff was responsible for its maintenance. These observations indicate a failure in maintaining a clean and homelike environment for the residents.
Failure to Update PASARR Screenings for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer residents with newly identified mental disorders to the appropriate state-designated authority for review, as required by the Pre Admission Screening and Resident Review (PASARR) program. For Resident #16, the facility did not update the Level I PASARR screening upon admission in 2021, despite the resident having new psychiatric diagnoses of Unspecified Psychosis and Psychotic Disorder with Hallucinations. The only Level I screening available was from 2006, completed at another facility, which did not include these diagnoses. The Social Services Director confirmed the absence of an updated screening. Similarly, for Resident #125, the facility did not conduct a new Level I PASARR screening after the resident was diagnosed with mental illnesses, including Dementia without Behavior Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder in 2023. The existing Level I screening from 2022 did not reflect these diagnoses. Interviews with the Social Services Directors confirmed that no new screening was submitted to the appropriate agency following the new diagnoses.
Failure to Follow Care Plan for Resident's Smoking and Dialysis Dressing
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as Resident #72, by not ensuring that the resident did not have cigarettes in her possession and by not following the physician's orders regarding the removal of the resident's dialysis dressing. The resident, who was admitted with diagnoses including Encephalopathy, End Stage Renal Disease, Anxiety Disorder, Altered Mental Status, and Tobacco Use, was observed holding a pack of cigarettes on her lap while wheeling herself down the hall. Despite being assessed as an unsafe smoker requiring supervision, the resident was found with cigarettes, contrary to the care plan intervention that required the care team to store her smoking materials. The Director of Nursing confirmed that the resident should not have had cigarettes in her possession. Additionally, the facility did not follow the physician's orders to remove the resident's dialysis dressing on specified days. An observation on June 12 revealed that the resident had an old dressing on her left arm covering the dialysis cannulation site, with old blood noted on the dressing. The LPN confirmed that the dressing should have been removed earlier in the week, as per the physician's orders. These failures indicate a lack of adherence to the established care plan and physician's directives for the resident.
Care Plan Revisions Not Updated for Two Residents
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to deficiencies in their care. Resident #25, who was admitted with a ventral hernia, had a physician's order for an abdominal binder to be worn during the day for support. Despite this order, the resident consistently refused to wear the binder due to increased pain, which was not documented in the care plan. Observations and interviews confirmed that the resident was not wearing the binder on multiple occasions, and the LPN admitted to not applying it and failing to inform the physician of the resident's refusal. Resident #89's care plan was not updated to reflect a change in their code status from Full Code to DNR, as indicated by a physician's order and the resident's Lapost. The MDS coordinators responsible for updating the care plan were unaware of the change in code status, resulting in the care plan inaccurately stating the resident was Full Code. This oversight was identified during a review of the facility's policy on Advanced Directives, which requires the care plan to align with the resident's documented treatment preferences.
Improper Positioning of Urinary Catheter Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency. The resident, who was admitted with diagnoses including Bladder Disorder and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, had an intact cognitive status as indicated by a BIMS score of 15. Observations on the morning of June 10, 2024, revealed that the resident's urinary catheter bag was improperly positioned on the arm of his wheelchair, above the level of his bladder, rather than below it as required. An LPN confirmed the incorrect positioning during an interview and observation, acknowledging that the catheter bag should have been placed below the bladder. The resident had a history of refusing catheter care, but had not refused care in the past couple of months.
Failure to Change PEG Tube Dressing as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a PEG tube. The resident, who was admitted with diagnoses including malignant neoplasm of overlapping sites of the oropharynx and carcinoma in situ of the skin of the right upper limb, was receiving 26-50% of his nutrition through tube feeding. According to the physician's orders, the PEG site was to be cleansed with soap and water, patted dry, and a split gauze dressing applied daily. However, during an observation and interview, it was found that the dressing on the resident's PEG tube site had not been changed for three days, as it was dated three days prior. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, confirmed that the dressing had not been changed as required by the physician's orders. Both staff members acknowledged that the dressing should have been changed daily, as per the orders, but it had not been done, leading to a lapse in the care provided to the resident. This oversight in following the prescribed care regimen for the PEG tube site represents a deficiency in the facility's adherence to medical orders and protocols for enteral feeding care.
Improper Medication Storage and Self-Administration
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by eye drops being left at the bedside of a resident. The resident, who was admitted with diagnoses including preglaucoma and occipital neuralgia, had a BIMS score indicating moderate cognitive impairment. Despite this, the resident was found to have eye drops on her dresser and at her bedside, which she sometimes administered herself without a formal assessment for self-administration by the interdisciplinary care planning team. The facility's medication administration policy requires that residents may only self-administer medications if deemed safe by the attending physician and care planning team. However, the resident had not been assessed for this capability. An LPN confirmed that the eye drops should not have been left at the bedside, indicating a lapse in adherence to the facility's medication storage and administration policies.
Failure to Provide Timely and Adequate Meals
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet to meet the nutritional needs of two residents. Resident #51, who has multiple diagnoses including Acute Kidney Failure and Celiac Disease, did not receive breakfast on the morning of 06/10/2024 before leaving for a doctor's appointment. The resident reported that the kitchen was out of plates and eggs, and a CNA confirmed that the resident did not receive her breakfast tray before her appointment. The resident left for her appointment without eating and did not have a meal until lunch upon her return. Resident #92, diagnosed with Interstitial Pulmonary Disease and Peripheral Vascular Disease, was also affected by the facility's failure to provide timely meals. On the same morning, the resident was scheduled for a doctor's appointment and did not receive breakfast because it was late. Both the resident and a family member reported that meals were frequently late and cold. An LPN confirmed that breakfast should have been served by 8:00 a.m., and any delay beyond that time was considered late. As a result, the resident left for her appointment without having breakfast.
Delayed Meal Service Due to Insufficient Dietary Staff
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal delivery for 57 residents consuming meals from Kitchen 3. According to the facility's policy, residents should receive meals at scheduled times, with breakfast at 7:30 a.m. and lunch at 11:30 a.m. However, interviews and observations revealed that breakfast and lunch trays were consistently delivered late to residents on Hall A. For instance, a resident reported not receiving breakfast until almost 9:00 a.m., and another resident confirmed that breakfast was often late. Observations on June 10 and June 11 showed that the last breakfast and lunch trays were delivered significantly past the scheduled times. The Dietary Manager (S11DM) acknowledged that Kitchen 3 faced challenges, including poor phone reception and the need for staff to walk to Kitchen 1 for additional supplies, which contributed to delays. The Dietary Supervisor (S23DS) confirmed that all food was prepared in Kitchen 1, with Kitchens 2 and 3 used for distribution. The lack of coordination and communication between the kitchens and the CNAs responsible for distributing meal trays further exacerbated the issue, leading to the deficiency in timely meal service.
Failure to Notify Nursing Staff of Resident's Distress
Penalty
Summary
The facility failed to ensure that environmental staff possessed the necessary qualifications or competencies, as evidenced by an incident involving a housekeeping staff member, S9Hsk, who did not notify nursing staff when a resident was heard yelling for help. During a random observation, a surveyor noted that Resident #93 was yelling for help from behind a closed door. Despite hearing the resident's cries, S9Hsk continued with her duties without investigating or notifying the nursing staff. This incident occurred shortly after S9Hsk was hired, and she confirmed that she had completed onboarding training, which included instructions to report any changes in a resident's behavior to the nursing staff. The housekeeping supervisor, S8HskSup, confirmed that the expectation for housekeeping staff is to use the resident's call button to alert the nursing staff and wait with the resident until help arrives. Alternatively, they should notify the supervisor by cell phone if they cannot reach the call button. However, S9Hsk did not follow these procedures and failed to notify anyone about the resident's distress. The facility administrator expressed disbelief that S9Hsk did not interpret the resident's screaming as a sign of distress, indicating a gap in the staff's understanding of their responsibilities in such situations.
Failure to Protect Resident Confidential Information
Penalty
Summary
The facility failed to protect confidential information for a resident by not enabling the computer's privacy screen during a treatment being administered to another resident. This incident was observed when a treatment cart was left unattended outside a resident's room with the computer screen visible, displaying private medical information about another resident. The facility's policy on confidentiality and personal privacy, which was last reviewed in January 2024, mandates that personal and medical records be safeguarded and access limited to authorized staff. During interviews, the Assistant Director of Nursing confirmed that the expectation for treatment carts is the same as for medication carts, requiring computer screens to be locked when unattended. The Treatment LPN, responsible for documenting on the computer present on the treatment cart, acknowledged that the privacy screen should be locked when the cart is left unattended. She admitted to not locking the computer screen when she left the cart in the hallway to provide care to a resident, thus failing to protect the confidentiality of resident information.
Failure to Ensure Resident is Free from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary physical restraints. The resident, who had a history of Traumatic Subdural Hemorrhage, Major Depressive Disorder, and Dementia, was placed on a concave mattress as a fall prevention measure. However, there was no physician's order or assessment for the use of this mattress, which effectively restrained the resident by preventing them from getting out of bed without assistance. Interviews with various staff members, including the Hospice Nurse, Assistant Director of Nursing, Director of Nursing, and a Licensed Practical Nurse, revealed that the concave mattress was used to prevent the resident from rolling out of bed, but none of them considered it a restraint, and therefore, no restraint assessment was completed. The facility's policy on the use of restraints states that restraints should only be used to treat a resident's medical symptom and never for discipline, staff convenience, or fall prevention. Despite this policy, the concave mattress was used without proper assessment or physician's orders, effectively restraining the resident. The staff's misunderstanding of what constitutes a restraint led to the failure to conduct a necessary evaluation, resulting in the resident being subjected to an unnecessary physical restraint.
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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) |
|---|---|---|---|---|
| Cornerstone At The Ranch | 1 mi | ★★★★★ | 0 | 0 |
| Louisiana Extended Care Hospital Of Lafayette | 3.9 mi | ★★★★★ | 8 | 0 |
| Camelot Rehabilitation At Magnolia Park | 4.2 mi | ★★★★★ | 4 | 0 |
| Camelot Of Broussard | 4.2 mi | ★★★★★ | 8 | 0 |
| Lady Of The Oaks Retirement Manor | 4.8 mi | ★★★★★ | 0 | 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.