Below average — CMS composite of the measures below.
The next survey window likely opens 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 River Oaks Retirement Manor during CMS and state inspections, most recent first.
Failure to document verbal orders for a resident’s medications. A resident with stroke, dementia, UTI, and severe cognitive impairment had Invanz, Lidocaine HCL, and Sodium Chloride listed on the MAR, but the EMR did not contain written physician orders or nurse documentation for the medications. The DON confirmed the missing documentation and stated the nurse should have entered the order into the record and documented it in a progress note or nurse assessment.
Daily nurse staffing information was not posted in a prominent, readily accessible location for residents and visitors. A surveyor could not initially locate the posting in the main areas and only found it in a small alcove off a main walkway near the employee time clock and doors marked Laundry, Boiler Room, and Employees Only. The DON acknowledged the location could be perceived as not very visible.
Failure to Remove Used PPE Before Exiting Resident Room: A Treatment Nurse was observed completing wound care for a resident on enhanced barrier precautions and then exiting the room wearing the same gown and gloves used during care. The ADON observed the event and confirmed the PPE should have been removed and discarded inside the room before the nurse left. The DON later reviewed the EBP policy and confirmed PPE should be discarded in a trash can inside the resident’s room.
The facility did not ensure that the most recent complaint survey results were available for residents and visitors to review. During a Resident Council meeting, residents with intact cognition were unaware of where to find state inspection results. The survey results binder, located near the entrance, lacked the latest complaint survey results. Interviews revealed that the DON was responsible for updating the binder but failed to do so.
Two residents experienced deficiencies in their living environment. One resident with paraplegia had stained bed linens that were not changed despite multiple observations. Another resident with cerebral infarction had a toilet seat that was partially detached, which was not addressed due to a lack of regular maintenance checks. These issues were confirmed by staff, including CNAs and the Maintenance Supervisor.
A resident with intact cognition reported missing brown pants to a laundry employee, who failed to report the issue to the Social Services Director, preventing the initiation of a grievance process. The facility's policy requires grievances to be promptly investigated and resolved, which did not occur in this instance.
A facility failed to follow a physician's order for a resident's indwelling catheter size, using a 16 Fr/5 cc bulb instead of the prescribed 16 Fr/10 cc bulb. The resident had multiple urinary conditions, and the discrepancy was confirmed by the DON, with no new order for the smaller catheter size.
A facility failed to ensure the correct use and installation of bed rails, leading to a resident's entrapment and injury. The facility did not use appropriate alternatives before bed rails, nor did it ensure bed dimensions were suitable for residents. A resident became entrapped between an air mattress and a modified bed rail, resulting in a fracture. The facility's staff were not adequately trained, and maintenance did not follow manufacturer's guidelines, contributing to the incident.
A facility failed to effectively oversee the use of bed rails, resulting in a resident becoming entrapped and sustaining a fracture. The administration did not follow manufacturer's guidelines for bed rail use, affecting five residents. Staff interviews revealed a lack of training and adherence to safety protocols, and care plans lacked specific interventions for bed rail safety.
Failure to Document Verbal Orders for Resident Medication Administration
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality when a nurse did not follow the facility’s verbal orders policy for Resident #3. The policy stated that physician orders received by telephone were to be entered into the medical record manually or electronically. Resident #3’s record showed she was admitted with diagnoses including stroke, dementia, and UTI, and her BIMS score was 3, indicating severe cognitive impairment. Review of Resident #3’s November 2025 MAR showed multiple medications, including Invanz injections, Lidocaine HCL injection, and Sodium Chloride IV solution, with discontinue dates listed on the MAR. However, review of the electronic medical record, including physician orders, progress notes, and nurse assessment notes, did not reveal written physician orders for those medications. The DON reviewed the record and confirmed there were no written physician orders on the MAR for the medications, and also confirmed there was no written physician order by the nurse on a progress note or nurse assessment for the Sodium Chloride on 11/14/2025 and Invanz on 11/16/2025.
Daily Nurse Staffing Information Not Posted in a Prominent Location
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. The facility policy titled "Posting Direct Care Daily Staffing Numbers," last reviewed on 04/05/2025, stated that the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care is to be posted in a prominent location accessible to residents and visitors and in a clear and readable format. On 12/08/2025, a surveyor observed the main prominent areas of the facility and was unable to visually locate the staffing information. After asking a staff member for assistance, the surveyor was directed to a small alcove off a main walk area where bulletin boards and the employee time clock were located, and the staffing information was posted on a back wall bulletin board. The surveyor and the DON later observed that the staffing information was posted on the inner wall of the alcove near a main hallway, connected to a small hall with doors labeled Laundry, Boiler Room, and Employees Only, and it was not easily visible from the main walk area. The DON stated that the location used to post the daily nurse staffing information could be perceived as not a very visible area.
Failure to Remove Used PPE Before Exiting Resident Room
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff did not remove PPE before exiting a resident’s room that was on enhanced barrier precautions. During observation on 12/09/2025 at 8:50 a.m., the Treatment Nurse was seen completing wound care/treatment for Resident #28 and then exiting the room wearing the same gown and gloves used during the treatment. When asked, the nurse stated she should not have exited the room wearing the used PPE. The Assistant Director of Nurses was present in the hall outside the room and observed the nurse exit while still wearing the PPE. The Assistant Director of Nurses confirmed the used PPE should have been removed and discarded inside the resident’s room before exiting. The Director of Nurses later reviewed the enhanced barrier precautions policy and confirmed that PPE should be discarded in a trash can inside the resident’s room and not after leaving the room.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to maintain resident rights by not ensuring that the results of the most recent complaint survey were available for residents, visitors, or other individuals to review. This deficiency was identified during a Resident Council meeting attended by four residents, all of whom had intact or moderately intact cognition as indicated by their BIMS scores. These residents were unaware of the availability and location of the state inspection results. An observation confirmed that the facility's binder, labeled 'Annual State Survey Results' and located near the entrance, did not contain the most recent complaint survey results. Interviews with facility staff revealed a lack of clarity and execution of responsibilities regarding the updating of the survey results binder. The Administrator indicated that it was the Director of Nursing's responsibility to update the binder. The Director of Nursing confirmed this responsibility and acknowledged that the most recent complaint survey results were not included in the binder, thus not available for review by residents, visitors, or other individuals.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. Resident #47, who has diagnoses including paraplegia, muscle wasting and atrophy, and unspecified dementia, was observed on multiple occasions with bed linens that had dark red stains. Despite the observations made on consecutive days, the stained linens were not changed, which was confirmed by two CNAs and the Director of Nursing, who acknowledged that linens should be clean and free of stains. Resident #74, with diagnoses including cerebral infarction, hemiplegia and hemiparesis, and dysphagia, was found to have a toilet seat cover and seat that were partially detached from the toilet. This was confirmed by the resident, two CNAs, and the Maintenance Supervisor. The Maintenance Supervisor admitted that he did not conduct regular checks in residents' rooms and only addressed issues when they were reported in the maintenance work order binder. This lack of maintenance oversight contributed to the unsafe and non-homelike environment for Resident #74.
Failure to Initiate Grievance Process for Missing Personal Item
Penalty
Summary
The facility failed to initiate a grievance process for a resident who reported a missing personal item. The resident, who had intact cognition as indicated by a BIMS score of 15, reported to a laundry employee that a pair of her brown pants had been missing for four months. Despite this report, the laundry employee did not inform the Social Services Director (SSD) about the missing item, which is a necessary step for creating an official grievance. The Social Services Director confirmed that she was not informed about the missing pants and acknowledged that the resident had an inventory log of the pants labeled with her name. The facility's grievance policy requires that any grievances or complaints be promptly investigated and resolved, but this process was not initiated in this case due to the failure of the laundry employee to report the issue to the SSD.
Failure to Follow Physician's Order for Catheter Size
Penalty
Summary
The facility failed to implement the resident's plan of care by not adhering to a physician's order regarding the size of an indwelling catheter for a resident. The resident, who was admitted with conditions including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Retention of Urine, Overactive Bladder, Hydronephrosis with Renal and Ureteral Calculous Obstruction, and Urinary Tract Infection, had a physician's order for a 16 Fr/10 cc bulb catheter. However, during an observation, it was noted that the resident had a 16 Fr/5 cc bulb catheter instead. The Director of Nursing confirmed that the nurse should have used the 16 Fr/10 cc bulb catheter as per the doctor's order and verified that there was no new order for the smaller bulb catheter.
Improper Bed Rail Use Leads to Resident Entrapment and Injury
Penalty
Summary
The facility failed to ensure the correct use and installation of bed rails, leading to a significant risk of entrapment for residents. The facility did not identify and use appropriate alternatives before resorting to bed rails, nor did it ensure that the bed dimensions were suitable for the residents' size and weight. This oversight resulted in the use of incompatible bed frames, mattresses, and bed rails, which were not installed according to the manufacturer's recommendations. Additionally, the facility did not adequately assess the residents' risk for entrapment and safety before applying modified side rails with wooden boards, which were not recommended by the manufacturer. The deficiency was highlighted by an incident involving a resident who attempted to climb over the modified side rail and became entrapped between the air mattress and the bed rail. This resulted in a left femoral neck fracture, requiring surgical intervention. The resident's care plan did not include specific interventions for the use of the bed rails, nor did it provide for direct monitoring and supervision to ensure safety and reduce the risk of entrapment. The facility's failure to document or assess the resident's cognition, size, weight, and medical conditions further contributed to the incident. The facility's maintenance staff routinely installed bed rails with wooden boards without referring to the manufacturer's guidelines, and there was no documented evidence of inspections to ensure the safety and compatibility of the equipment. The facility's staff, including CNAs and nurses, were not adequately trained on what to do if a resident became entrapped in the bed rails, and there was no specific training provided prior to the incident. The facility's administration was aware of the use of wooden boards but did not verify their appropriateness or compliance with safety guidelines.
Deficiency in Bed Rail Oversight Leads to Resident Injury
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a deficiency in the oversight of bed rail use, assessment, and monitoring. This deficiency was identified when Resident #1 attempted to climb over a boarded side rail and became entrapped between the air mattress and the modified bed rail, resulting in a left femoral neck fracture. The facility did not have a system in place to ensure the appropriate use of bed rails according to the manufacturer's guidelines, which contributed to the incident. The deficiency was further compounded by the fact that four other residents (#R1, #R2, #R3, and #R4) were using the same type of bed, air mattress, and modified bed rail as Resident #1, putting them at high risk of entrapment. The facility's administration did not refer to the manufacturer's recommendations for the proper use of bed rails and failed to assess and monitor these residents adequately. The administration believed the benefits of the boarded bed rails outweighed the risks, despite the potential for serious injury. Interviews with facility staff revealed a lack of adherence to manufacturer's guidelines and insufficient training on resident entrapment. The Director of Nursing (S1DON) and the Administrator (S2ADM) acknowledged that the boarded bed rails were in place before their tenure and had not been questioned or assessed for safety. Maintenance staff also confirmed that they did not follow manufacturer's guidelines when installing the bed rails. The facility's care plans did not include specific interventions or monitoring for the safe use of bed rails, contributing to the deficiency.
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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) |
|---|---|---|---|---|
| Amelia Manor Nursing Home | 1 mi | ★★★★★ | 5 | 0 |
| Lady Of The Oaks Retirement Manor | 3.8 mi | ★★★★★ | 0 | 0 |
| Courtyard Manor Nurse Care Center & Assisted Liv | 4.4 mi | ★★★★★ | 5 | 0 |
| Louisiana Extended Care Hospital Of Lafayette | 4.5 mi | ★★★★★ | 8 | 0 |
| Cornerstone At The Ranch | 5 mi | ★★★★★ | 0 | 0 |
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