Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Senior Village Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to document GDR or rationale for psychotropic use: A resident with generalized anxiety disorder, bipolar disorder, and depression was prescribed multiple psychoactive meds, including Benadryl, Divalproex, Meclizine, and Rexulti. A pharmacy consultant review asked the physician to indicate whether dose reduction was desired or provide a rationale for continued use, but the physician did not document a GDR attempt or a clinical rationale in the EHR, and the DON confirmed the form was not completed by the physician.
A resident had an emergency transfer to a local hospital, but the facility's Ombudsman emergency transfer list did not include the transfer and there was no other evidence that the State LTC Ombudsman was notified in writing. The Assistant Administrator confirmed the omission, and the DON stated the transfer should have been listed as required.
Inaccurate resident assessments were identified for two residents. One resident with serious mental illness diagnoses had Level II PASRR approval documented, but both the admission MDS and significant change MDS incorrectly coded PASRR as “No.” Another resident with cerebral infarction and atrial fibrillation had aspirin documented on the MAR during the MDS lookback period, but the Quarterly MDS incorrectly coded antiplatelet use as “No”; MDS staff confirmed the coding should have been “Yes.”
The facility failed to complete and implement a comprehensive care plan for two residents. One resident had an ordered wound treatment for an excoriated left buttock area, but the TAR lacked nurse initials on multiple occasions showing no documentation that the care was provided. Another resident had upper quarter bed rails in use for months, yet the care plan did not address the bed rails, and the DON confirmed the omission.
Failure to Complete Comprehensive Care Plan Timely: A resident admitted with acute respiratory failure with hypoxia, DM2, and HTN did not have a person-centered comprehensive care plan completed within the required timeframe after the CAA was finished. The care plan only included a few focused items such as Full Code, a lifting plan, and bed hold notice, and it did not include interventions for the resident’s medical conditions. The MDS nurse could not show that the care plan was completed on time, and the DON confirmed there was no evidence of completion.
Incorrect Zinc Dose Administered: A resident with CKD and heart disease had a current order for Zinc Sulfate 220 mg daily, but the MAR listed Zinc without a dosage. An LPN was observed giving Zinc 50 mg instead of the ordered dose, and the DON confirmed that Zinc 220 mg was the current order and should have been administered.
A resident with severe cognitive impairment and multiple medical conditions had a physician's order for oxygen saturation checks every shift, with instructions to administer oxygen if levels fell below 92%. Review of the MAR and staff interviews confirmed that these checks were not performed or documented, resulting in a failure to follow the physician's order.
A resident with severe cognitive impairment was found with an unexplained shoulder dislocation, which was not immediately reported to the State Survey Agency as required. Nursing staff and administration did not recognize the need to report the injury, believing only fractures required notification, resulting in a failure to comply with reporting regulations.
The facility failed to submit accurate PBJ staffing data, showing low weekend staffing levels. Weekdays had 3-6 RNs and 7-9 LPNs, while weekends had only 1 RN and 4 LPNs. Administrative staff were counted in weekday staffing but not on weekends, leading to discrepancies. The DON and Administrator were unaware of the issue, which was due to problems with inputting contract/agency staff and misclassification of administrative duties.
The facility failed to transmit MDS assessments within the required 14-day timeframe for several residents. For example, a resident's Quarterly MDS was completed in early August but not transmitted until early September. Similarly, multiple residents' Discharge MDS assessments completed between March and May were all transmitted in September. These delays were confirmed by staff during interviews.
The facility failed to ensure food safety standards were met, as dietary staff did not maintain proper holding temperatures for food on the steam table. S13Cook did not verify or record most food temperatures, with some items observed below the required 135 degrees Fahrenheit. This deficiency potentially affected 111 residents receiving meals from the kitchen.
A resident's personal equipment, including a CPAP machine and mask sanitizer, was found covered with dust and lint, indicating a failure by the facility's housekeeping staff to maintain a clean and sanitary environment. This was confirmed by both an LPN and a housekeeper, with the DON acknowledging the responsibility of the housekeeping staff in ensuring cleanliness.
A facility failed to accurately complete a resident's MDS assessment by incorrectly coding the use of an anticoagulant. A review of the resident's MAR and physician orders showed no order for such medication, and an interview confirmed the error.
A resident with urinary retention and a Foley catheter did not receive consistent catheter care as required by the facility's policy. Despite having an intact cognitive status, the resident reported infrequent cleaning of the catheter site by staff, leading him to perform the task himself during showers. Staff confirmed the absence of catheter care documentation in the care plan, MAR, and TAR.
A resident with End Stage Renal Disease experienced significant weight loss due to the facility's failure to implement the RD's recommendation for nutritional supplementation. Despite the RD's assessment and recommendation for a 4-ounce house supplement, there was no evidence of the supplement being provided or a physician's order being obtained. Interviews with staff confirmed the oversight and lack of communication regarding the resident's nutritional needs.
The facility failed to ensure food was prepared according to standardized recipes, affecting meal quality for residents. A dietary manager/cook prepared nectar thickened milk without a recipe, resulting in an overly thick consistency. Additionally, an okra and tomatoes dish was made using unlisted ingredients and incorrect quantities, as the cook followed personal preferences instead of the recipe. The dietary manager confirmed that recipes were available and should be used.
A facility failed to maintain safe operating conditions for equipment, as an air conditioner in a resident's room was observed leaking a liquid substance on two occasions. Wet towels were found under the unit, and maintenance staff were initially unaware of the issue. Upon inspection, the maintenance staff confirmed the leak and the unsafe condition of the air conditioner.
Failure to Document GDR or Rationale for Psychotropic Use
Penalty
Summary
The facility failed to ensure that the physician documented a Gradual Dose Reduction (GDR) attempt or a clinical rationale for not reducing psychotropic medication for Resident #2. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, and depression. A Pharmaceutical Consultant Report dated 10/24/2025 identified routine psychoactive medications for review, including Benadryl 25 mg every 6 hours as needed for itching, Divalproex DR 250 mg at bedtime, Meclizine 12.5 mg every 12 hours as needed for dizziness, and Rexulti 0.5 mg daily, and asked the physician to indicate whether a dose reduction was desired or provide a rationale for continued use. The report showed that the physician did not indicate whether a dose reduction was indicated or not. Review of the resident’s EHR also found a psychiatric progress note dated 11/03/2025 that documented routine follow-up and medication management, but no evidence that a GDR was attempted or that a clinical rationale was documented explaining why dose reduction was contraindicated. During interview on 12/03/2025, the DON confirmed the Pharmaceutical Consultant Report was not completed by the physician and stated the physician had addressed the resident’s medication in progress notes, but the record review did not show documentation of a GDR attempt or rationale for continued use.
Failure to Notify Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to notify the State's Long-Term Care Ombudsman in writing of an emergency transfer for Resident #7, one of four residents reviewed for accidents. Review of the electronic medical record showed the resident was admitted to the facility and later had an emergency transfer to a local hospital. However, review of the facility's Ombudsman notification lists for July 2025 and August 2025 did not show the resident's 08/20/2025 transfer, and there was no further evidence that the Ombudsman had been notified. During interviews, the Assistant Administrator stated she was partially responsible for the accuracy of the emergency transfer list and confirmed the resident's transfer was omitted, while the Director of Nursing stated the Assistant Administrator was solely responsible for the list and confirmed the transfer should have been included as required.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 2 residents. For Resident #1, the EMR showed an admission to the facility with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and bipolar disorder, severe, with psychotic features. The resident’s Form 142 dated 05/08/2025 and 08/16/2025 showed approval for admission by Level II authority, but both the admission MDS with ARD 06/05/2025 and the Significant Change MDS with ARD 08/08/2025 were coded “No” for Section A1500 PASARR, indicating the resident was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. For Resident #43, the EHR showed diagnoses including cerebral infarction and atrial fibrillation. The Quarterly MDS with ARD 10/02/2025 coded Section N0415, Antiplatelet, as “No,” indicating the resident did not receive an antiplatelet during the 7-day lookback period. However, the MAR showed the resident received aspirin, an antiplatelet, during the lookback period from 09/26/2025 through 10/02/2025. During interview and record review, the MDS staff confirmed the antiplatelet item should have been coded “Yes.”
Incomplete Care Planning and Documentation for Wound Care and Bed Rails
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents. For one resident with diagnoses including age-related osteoporosis, cognitive communication deficit, and hereditary and idiopathic neuropathy, the electronic record showed an order dated 09/07/2025 to cleanse an excoriated area to the left buttock with normal saline and apply zinc oxide twice daily until resolved. Review of the September, October, and November 2025 TARs showed multiple dates with no nurse initials or other evidence that the ordered wound care was completed, and the DON confirmed the missing initials and agreed the treatments should have been documented as performed. For another resident with diagnoses including chronic kidney disease and acute diastolic congestive heart failure, the medical record contained no care plan for the use of bed rails. Observations on 12/01/2025 and 12/03/2025 showed the resident in bed with upper quarter bed rails in place, and two CNAs stated the resident had bed rails for months or at least a month. The DON confirmed the resident had used bed rails since admission on 02/07/2025 and acknowledged that the care plan did not mention bed rails.
Failure to Complete Comprehensive Care Plan Timely
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan within 7 days after completion of the comprehensive assessment for Resident #16. The facility policy titled, Care Plan Process, stated that the RAI is used to determine guidelines for revisions and completion dates for the Comprehensive Care Plan, and the CMS RAI Manual stated that the care plan completion date is no later than 7 calendar days after the CAA completion date. Resident #16 was admitted with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus, and essential hypertension. The resident's admission MDS showed an ARD of 10/08/2025 and a CAA completion date of 10/09/2025. Review of the resident's care plan showed only 3 focused areas with interventions initiated on 10/02/2025: Full Code, Resident Lifting Plan, and LA bed hold notice upon transfer/leave. The care plan did not include focused areas with interventions related to the resident's medical conditions. During interview, the MDS nurse failed to provide evidence that a comprehensive person-centered care plan was completed within 7 calendar days of CAA completion, and the DON confirmed that MDS nurses were responsible for creating care plans but could not provide evidence that the care plan had been completed within the required timeframe.
Incorrect Zinc Dose Administered
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure accurate administration of all drugs for Resident #79. The resident was admitted with diagnoses including chronic kidney disease and atherosclerotic heart disease of native coronary artery without angina pectoris. A physician order dated 11/17/2025 directed Zinc Sulfate 220 mg by mouth once daily, and the MAR for December 2025 showed an order dated 11/18/2025 for Zinc oral tablet, 1 tablet by mouth one time a day for wound healing, but the MAR did not include the dosage for the medication. On 12/02/2025 at 8:44 a.m., S5LPN was observed administering Zinc 50 mg to Resident #79. During review of the MAR with S5LPN, she confirmed there was no dosage listed on the order and stated she should have known the correct dose before administering the medication. On 12/03/2025 at 3:55 p.m., S2DON reviewed the resident's Nursing Home Progress Note and confirmed that Zinc 220 mg was the current order and that Zinc 220 mg should have been administered to Resident #79.
Failure to Follow Physician's Orders for Oxygen Saturation Monitoring
Penalty
Summary
A deficiency was identified when the facility failed to follow a physician's order for a resident with severe cognitive impairment and multiple diagnoses, including severe protein-calorie malnutrition, anorexia, aphasia, and cognitive communication deficit. The physician's order required that the resident's oxygen saturation be checked every shift, and if the saturation was less than 92%, oxygen should be administered at 2 liters per minute via nasal cannula as needed. Review of the resident's medication administration record (MAR) for two consecutive months showed no evidence that these oxygen saturation checks were performed or documented. Interviews with the LPN responsible for the resident and the Director of Nursing confirmed that the required oxygen saturation checks were not documented in the task documentation, nurse's notes, or MAR. Both staff members acknowledged the existence of the physician's order and the lack of evidence that the order was followed, confirming the deficiency in care for the resident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin involving a resident to the State Survey Agency within the required two-hour timeframe after discovery. The incident involved a resident with severe cognitive impairment who was found to have swelling in the right shoulder, hand, and arm, which was first noticed by the resident's sister and subsequently assessed by nursing staff. The injury was not witnessed, and the resident was unable to provide an explanation due to cognitive limitations. The resident was transferred to the hospital, where an X-ray confirmed an anterior shoulder dislocation. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the Director of Nursing and the Administrator did not report the incident to the State Survey Agency, as they believed only fractures required reporting. The facility was unable to determine how or when the injury occurred, and the event was not reported as required by regulation. This deficiency was identified through record review and staff interviews, and it had the potential to affect all residents in the facility.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit accurate payroll information for direct care staffing as required by CMS. During the review of the PBJ Staffing Data Report for FY Quarter 3 2024, it was found that there were triggers for excessively low weekend staffing. The facility's staff reporting forms from April to June 2024 showed a significant discrepancy in staffing levels between weekdays and weekends. On weekdays, there were 3-6 RNs and 7-9 LPNs, while on weekends, there was only 1 RN and 4 LPNs for day shifts. This discrepancy was not accurately reflected in the PBJ system, leading to the deficiency. Interviews with the Director of Nursing (S3DON) and the Administrator (S10ADM) revealed that they were unaware of the low weekend staffing and believed that state staffing ratio requirements were met. The issue was attributed to problems with inputting contract/agency staff into the PBJ system. Additionally, administrative nursing staff were counted in weekday staffing hours but not on weekends, and these roles were not correctly categorized in the PBJ system. The Administrative Assistant (S9AA) confirmed that contract/agency staffing hours were manually inputted, and there was a misunderstanding about the classification of administrative duties as direct care staffing.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for several residents were transmitted within the required timeframe of 14 days after completion. This deficiency was identified through record reviews and interviews, revealing that eight residents had their MDS assessments transmitted late. For instance, Resident #45's Quarterly MDS, with an Assessment Reference Date (ARD) of July 25, 2024, was completed on August 8, 2024, but not transmitted until September 9, 2024. Similarly, Resident #10's Quarterly MDS, with an ARD of August 6, 2024, was completed on August 20, 2024, and transmitted on September 6, 2024. These delays were confirmed during an interview with S7MDS, who acknowledged that the assessments were not transmitted within the required timeframe. Further review showed that several residents' Discharge - return not anticipated MDS assessments were also transmitted late. For example, Resident #8's assessment, with an ARD of April 5, 2024, was completed on April 19, 2024, but not transmitted until September 10, 2024. Similar delays were noted for Residents #23, #122, #67, #105, and #112, with completion dates ranging from March to May 2024, but all transmitted on September 10, 2024. During an interview on September 10, 2024, S7MDS confirmed that these assessments were completed but not transmitted within the required 14-day period after completion.
Failure to Maintain Proper Food Holding Temperatures
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a survey. The dietary staff, specifically S13Cook, did not ensure that all foods on the steam table maintained adequate holding temperatures before being served. The facility's policy required potentially hazardous cooked foods to be held at a minimum of 135 degrees Fahrenheit or higher. However, during the observation, S13Cook was seen checking food temperatures but did not allow the surveyor to verify the thermometer readings. She recorded temperatures for only a few items and failed to check the temperature of several foods, including pureed beans and gravy. Some foods, such as pureed sausage and pureed vegetables, were observed at temperatures below the required 135 degrees Fahrenheit. S13Cook began serving food without verifying or recording most of the food temperatures, claiming that all were above 140 degrees Fahrenheit. When questioned, she removed food pans from the line and placed them back in the steamer. The Registered Dietician, S5RD, stated that the holding temperature should be 130 degrees Fahrenheit or above, which contradicts the facility's policy. The Dietary Manager, S11DM, confirmed that S13Cook did not conduct the food temperature checks correctly and should have recorded the temperatures as they were taken. This deficiency had the potential to affect 111 residents who received food from the kitchen.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident, specifically regarding the cleanliness of personal equipment in the resident's room. The resident, who was admitted with diagnoses including Sleep Apnea and Insomnia, had a CPAP machine, mask sanitizer device, a small fan, and a multi-plug extension cord that were observed to be covered with dust and lint. These observations were confirmed by both a Licensed Practical Nurse and a Housekeeper, who acknowledged that it was the responsibility of the housekeeping staff to ensure the cleanliness of the resident's personal equipment and room. The Director of Nursing also confirmed that the housekeeping staff should have maintained the cleanliness and sanitation of the resident's environment.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accurate completion of a resident's Minimum Data Set (MDS) assessment. Specifically, the Quarterly MDS assessment for Resident #9 inaccurately indicated the use of an anticoagulant under Section N, Medications. Upon review of the resident's Medication Administration Record (MAR) and physician orders for May 2024, it was found that there was no order for an anticoagulant. During an interview on September 10, 2024, with S1MDS, it was confirmed that Resident #9 was not on an anticoagulant, and the MDS was incorrectly coded.
Failure to Implement Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing catheter care for a resident diagnosed with Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Urinary Retention. The resident, who had an intact cognitive status as indicated by a BIMS score of 14, had a physician's order for a Foley catheter. However, the care plan, Medication Administration Record (MAR), and Treatment Administration Record (TAR) did not include catheter care instructions, which should have been performed every shift according to the facility's policy. Interviews with staff and the resident revealed that catheter care was not consistently provided. The resident reported that staff only cleaned around the catheter site following bowel movements and not on a daily basis. The resident also mentioned that he had to clean the area himself during showers. Staff members, including the Director of Nursing, confirmed the absence of catheter care documentation in the care plan, MAR, and TAR, acknowledging that it should have been included and performed regularly.
Failure to Implement Nutritional Supplementation for Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with End Stage Renal Disease and other significant health conditions. The resident experienced a significant weight loss of 24.26% over two months, dropping from 175.6 pounds to 133 pounds. The Registered Dietician (RD) had recommended nutritional supplementation to address the resident's poor intake, which was documented as 25% of most meals, occasionally reaching 75%. Despite these recommendations, there was no evidence in the resident's clinical record that the suggested 4-ounce house supplement was provided, nor was there a physician's order for the supplement. Interviews with facility staff, including an LPN, the RD, and the Director of Nursing (DON), confirmed the oversight. The LPN was unaware of the RD's recommendations, and the RD stated that she had communicated the need for supplementation to the staff, who were responsible for forwarding the recommendations to the physician. The DON confirmed that the RD's recommendations should have been sent to the physician for an order, but acknowledged that there was no evidence that the resident received the recommended supplement, nor was there an order in place for it.
Failure to Follow Standardized Recipes in Food Preparation
Penalty
Summary
The facility failed to ensure that food was prepared according to standardized recipes, which compromised the palatability and attractiveness of meals served to residents. During an observation, a dietary manager/cook was seen preparing nectar thickened milk without following a recipe, adding undetermined amounts of milk and powdered thickener until the desired consistency was achieved. This method resulted in a liquid that was excessively thick and difficult to pour, contrary to the preparation instructions on the thickener container, which specified that the liquid should be thickened by the glass to achieve the correct consistency. Additionally, the preparation of an okra and tomatoes dish was observed, where the dietary manager/cook used ingredients not listed in the standardized recipe, such as tomato sauce, and significantly deviated from the specified quantity of okra. The dietary manager/cook admitted to preparing the dish according to personal preference rather than following the recipe. The dietary manager confirmed that all recipes for the weekly menus were available in a binder and should be used by the staff when preparing meals, indicating a failure to adhere to established procedures.
Leaking Air Conditioner in Resident's Room
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, as evidenced by an air conditioner leaking a liquid substance in a resident's room. On two separate occasions, surveyors observed the air conditioner attached to the wall leaking, with multiple towels placed underneath the unit, all of which were wet. During an interview and inspection, the maintenance staff member stated he was unaware of the leaking air conditioner in the resident's room. Upon inspection, he confirmed the presence of wet towels under the air conditioner and acknowledged that the unit was leaking and not in safe operating condition.
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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 Opelousas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Manor Of Opelousas | 3.7 mi | ★★★★★ | 6 | 0 |
| Our Lady Of Prompt Succor Nursing Facility | 4.5 mi | ★★★★★ | 8 | 0 |
| Acadia St. Landry Nursing & Rehabilitation Center | 9.4 mi | ★★★★★ | 10 | 0 |
| J. Michael Morrow Memorial Nursing Home | 10.4 mi | ★★★★★ | 0 | 0 |
| Evangeline Oaks Guest House | 12.1 mi | ★★★★★ | 14 | 0 |
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