Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 St. Francisville Nursing And Rehab, Llc during CMS and state inspections, most recent first.
Failure to Notify Physician of Post-Fall Change in Condition: A resident who was previously independent with ambulation, transfers, toileting, and continence fell and then continued to have hip pain, could not bear weight, stayed in bed, and needed staff help with incontinence care and ADLs. Staff obtained an initial x-ray that was negative, but did not notify the NP/MD or on-call provider of the ongoing change in condition until several days later, when the resident was sent to the hospital and found to have a hip fracture and pubic rami fractures requiring surgery.
A resident with intact cognition and baseline independence in transfers, toileting, and ambulation fell and then continued to have left hip pain, stayed in bed, and needed staff help with incontinence care. Staff observed grimacing, guarding, and complaints of pain during ADL care, but did not consistently assess the pain, notify the NP/MD or on-call provider, or give ordered pain meds, including missed pregabalin doses and no use of the standing Tylenol order. The resident was later sent to the hospital, where CT showed a femoral neck fracture and pubic rami fractures requiring surgery.
Missed medication doses occurred when staff failed to ensure ordered drugs were available and administered as prescribed. A resident with pain and psychiatric orders missed Lidocaine patches and Risperidone, two residents with anticoagulant and UTI prophylaxis orders missed Eliquis and Macrobid, and another resident missed Pregabalin doses. Staff documented medications as unavailable, did not consistently notify the NP, DON, or pharmacy, and did not check the emergency kit even when the medications were listed there.
A resident with a hx of PE, anticoagulant use, paraplegia, and an indwelling catheter missed multiple ordered doses of Eliquis and Macrobid. MARs and nursing notes showed the meds were documented as not available, reordered, or awaiting delivery, but staff did not check the emergency med kit or notify the pharmacy or NP. The pharmacist confirmed the meds had been filled, and the DON and NP stated they were not notified of the missed doses.
Therapeutic diet orders were not followed for four residents with active double-portion orders. The residents, including individuals with dementia, abnormal weight loss, cerebral infarction, Alzheimer’s disease, and digestive tract surgery history, were observed at lunch receiving only one plate of food each. Staff confirmed the meal tickets showed double portions were ordered and that these residents should have received two plates.
Improper food storage and inadequate dishwashing sanitization were observed in the kitchen. A dietary supervisor found raw meat products stored directly above eggs and dairy in the refrigerator, contrary to facility policy, and observed the dishwasher fail to reach 120 degrees during the rinse cycle for 4 of 5 loads. The dietary supervisor and the administrator both confirmed the storage and dishwasher practices were not correct.
Failure to Follow EBP During High-Contact Care: Staff did not follow EBP for residents with PEG tubes, a pressure ulcer, and enteral feeding needs. An LPN and CNAs performed wound care, PEG care, peri-care, and tube feeding without the required gown use, and one CNA also moved from dirty to clean care without removing soiled gloves, performing hand hygiene, or donning clean gloves. The DON confirmed gown and glove use was expected for these high-contact care activities.
Dirty Wheelchair Not Maintained in Sanitary Condition: A resident was observed sitting in a wheelchair whose frame and wheel area were covered with thick gray dust, hair, and debris. CNAs and the ADON confirmed the wheelchair needed cleaning, and the DON stated staff were expected to follow the wheelchair cleaning schedule and keep wheelchairs from being dirty.
PEG Free Water Flushes Not Infused as Ordered: A resident with a PEG tube, cerebral palsy, and malnutrition had an order for continuous tube feeding with free water flushes at 54 mL/hr, but the pump was set to 300 mL every 4 hours instead. An LPN and the DON both confirmed the free water was not infusing at the ordered rate.
Incomplete and inaccurate eating documentation was found for a resident with dementia, dysphagia, and hemiplegia/hemiparesis. CNA records had missing entries and one entry incorrectly showed the resident as independent with eating, even though observation and staff interviews confirmed he required 1-on-1 feeding assistance, verbal and tactile cues to swallow, and mouth checks during meals.
Two residents who were incontinent and dependent on staff for toileting and transfers did not receive incontinence checks and care at least every two hours as care planned. One resident with dementia remained in a wheelchair for several hours without any incontinence check and was later found with a saturated brief and clothing. Another cognitively intact resident with hemiplegia reported not being changed for many hours after being gotten up early by night shift, was found double-briefed with both briefs and clothing saturated with urine and stool, and on another day was again found with urine saturated through her brief, clothing, lift pad, and wheelchair cushion. CNAs and nursing staff acknowledged that incontinence rounds should occur every two hours and that double briefing was not appropriate, but confirmed that these residents were not checked or changed as frequently as required.
A cognitively intact resident with cerebrovascular disease, hemiplegia, generalized muscle weakness, and frequent bowel and bladder incontinence, care planned for incontinence checks at least every two hours and as needed, was not provided timely incontinence care when only three CNAs were assigned to a hall of 40 residents, many incontinent and several requiring Hoyer lifts. The resident was repeatedly found with urine-saturated briefs, clothing, and wheelchair equipment after being left unchanged for extended periods following early-morning transfers out of bed. CNAs reported being assigned 12–13 residents each, including multiple two-person assist and Hoyer-lift residents, and stated they could not complete two-hour incontinence rounds, resulting in delayed changes, missed or delayed showers, and residents remaining soiled due to insufficient staffing despite facility expectations for two-hour incontinence rounds.
A resident with severe cognitive impairment and psychiatric diagnoses struck another resident on the head, resulting in the victim expressing fear and choosing to remain in her room to avoid further harm. Staff and another resident confirmed the incident and the affected resident's subsequent fear, indicating psychosocial harm despite no physical injury. Facility policies prohibiting abuse were not effectively implemented, leading to a failure to protect the resident from abuse by another resident.
The facility did not submit accurate direct care staffing data to CMS, resulting in triggers for low staffing ratings, no RN hours, and lack of licensed nursing coverage for 24 hours per day. The administrator confirmed that staffing codes were not correctly transferred to the PBJ report, and a final validation report was not available for the affected month.
Two residents with active diagnoses of PTSD were not accurately coded for this condition in their MDS assessments. The staff member responsible for MDS completion confirmed the omission after reviewing the residents' records, and the DON stated that assessments are expected to reflect all active diagnoses.
A resident with a history of traumatic subdural hemorrhage and dysphonia did not receive a timely ENT specialist appointment as ordered by a physician and nurse practitioner. The referral was initially denied based on internal guidelines, and staff failed to notify the appropriate clinical leaders or schedule the appointment until the resident developed shortness of breath. Lack of a system to reconcile NP progress notes with physician orders contributed to the delay in care.
Two residents with PTSD were not care planned for their diagnosis, and staff were unaware of necessary trauma-informed interventions. One resident displayed agitated and aggressive behaviors without appropriate care plan interventions, and trauma assessments did not capture essential details for individualized care.
Surveyors found that a multi-dose insulin vial for a resident was opened and stored in the medication room refrigerator without being dated, as required by facility policy. An LPN confirmed the vial should have been dated upon opening. In a separate incident, another LPN left a medication cart unlocked and unattended in a hallway while providing resident care. The DON confirmed expectations for proper labeling and securing of medications.
Surveyors found that kitchen staff failed to properly label and date opened food items, did not sanitize food thermometers between uses, served ground beef at temperatures below the required 160°F, and did not maintain the kitchen air conditioner in a sanitary condition. These deficiencies were confirmed by dietary and administrative staff.
A resident with paraplegia and a urinary catheter was observed multiple times with an uncovered urinary drainage bag, despite facility policy requiring such bags to be covered to maintain dignity. Staff confirmed the bag should have been covered, and the cover was found on the floor next to the resident's wheelchair.
A resident with a broken tooth and recent dental infection did not receive a timely referral to an oral surgeon and endodontist for extraction and root canal, despite physician orders and care plan interventions. The staff member responsible for scheduling was unaware of the order due to a missed communication step, resulting in the appointment not being made.
Staff failed to follow proper hand hygiene and glove-changing protocols during perineal care for two residents with incontinence. CNAs did not perform hand hygiene before care, did not change gloves when moving from dirty to clean tasks, and touched clean items and room surfaces with soiled gloves, contrary to facility policy.
A resident with severe cognitive impairment and known behavioral issues physically assaulted two other residents, causing harm. The facility failed to provide adequate supervision, allowing the resident to engage in physical altercations. This resulted in one resident being hospitalized for injuries and another experiencing a fall.
A resident with severe cognitive impairment and known behavioral issues was not properly supervised, leading to an assault on another resident. The assigned CNA failed to maintain line of sight supervision, allowing the resident to enter a peer's room and cause harm. Despite being in-serviced on supervision requirements, the CNA admitted to taking his eyes off the resident, resulting in the incident.
A facility failed to ensure a cognitively impaired resident received timely treatment and care after a fall. An LPN did not transcribe or implement new orders for Tylenol and an X-Ray, nor did she communicate the resident's change in status to oncoming staff. This resulted in a delayed diagnosis of a displaced left femoral neck fracture, requiring surgical intervention.
The facility failed to accurately document the administration of Tylenol for a resident with severe cognitive impairment and multiple diagnoses. Despite the medication being administered on two occasions, it was not recorded in the MAR or transcribed into the electronic medical record.
The facility failed to accurately code the MDS for PASRR for two residents, despite having Level II PASRR approvals. The Director of Nursing and Chief Compliance Officer confirmed the inaccuracies during interviews.
The facility failed to update a resident's care plan to include interventions for removing the water pitcher from the room, despite the resident's tendency to replace thickened liquids with regular water. Staff interviews confirmed this oversight.
The facility failed to ensure a clean and safe environment for a resident, as the air conditioner cover was detached and a nightstand drawer was missing. Staff did not report these issues to maintenance, and they were only discovered during an observation.
The facility failed to post the required nurse staffing information on a daily basis. An observation revealed that the posted staffing data was outdated and lacked documentation of the facility name, resident census, and actual hours worked. The ADON confirmed the staffing report was not posted as required and was missing critical information.
Failure to Notify Physician of Post-Fall Change in Condition
Penalty
Summary
The facility failed to notify the resident’s physician when the resident had a change in condition after a fall, including continued left hip pain, decreased ability to ambulate, and new dependence on staff for ADLs and incontinence care. The resident was cognitively intact, with a BIMS of 15, and prior to the fall was independently ambulatory, independent with transfers and toileting hygiene, and continent of bladder and bowel. After the fall, the resident remained in bed, required staff assistance for perineal care, and continued to complain of pain during care and movement. On 05/15/2026, the resident fell in the hallway after tripping over a shoe and reported left hip/buttocks pain. Staff assisted the resident to bed, gave Tylenol, and obtained a left hip x-ray that showed no acute fracture. Nursing notes and staff interviews showed that over the next several days the resident did not get out of bed as usual, could not ambulate independently, required incontinence briefs and staff assistance with elimination care, and continued to report pain. Multiple staff members stated these changes were different from the resident’s baseline and should have been reported to the NP/MD or on-call provider. The resident was not sent for further evaluation until the morning of 05/18/2026, when the NP was finally notified and the resident was transferred to the hospital. Hospital imaging revealed a mildly impacted left femoral neck fracture and traumatic nondisplaced fractures of the left superior and inferior pubic rami, and the resident required surgical intervention. Interviews with nursing staff and the NP confirmed that the resident’s continued pain, inability to bear weight, and new need for incontinence care were changes in condition, and that the on-call provider was not contacted during the weekend despite these changes.
Failure to Assess and Treat Pain After Fall
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a cognitively intact resident after a fall, and failed to adequately assess and intervene when the resident continued to report left hip pain. The resident had diagnoses including other frontotemporal neurocognitive disorder and polyneuropathy, but her quarterly MDS showed a BIMS of 15 and she was independent with toileting hygiene, transfers, and ambulation before the incident. After the fall, she reported left hip/buttocks pain, and an x-ray was obtained and read as showing no acute osseous abnormality, with a caveat that hip fractures may be occult on radiographs. Following the fall, staff observed that the resident remained in bed, required incontinence care, and was no longer ambulating or transferring as usual. Multiple CNAs and LPNs described the resident guarding her left hip, grimacing, taking deep breaths, and saying she was in pain during care. The resident stated she had been staying in bed since the fall and needed a brief for urination and bowel movements because of left hip pain. Staff interviews confirmed this was a change from her baseline, when she was up, continent, and independent with transfers and toileting. Nursing staff did not consistently assess the resident’s pain, notify the NP/MD or on-call provider about the ongoing pain, or administer pain medication as ordered. The resident’s standing Tylenol order was not transcribed into her physician orders, and the MAR showed no other pain medication was given despite documented pain and continued complaints. Pregabalin doses were missed on multiple occasions, and staff acknowledged they did not notify the provider when the medication was unavailable. On the morning the resident was finally assessed by the NP, she was unable to ambulate and was transferred to the hospital, where CT imaging revealed a mildly impacted left femoral neck fracture and nondisplaced fractures of the left superior and inferior pubic rami, requiring surgical intervention.
Missed Medication Administration Due to Unavailable Drugs and Inconsistent Reordering
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure medications were accurately acquired, received, dispensed, and administered as ordered for residents #10, #46, and #100. The deficiency involved missed doses of prescribed medications because staff documented medications as unavailable, did not administer them, and did not consistently notify the NP, DON, or pharmacy. The report also states that staff did not check the emergency medication kit when medications were unavailable, even though some of the missed medications were listed as available in the kit. Resident #10 was cognitively intact and had diagnoses including critical illness myopathy, CKD stage 3B, and lumbar spondylosis. He was ordered Lidocaine patches daily for pain and Risperidone 0.5 mg daily for antipsychotic use. The MAR showed multiple Lidocaine patch doses were left blank or marked as other, and staff confirmed the patches were not available and were not administered on several dates. Staff also confirmed the morning Risperidone dose was missed on two dates because the medication was unavailable in the facility. One LPN documented a dose as given in error even though it was not administered, and staff stated they did not notify the NP or DON and did not check the emergency kit. Resident #46 had diagnoses including a history of pulmonary embolism, long-term anticoagulant use, paraplegia, and neurogenic bladder, and was cognitively intact. He was ordered Eliquis 5 mg twice daily and Macrobid 100 mg daily for UTI prophylaxis. The MAR showed multiple missed doses of both medications over several days. Staff stated the medications were not available, that they reordered some doses electronically, but they did not notify the NP, pharmacy, or other facility staff in a consistent manner, and they did not check the emergency kit. The pharmacist and DON confirmed the emergency kit contained Eliquis and Macrobid, and the NP stated she was not notified of the missed doses. Resident #100 had diagnoses including other frontotemporal neurocognitive disorder and polyneuropathy and was ordered Pregabalin 75 mg three times daily. The MAR showed missed Pregabalin doses because the medication was not available. An LPN confirmed one missed evening dose and stated she did not contact the pharmacy or NP. Another LPN confirmed a missed morning dose and said she verbally notified the NP. The NP stated nurses had told her the resident was running low, but the hard script was not sent until later, and the pharmacy stated the medication should have been ordered sooner to avoid the resident running out.
Missed Anticoagulant and Antibiotic Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when ordered Eliquis and Macrobid were not administered as prescribed. The resident had diagnoses including a personal history of pulmonary embolism, long-term current use of anticoagulants, paraplegia, and neuromuscular dysfunction of the bladder. The resident’s MDS indicated a BIMS of 15, showing he was cognitively intact, and he had an indwelling catheter and was receiving anticoagulants. The physician orders included Eliquis 5 mg by mouth twice daily for history of thromboembolism related to a personal history of pulmonary embolism and Macrobid 100 mg by mouth daily for UTI prophylaxis. The MAR showed multiple missed doses of Eliquis and Macrobid. Nursing notes documented that Macrobid was “not available” on several occasions and that Eliquis was “reordered,” “on order,” “awaiting delivery,” “pending delivery,” or “not available” on multiple occasions. The record contained no documented evidence that the pharmacy or provider were notified that the medications were not available for administration. Interviews with nursing staff confirmed that the medications were not administered because they were not available, but staff did not check the facility’s emergency medication kit, did not notify the pharmacy or the Nurse Practitioner, and did not recall using the emergency kit. The pharmacist stated Macrobid had been filled with a 30-day supply and Eliquis had been filled with a 14-day supply, and there was no documented evidence the pharmacy was notified of the missed doses. The emergency kit contained Eliquis 2.5 mg tablets and Macrobid 100 mg capsules. The DON and NP both stated they expected the medications to be administered as ordered and confirmed they were not notified of the missed doses.
Therapeutic Diet Orders Not Followed for Residents Receiving Double Portions
Penalty
Summary
Therapeutic diets were not provided as ordered for 4 of 11 residents reviewed for dining. Resident #5 had diagnoses including dementia and abnormal weight loss, and his current physician orders included double portions with a start date of 01/22/2026. Resident #31 had diagnoses including cerebral infarction and Alzheimer's disease, and his current physician orders included double portions with a start date of 06/03/2024. Resident #50 had diagnoses including dementia and abnormal weight loss, and his current physician orders included double portions with a start date of 10/29/2025. Resident #87 had diagnoses including cerebral infarction and acquired absence of other specified parts of the digestive tract, and his current physician orders included double portions with a start date of 04/02/2026. On 05/20/2026 at 11:44 a.m., the four residents were observed eating lunch in the restorative dining room and each was receiving one plate of food. At 12:25 p.m., S12RCNA reviewed the meal tickets and confirmed the residents were supposed to receive double portions and did not. At 12:29 p.m., S16DM stated residents with double portion orders are expected to receive two plates of food and confirmed these four residents had active orders for double portions and should have received two plates. At 2:50 p.m., S2ADMIN confirmed all residents with an order for double portions should receive double portions for all meals.
Improper Food Storage and Inadequate Dishwashing Sanitization
Penalty
Summary
Food was not stored and dishes were not sanitized under sanitary conditions. During a kitchen tour with the dietary supervisor, two boxes of diced chicken, two boxes of sausage, and a container with two rolls of ground meat were observed stored directly above eggs and dairy products in the facility refrigerator. The facility policy stated that uncooked and raw animal products are to be stored separately and below fruits, vegetables, and other ready-to-eat foods to prevent meat juices from dripping onto them. The dietary supervisor confirmed the meat products should not have been stored above dairy products and stated dietary staff had been trained to store meat products in a separate refrigerator from dairy products. The facility also failed to ensure the dishwasher reached 120 degrees during the rinse cycle. During observation of the dishwashing process, five sets of dishes were washed, and the rinse cycle did not reach 120 degrees for four of the five sets. The dietary supervisor confirmed the dishwasher did not reach 120 degrees during the rinse cycle until the fifth set of dishes was washed and stated the dishwasher should reach 120 degrees during each rinse cycle to ensure proper sanitization. The administrator also confirmed meat products should not be stored above dairy products and that the dishwasher should reach 120 degrees during the rinse cycle each time it is utilized.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The deficiency involved staff not following Enhanced Barrier Precautions (EBP) for residents who had wounds and/or indwelling medical devices, including PEG tubes and enteral feeding. The facility’s policy stated that EBP requires targeted gown and glove use during high-contact resident care activities such as wound care, device care or use, hygiene, and changing briefs. For one resident with a PEG tube and a left gluteal pressure ulcer, staff observed performing wound care and PEG site care did not don a gown during the treatment. A CNA assisted with turning the resident in bed during the care and also did not don a gown. The resident’s record showed orders for daily treatment of the pressure ulcer and PEG site, and the care plan identified the resident as being on EBP due to infection risk related to the PEG site. For another resident with enteral feeding orders, a CNA performed peri-care by removing a soiled brief and cleaning the resident, then applied a clean brief and straightened clothing and linens without removing the soiled gloves, performing hand hygiene, or donning clean gloves. The CNA also did not don a gown during the high-contact care. For a third resident with PEG tube status, an LPN administered tube feeding and water flushes without donning a gown while handling the PEG tube and providing feeding care. The DON confirmed that staff should have worn a gown and gloves for these EBP high-contact care activities.
Dirty Wheelchair Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to ensure resident equipment was maintained in a sanitary manner by not keeping a wheelchair clean for Resident #99. On 05/18/2026 and 05/19/2026, surveyors observed Resident #99 sitting in a wheelchair in the hallway, and the wheelchair frame appeared to be covered in approximately 1/2 inch thick gray, dust-like substance. The frame near the wheels also had approximately 1/2 inch thick hair and dust wrapped around it. During interviews on 05/19/2026, S32CNA and S34CNA both observed the wheelchair base covered in thick dust and hair and confirmed it needed to be cleaned. S32CNA stated night shift CNAs were expected to clean the wheelchairs. S15ADON also observed the findings and stated night shift CNAs had a schedule to clean odd room wheelchairs every Monday, Wednesday, and Friday, and even room wheelchairs every Tuesday, Thursday, and Saturday. S15ADON stated CNAs were expected to clean the entire wheelchair and confirmed Resident #99's wheelchair needed to be cleaned. S1DON stated she expected CNA staff to follow the process for cleaning wheelchairs and that wheelchairs should not be dirty.
PEG Free Water Flushes Not Infused as Ordered
Penalty
Summary
Resident #1, admitted on 09/24/2025 with diagnoses including Cerebral Palsy, Moderate Protein-Calorie Malnutrition, and Other Complications of Gastrostomy, had physician orders for enteral feeding of Two cal continuous feed at 40 mL/hour and free water flushes at 54 mL/hr via PEG tube. The resident’s care plan identified a problem of risk for altered fluid balance related to modified diet (NPO) with PEG and included the intervention to provide fluids via PEG as ordered. During observation on 05/19/2026, the resident was seen with tube feeding and water flushes infusing via pump, but the pump did not immediately display the water flush rate. When the pump selections were checked, the water flush rate was found to be set at 300 mL every four hours instead of the ordered 54 mL/hr. An LPN reviewed the record and confirmed the water flush was not infusing at the ordered rate and should have been. The DON also confirmed the free water was infusing at 300 mL every four hours and should have been at 54 mL/hr.
Incomplete and Inaccurate Eating Documentation
Penalty
Summary
The facility failed to maintain resident records in accordance with accepted professional standards for Resident #5, specifically by not documenting his eating ability and performance daily and accurately. The facility policy required all services provided to the resident and any changes in condition to be documented in the medical record in an objective, complete, and accurate manner. Resident #5’s clinical record showed diagnoses including dementia, dysphagia, and right dominant side hemiplegia and hemiparesis, and his care plan directed staff to provide verbal and tactile cues to swallow, check his mouth for clearance, and continue these interventions until the meal was completed. Review of the CNA documentation report for GG-Eating showed missing entries on multiple April 2026 dates, and one completed entry on 04/29/2026 recorded Resident #5 as independent for eating at two meal times and as requiring supervision at one meal time. However, observation of Resident #5 during lunch on 05/20/2026 showed he required 1-on-1 feeding assistance throughout the meal, with verbal and tactile cues to swallow multiple times per bite, alternating liquids and solids, and mouth checks during the meal. Interviews with the CNA and ADON confirmed that Resident #5 was not independent with eating, that he required at least close supervision due to cognitive safety concerns and swallowing issues, and that the documentation was incomplete and inaccurate.
Failure to Provide Timely Incontinence Care and Checks for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and checks, as care planned, for residents who were unable to manage their own toileting and hygiene. One resident with dementia and psychotic disturbance was care planned as always incontinent of bowel and bladder, dependent on staff for toileting hygiene, and requiring substantial/maximal assistance for transfers. Her care plan directed staff to change soiled clothing after each incontinent episode and to provide incontinence care during rounds and as needed. On the day in question, she was observed seated in her wheelchair in the dining room from mid-afternoon through early evening, then moved by a CNA from the dining room to a common area without any incontinence check. She remained in the common area until nearly 8:00 p.m. with no staff providing incontinence checks or care during that time. When two CNAs transferred this resident to bed at approximately 7:55 p.m., they found her incontinence brief and shorts saturated with urine. Both CNAs confirmed the saturation and stated that she should have been changed at least every two hours and should not have been that wet, noting that she was usually dry at bedtime and was not a heavy wetter. The CNA assigned to her from 6:00 a.m. to 6:00 p.m. confirmed that the last incontinence care she provided was sometime before 3:30 p.m. and acknowledged that incontinence care should be provided every two hours and as needed. Another CNA confirmed she moved the resident from the dining room to the common area without performing an incontinence check, despite knowing the resident was incontinent and that incontinence care should be provided every two hours and as needed. A second resident, cognitively intact with a history of cerebrovascular disease, generalized muscle weakness, and hemiplegia/hemiparesis, was care planned as frequently incontinent of bowel and bladder, dependent on staff for toileting hygiene and transfers, with instructions to change soiled clothing after each incontinent episode and to check at least every two hours and as needed. This resident reported that night shift staff got her up daily around 4:00 a.m. and that she had not been changed since getting out of bed that morning, stating she needed to be changed. She reported that day shift CNAs did not provide incontinence care every two hours or when needed, and that they typically only changed her when putting her back to bed in the afternoon. She also stated she had requested two briefs be put on her because she knew how long she would sit without being changed and that she wanted staff to check her every two hours because she did not always know when she had urinated or had a bowel movement. When two CNAs transferred this resident to bed in the afternoon via Hoyer lift, they found she was wearing two incontinence briefs, both saturated with urine, with her pants also saturated and a bowel movement present. The day-shift CNA assigned to her confirmed the resident was always incontinent, required a Hoyer lift, had been up in her wheelchair when the CNA arrived for her shift, and had not received incontinence care during that shift until the 3:42 p.m. transfer. She stated incontinence rounds should have been conducted every two hours, that the resident had not refused care, that the resident should not have been double briefed, and that on each shift she never checked or changed the resident before 1:00 p.m. The night-shift CNA confirmed she double briefed the resident that morning, acknowledged she should not have placed two briefs on any resident, and stated she did so to try to prevent the resident’s clothing from being soiled by 8:00 a.m. On the following morning, the same resident reported again that night shift had gotten her up with a Hoyer lift at 4:00 a.m., changed her brief before getting her up, and that she had not been changed since, stating she needed to be changed. Her watch, which she used to track time, showed accurate time. When two CNAs transferred her to bed around 8:31 a.m. to provide incontinence care, they found her urine had saturated through her incontinence brief, pants, lift pad, and wheelchair cushion, requiring replacement of the cushion. Multiple CNAs and LPNs, as well as the ADON and DON, stated that incontinence rounds and checks should occur at least every two hours and as needed, and confirmed that both residents were incontinent and dependent on staff for toileting and transfers. Despite these expectations and care plan directives, the documented observations and interviews showed prolonged periods without incontinence checks or care, double briefing, and residents remaining in saturated briefs and clothing.
Insufficient CNA Staffing Led to Delayed Incontinence Care and Prolonged Soiling
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to deliver timely incontinence care as required by resident assessments and care plans. Facility policy on sufficient and competent nursing staff states that staffing numbers and skill requirements are to be based on resident plans of care, resident assessments, and the facility assessment, and that minimum state staffing requirements are not necessarily sufficient. The facility assessment for 2026 noted that residents ranged from very high to very low functioning, with more residents needing two-person assistance or supervision, and identified that CNAs, LPNs, and RNs were required, with staffing set at the minimum standard of 2.35 hours per person per day. On the dates reviewed, the census showed 99 residents, with 40 residents on Hall E, where only three CNAs were assigned for the 6:00 a.m. to 6:00 p.m. shift, despite 27 residents on that hall being incontinent of bladder and 7 requiring Hoyer lift transfers. Resident #4 was cognitively intact, with a BIMS score of 15, and had diagnoses including cerebrovascular disease, generalized muscle weakness, anxiety disorder, hemiplegia and hemiparesis, and depression. Her MDS and care plan documented that she was frequently incontinent of bladder and bowel and dependent on staff for toileting hygiene and transfers, with an intervention to change soiled clothing after each incontinent episode and to check at least every two hours and as needed. Resident #4 reported that night shift staff got her out of bed at 4:00 a.m. and that she had not been changed since that time, stating that day shift did not provide incontinence care every two hours or when needed and that CNAs told her they were short staffed. At 3:42 p.m. on one survey day, she was observed being transferred to bed via Hoyer lift, at which time she was found wearing two incontinence briefs, both saturated with urine, and her pants were also saturated. The CNAs assigned to Hall E confirmed that they were unable to complete incontinence rounds every two hours due to insufficient staffing relative to resident needs. The CNA assigned to Resident #4 stated she was responsible for 13 residents, that Resident #4 required a Hoyer lift for transfers, and that on days she worked she never checked or changed Resident #4 before 1:00 p.m., confirming that Resident #4 had not received incontinence care during her shift until 3:42 p.m. She also stated she checked and changed other incontinent residents only two to three times during a 12-hour shift. On the following day, Resident #4 again reported being gotten up at 4:00 a.m. and changed at that time; at 8:31 a.m., when she was transferred back to bed for incontinence care, her urine had saturated through her brief, pants, lift pad, and wheelchair cushion. The CNA again confirmed that Resident #4 should have been changed before breakfast but had not been due to lack of time. Other CNAs on Hall E reported being assigned 12 residents each, with multiple residents requiring two-person assistance and Hoyer lifts, and stated that incontinence checks fell behind, some residents soiled their clothing, and required showers/baths and Hoyer transfers could not always be completed timely. The ADON and DON stated they expected incontinence rounds every two hours and that staffing assignments were based on census and an assumption that acuity was evenly distributed, with three CNAs assigned to each hall, including Hall E with 40 residents.
Failure to Protect Resident from Physical Abuse and Psychosocial Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse and psychosocial harm when one resident struck another on the head. Specifically, a resident with severe cognitive impairment and diagnoses including Paranoid Schizophrenia, Bipolar Disorder, and Dementia approached another resident from behind and hit her on the head while she was sitting on a couch. The incident was witnessed by staff and another resident, and was documented in both the clinical record and state agency report. The resident who was struck immediately expressed fear of the other resident and was observed holding her head after the incident. Following the event, the resident who was hit reported to staff and her roommate that she was afraid of the resident who struck her and did not feel safe in her environment. She chose to remain in her room out of fear and expressed concern when the other resident returned from the hospital. Interviews with staff and another resident confirmed that the affected resident verbalized her fear and desire to avoid the individual who had hit her. The facility's own policies prohibit all forms of abuse, including physical and psychological harm, and require protection of residents from abuse by anyone, including other residents. Despite the absence of physical injury or significant decline in mental or physical functioning, the resident experienced psychosocial harm as evidenced by her expressed fear and change in behavior following the incident. The facility's documentation and staff interviews confirmed that the resident was initially fearful and that being hit on the head constituted physical abuse. The event demonstrated a failure to ensure the resident's right to be free from abuse and to feel safe in her living environment.
Failure to Submit Accurate Direct Care Staffing Data
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report for the first quarter of fiscal year 2025 revealed multiple triggers, including a One Star Staffing Rating, excessively low weekend staffing, no Registered Nurse (RN) hours, and lack of licensed nursing coverage for 24 hours per day. The infractions for no RN hours and lack of licensed nursing coverage occurred throughout December 2024. During an interview, the administrator responsible for PBJ uploads confirmed that the PBJ Final Validation Report for December 2024 was not available and acknowledged that the codes for direct care staffing were not accurately transferred to the PBJ report for that month.
Failure to Accurately Code PTSD Diagnoses in Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current diagnoses of two residents with Post-Traumatic Stress Disorder (PTSD). Review of the clinical records for both residents showed that each had an active diagnosis of PTSD upon admission. However, examination of their respective Quarterly Minimum Data Set (MDS) assessments revealed that the PTSD diagnosis was not marked as present in Section I: Active Diagnoses. During interviews, the staff member responsible for completing the MDS assessments confirmed that the PTSD diagnosis should have been indicated for both residents but was not. The Director of Nursing stated that MDS nurses are expected to complete assessments that accurately reflect each resident's active diagnoses and current status.
Failure to Arrange Timely ENT Referral Following Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by not arranging a timely appointment with an ENT specialist as ordered. The resident, who had a history of traumatic subdural hemorrhage and dysphonia, had a physician order dated 02/18/2025 requesting referral to a private physician for evaluation of persistent hoarseness. This referral was denied based on internal guidelines, and there was no documented notification to the DON or NP regarding the denial. Subsequently, a nurse practitioner noted on 03/05/2025 that a referral to a local ENT should be made, but there was no evidence that this appointment was scheduled at that time. Interviews revealed that the staff responsible for scheduling appointments was not aware of the need for an ENT referral until 04/10/2025, when the resident presented with shortness of breath. The DON confirmed that there was no system in place to cross-check nurse practitioner progress notes with physician orders, which contributed to the delay in scheduling the necessary specialist appointment. The lack of communication and follow-through on the referral orders resulted in the resident not receiving timely evaluation and care as directed by medical professionals.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care and services in accordance with professional standards of practice for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Both residents had an active diagnosis of PTSD documented in their clinical records, but their care plans did not address this diagnosis. One resident exhibited aggressive and agitated behaviors, including responding to internal stimuli and yelling at staff and peers, yet there were no care plan interventions in place to address or manage PTSD-related symptoms. Interviews with staff revealed a lack of awareness regarding the residents' PTSD diagnoses and the absence of trauma-informed interventions. The LPN assigned to one resident was unaware of the PTSD diagnosis and confirmed that no interventions had been established. The staff member responsible for MDS assessments and care plans acknowledged that both residents should have been care planned for PTSD but were not. Additionally, the social services designee admitted to not knowing the specific trauma histories of the residents and confirmed that trauma assessments did not include details necessary for appropriate care planning.
Failure to Properly Label Insulin Vial and Secure Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to comply with accepted professional principles for the storage and labeling of drugs and biologicals. During an observation in the medication room, an opened multi-dose vial of insulin labeled for a specific resident was found in the refrigerator without a date indicating when it was opened. The LPN present confirmed that the vial should have been dated upon opening, in accordance with facility policy, but was not. Additionally, surveyors observed that Medication Cart #3 was left unattended and unlocked in a hallway for several minutes while the responsible LPN was performing resident care in a closed room. The LPN acknowledged that the cart should have been locked before leaving it unattended. The Director of Nursing confirmed that staff are expected to label and date multi-dose vials upon opening and to keep medication carts locked when not under direct observation.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food storage, preparation, and sanitation. During an inspection, opened food items in the refrigerator and freezer, such as green grapes, pancakes, dough, ice cream, pie dough sheets, beef patties, green onions, chocolate syrup, and waffles, were found unsealed, unlabeled, and undated. Staff interviews confirmed that all opened food products should have been sealed, labeled, and dated according to facility policy, but this was not done. Additionally, the kitchen's air conditioning unit was observed to be covered in a thick, gray substance and a plastic piece next to it was covered in a spotted black substance, both of which were confirmed by staff to be unsanitary and not properly maintained. Further observations revealed that a cook failed to properly sanitize a food thermometer between checking the temperatures of different food items, specifically between ground beef patties and mashed potatoes, which was acknowledged by staff as a risk for cross-contamination. The same cook also served ground beef patties at an internal temperature of 142 degrees Fahrenheit, below the required 160 degrees Fahrenheit, and admitted that the food should not have been served at that temperature. These deficiencies were confirmed by both dietary and administrative staff during interviews.
Failure to Maintain Resident Dignity by Leaving Urinary Drainage Bag Uncovered
Penalty
Summary
The facility failed to ensure that a resident's urinary drainage bag remained covered, as required by facility policy to maintain dignity. Observations revealed that the resident, who was cognitively intact and had diagnoses including paraplegia, chronic kidney disease, neuromuscular dysfunction of the bladder, and a cervical spinal cord injury, was seen in his room and later on the smoking patio with an uncovered urinary drainage bag. The drainage bag cover was observed on the floor next to the resident's wheelchair during one of the observations. Staff interviews confirmed that the urinary drainage bag should have been covered to maintain the resident's dignity, in accordance with the facility's policy. The Director of Nursing and a CNA both acknowledged that the standard of care was not met in this instance, as the resident's urinary drainage bag was left uncovered during multiple observations.
Failure to Arrange Dental Referral as Ordered
Penalty
Summary
The facility failed to ensure a referral was made to an oral surgeon as ordered for a resident who required dental services. The resident, who was moderately cognitively impaired and had a history of a bacterial infection and a broken tooth, had a physician's order dated 03/31/2025 for appointments with an oral surgeon and endodontist for a tooth extraction and root canal. The care plan included coordinating dental care and transportation as needed. Nurse's notes and a nurse practitioner note confirmed the need for referral following a dental abscess and antibiotic treatment. Despite these orders and documentation, the staff member responsible for scheduling appointments was not aware of the referral order, as she had not received the printed order report from the DON. As a result, the appointment for the necessary dental procedures was not made. Interviews with the staff confirmed the breakdown in communication and process, with the DON acknowledging that the order report should have been provided to the scheduler to ensure the referral was completed.
Failure to Follow Hand Hygiene and Glove Protocols During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene and glove use during perineal care for two residents with bowel and bladder incontinence. In both cases, certified nursing assistants (CNAs) did not perform hand hygiene before care, did not change gloves when moving from dirty to clean tasks, and touched clean items and room surfaces with soiled gloves. Specifically, one CNA performed perineal care, handled clean briefs, opened drawers, applied barrier cream, and adjusted the resident's environment without changing gloves or performing hand hygiene. The other CNA similarly failed to change gloves or sanitize hands while cleaning the resident, handling clean briefs and clothing, and changing bed linens. Both residents involved were care planned for incontinence and required assistance with perineal cleansing. The CNAs confirmed during interviews that they did not follow proper hand hygiene and glove-changing protocols as outlined in the facility's policy. The Director of Nursing also acknowledged that staff are expected to perform hand hygiene before care, when moving from dirty to clean, and after care, and to avoid touching items in the resident's room with soiled gloves.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving two residents who were victims of physical abuse by a third resident known for physically abusive behaviors. Resident #2, who had severe cognitive impairment and a history of behavioral disturbances, physically assaulted Resident #1 by punching him in the face and neck multiple times. This incident resulted in Resident #1 experiencing physical pain, facial swelling, and bloody drainage from the nose, necessitating evaluation and treatment at a local hospital. Prior to this incident, Resident #2 had a documented history of behavioral issues, including confusion, wandering, and previous altercations with peers. On a previous occasion, Resident #2 had pushed Resident #3, causing her to fall and sustain pain to her right hip, which required an x-ray. Despite these known behaviors, Resident #2 was left unattended by a CNA, which allowed the altercation with Resident #1 to occur. The facility's failure to maintain adequate supervision and implement effective interventions for Resident #2's known behaviors directly contributed to the incidents of abuse. The lack of continuous line-of-sight supervision, as required by Resident #2's care plan, allowed the resident to engage in physical altercations with other residents, resulting in harm.
Failure to Maintain Line of Sight Supervision Results in Resident Harm
Penalty
Summary
The facility failed to implement the comprehensive person-centered care plan for a resident with known physical behaviors towards others. The resident, who had severe cognitive impairment and a history of behavioral disturbances, was supposed to be under line of sight supervision as per their care plan. However, on the day of the incident, the assigned CNA did not maintain the required supervision, allowing the resident to enter another resident's room and physically assault them. The incident occurred when the resident entered a peer's room and hit them in the face and neck, resulting in the peer being sent to the hospital for evaluation and treatment. The CNA assigned to supervise the resident admitted to taking his eyes off the resident to assist another resident, which led to the failure in maintaining line of sight supervision. This lapse in supervision was despite the CNA having been in-serviced on the requirements of line of sight supervision prior to the shift. Interviews with staff revealed that the LPN on duty had to redirect the CNA multiple times regarding the supervision requirements, but did not report these issues to the Director of Nursing. The failure to maintain the required supervision as outlined in the care plan directly led to the physical altercation and subsequent harm to another resident.
Failure to Transcribe and Communicate Orders
Penalty
Summary
The facility failed to ensure a cognitively impaired resident received treatment and care in accordance with professional standards of practice. Specifically, an LPN did not transcribe new telephone orders for Tylenol and an X-Ray for the resident after a fall and complaint of pain. Additionally, the LPN did not implement the new telephone order for an X-Ray and failed to communicate the resident's change in status, fall, or new orders to oncoming staff before leaving the facility at the end of her shift. The resident, who had a history of falling and severe cognitive impairment, was found on the floor in the bathroom by her roommate. The LPN on duty at the time received orders from the on-call nurse practitioner to administer Tylenol and obtain an X-Ray. However, the LPN did not notify the X-Ray company or transcribe the orders into the resident's chart. The LPN documented the fall and X-Ray order in the 24-hour report book but did not verbally communicate this information to the oncoming staff. As a result, the resident's condition was not properly addressed until later in the day when another LPN and a nurse practitioner assessed the resident and ordered an X-Ray. The X-Ray revealed a displaced left femoral neck fracture, which required surgical intervention. The delay in treatment and communication resulted in actual harm to the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure a resident's medical record was maintained accurately and systematically in accordance with accepted professional standards and practices. Specifically, the facility did not transcribe and document the administration of Tylenol on the Medication Administration Record (MAR) for one resident. The resident, who had severe cognitive impairment and multiple diagnoses including a displaced intertrochanteric fracture of the left femur and dementia, experienced a fall and complained of pain. Despite receiving Tylenol for pain management, the administration of the medication was not documented in the resident's MAR or transcribed into the electronic medical record as per standard procedures. Interviews with the involved Licensed Practical Nurses (LPNs) confirmed that Tylenol was administered to the resident on two separate occasions on the same day, but neither instance was documented in the MAR. The Director of Nursing (DON) reviewed the records and confirmed the absence of documentation for the Tylenol administration. This failure to document medication administration accurately and systematically represents a deficiency in maintaining medical records in accordance with professional standards.
Inaccurate Coding of PASRR in MDS Assessments
Penalty
Summary
The facility failed to ensure residents' assessments accurately reflected their status by not properly coding the Minimum Data Set (MDS) for PASRR (Pre-admission Screening and Resident Review) for two residents. Resident #27 was admitted with a Level II PASRR approval dated 02/07/2013, but the Annual MDS assessment dated 05/10/2023 incorrectly coded Section A1500 as 'No' and left Section A1510 blank. Similarly, Resident #52, admitted with a Level II PASRR approval dated 10/11/2017, had an Annual MDS assessment dated 09/07/2023 that also incorrectly coded Section A1500 as 'No' and left Section A1510 blank. These inaccuracies were confirmed by the Director of Nursing (S3DON) and the Chief Compliance Officer (S2CCO) during interviews conducted on 03/20/2024. Both S3DON and S2CCO verified that the residents' Form 142 indicated approval for nursing home admission by the Level II authority, and they confirmed that the MDS assessments should have been coded as 'Yes' in Section A1500. The failure to accurately code the MDS assessments for these residents indicates a lapse in ensuring that the residents' assessments accurately reflected their status, specifically regarding their PASRR evaluations.
Failure to Update Care Plan for Hydration Needs
Penalty
Summary
The facility failed to develop a comprehensive person-centered plan of care for a resident diagnosed with dysphagia. The resident was admitted with a requirement for nectar thick liquids, but the care plan did not include interventions to remove the water pitcher from the resident's room. Interviews with staff members, including a CNA, LPN, and MDS coordinator, revealed that the resident would dump out thickened liquids and replace them with regular water, which was not reflected in the care plan. The Director of Nursing confirmed that all care plans should accurately reflect the care being provided.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a clean and safe environment for Resident #36. During observations on 03/18/2024 and 03/19/2024, it was noted that the front cover of the air conditioner/heater unit in Resident #36's room was detached and laying on the floor. Additionally, the nightstand on the left side of the resident's bed was missing the third drawer. These issues were confirmed by the Director of Nursing (S3DON) during an observation on 03/19/2024, who acknowledged that staff should have reported these concerns to maintenance but had not done so. Interviews with the Director of Nursing (S3DON) and the Maintenance Director (S10MD) revealed that staff are expected to write environmental concerns in a maintenance log book to notify maintenance of any issues. However, no entries had been made in the log book regarding the detached air conditioner cover and the missing drawer in Resident #36's room. The Maintenance Director stated that he checks the log book every other day and also performs random room checks in the mornings. He was only made aware of the issues in Resident #36's room the day before the interview and did not know how long they had been present.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis. An observation on 03/18/2024 at 8:10 a.m. revealed that the posted staffing data near the nurse's station was dated 03/17/2024 and lacked documentation of the facility name, resident census, and actual hours worked. During an interview on 03/18/2024 at 9:18 a.m., the Assistant Director of Nursing (ADON) confirmed that the staffing report for 03/18/2024 was not posted as required and was missing critical information such as the facility name, census, and total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Francisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Feliciana Chronic Disease | 11.8 mi | ★★★★★ | 7 | 0 |
| Louisiana War Veterans Home | 11.8 mi | ★★★★★ | 0 | 0 |
| Pointe Coupee Healthcare | 14.1 mi | ★★★★★ | 1 | 0 |
| Lakeview Manor Nursing And Rehabilitation Center | 14.6 mi | ★★★★★ | 5 | 0 |
| Grace Nursing Home | 14.8 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St. Francisville Nursing And Rehab, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.