Inspection Reports for
Belle Teche Nursing & Rehab Center
1306 W ADMIRAL DOYLE DR, NEW IBERIA, LA, 70560
Back to Facility Profile6 Reports
Inspection Report — May 21, 2025
Routine CMS
Date: May 21, 2025
Visit Reason
Routine inspection of Belle Teche Nursing & Rehab Center to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to refer a resident for Level II PASARR evaluation, incomplete implementation of person-centered care plans, failure to revise care plans timely, inadequate assistance with activities of daily living, failure to implement fall prevention interventions, failure to monitor and coordinate nutritional care, incomplete respiratory care, food service safety violations, incomplete hospice documentation, lack of qualified social worker, inadequate infection control practices, and unsafe electrical equipment maintenance.
Deficiencies (12)
F0644: The facility failed to refer Resident #15 with bipolar disorder for Level II PASARR evaluation as required.
F0656: The facility failed to implement person-centered care plans for Residents #11, #65, and #86, including failure to ensure appropriate footwear and provision of prescribed drinking cups.
F0657: The facility failed to develop and revise comprehensive care plans timely for Residents #49 and #68, including failure to revise blood sugar monitoring and involve resident in care planning.
F0677: The facility failed to provide adequate grooming and personal hygiene assistance, resulting in uncombed hair and facial hair for Residents #11, #52, #64, #67, and #86.
F0689: The facility failed to implement appropriate fall prevention interventions for Resident #56 despite multiple falls.
F0692: The facility failed to assess and monitor nutritional status and coordinate care for Resident #71, resulting in significant unaddressed weight loss.
F0695: The facility failed to perform laryngectomy care as ordered for Resident #14, with multiple missing documentation signatures and resident report of missed care.
F0812: Dietary staff failed to wear beard restraints while preparing and distributing food, violating food safety standards.
F0849: The facility failed to obtain updated recertification of terminal illness and hospice plan of care for Resident #31.
F0850: The facility failed to employ a qualified full-time social worker as required for a facility with 150 licensed beds.
F0880: Laundry staff failed to wear appropriate personal protective equipment while handling soiled laundry, risking infection transmission.
F0908: The facility failed to maintain electrical patient care equipment safely by not replacing an electrical outlet plate near Resident #7's bed.
Report Facts
Licensed beds: 150
Weight loss percentage: 22.6
Number of falls: 13
Missing laryngectomy care signatures: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5SSD | Social Service Director | Named in PASARR referral deficiency and social worker qualification deficiency |
| S3ADON | Assistant Director of Nursing | Interviewed regarding care plan revisions, nutritional monitoring, and fall interventions |
| S6CCC/LPN | Clinical Care Coordinator/Licensed Practical Nurse | Responsible for care plan revisions and fall intervention implementation |
| S7LPN | Licensed Practical Nurse | Interviewed regarding footwear, grooming, and electrical outlet safety |
| S4DM | Dietary Manager | Interviewed regarding dietary safety and nutritional care coordination |
| S16RD | Registered Dietician | Interviewed regarding nutritional assessment and care coordination |
| S2DON | Director of Nursing | Interviewed regarding fall interventions, nutritional care, hospice documentation, and laryngectomy care |
| S1ADM/RN | Administrator/Registered Nurse | Interviewed regarding infection control and social worker qualifications |
| S12LS | Laundry Staff | Observed not wearing gown while handling soiled laundry |
| S13DA | Dietary Assistant | Observed not wearing beard restraint during food preparation |
| S14DA | Dietary Assistant | Observed not wearing beard restraint during food preparation |
Inspection Report — Apr 17, 2024
Routine CMS
Date: Apr 17, 2024
Visit Reason
Routine inspection of Belle Teche Nursing & Rehab Center to assess compliance with safety, dialysis care, and food service standards.
Findings
The facility failed to ensure an unsafe smoker resident wore a protective smoking apron, failed to conduct and document post dialysis assessments and communication for a resident requiring dialysis, and failed to maintain professional food service safety standards including rust, food residue, dented cans, grease build-up, and dust in the kitchen.
Deficiencies (3)
F 0689: The facility failed to ensure that Resident #23, an unsafe smoker, wore a protective smoking apron while smoking outside, resulting in burn holes in clothing and wheelchair.
F 0698: The facility failed to provide safe dialysis care for Resident #93 by not conducting comprehensive post dialysis assessments or documenting communication with the dialysis provider.
F 0812: The facility failed to maintain food service safety by allowing rust in the dishwashing area, food residue on stove surfaces, dented canned goods, grease build-up on storage bin lids, and dust on ceiling tiles.
Report Facts
Residents sampled: 34
Residents affected: 1
Residents affected: 1
Residents affected: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4SA (Smoke Aide) | Observed resident smoking without apron and admitted forgetting to put one on | |
| S3ADON (Assistant Director of Nursing) | Confirmed resident was unsafe smoker and not wearing smoking apron; placed apron on resident | |
| S1ADM (Administrator) | Confirmed resident was unsafe smoker and should not have been outside without smoking apron | |
| S7CDMLPN (Certified Dietary Manager, Licensed Practical Nurse) | Confirmed food service safety deficiencies in kitchen | |
| S2DON (Director of Nursing) | Confirmed dialysis post-care assessment and communication deficiencies |
Inspection Report — Apr 2, 2024
Annual Inspection CMS
Date: Apr 2, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with care planning requirements for residents, specifically focusing on those assessed for wandering on the Dementia Unit.
Findings
The facility failed to develop a person-centered care plan for one resident assessed as a definite risk for wandering. The care plan lacked goals to monitor wandering or elopement despite documented assessments indicating risk.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including measurable timetables and actions for a resident assessed as a definite risk for wandering on the Dementia Unit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Care Coordinator | Confirmed resident was assessed for wandering but not care planned accordingly. | |
| Assistant Director of Nursing | Confirmed residents assessed as wanderers should be care planned for wandering. |
Inspection Report — Mar 19, 2024
CMS
Date: Mar 19, 2024
Visit Reason
The inspection was conducted to assess the facility-wide assessment and its adequacy in determining resources necessary to care for residents, particularly those on the secured special care unit.
Findings
The facility failed to ensure the facility-wide assessment accurately evaluated the resident population and resources required for the secured special care unit. Specifically, the assessment tool did not address the needs of the secured special care unit residents or the staffing plan required to provide care.
Deficiencies (1)
F 0838: The facility failed to conduct and document a facility-wide assessment that included an accurate evaluation of the resident population and resources required for the secured special care unit. Resident #3's clinical record lacked evidence of adequate supervision, and the assessment tool dated 02/26/2024 did not address the secured special care unit's care and staffing needs.
Report Facts
Residents on secured special care unit: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Administrator | Interviewed and confirmed the facility's assessment tool did not address the secured special care unit | |
| Licensed Practical Nurse | Prepared the Resident Incident Report dated 07/16/2023 | |
| Housekeeper & Laundry | Reported Resident #3 was found on the floor |
Inspection Report — Mar 15, 2023
Routine CMS
Date: Mar 15, 2023
Visit Reason
Routine inspection of Belle Teche Nursing & Rehab Center to assess compliance with healthcare regulations including resident care, medication administration, infection control, and facility maintenance.
Findings
The facility had multiple deficiencies including improper billing practices, failure to notify physicians of resident changes, unsanitary and unsafe environmental conditions, inaccurate resident assessments, failure to follow physician orders, medication administration errors, improper respiratory and infection control practices, and failure to notify residents and families of COVID-19 positive staff cases.
Deficiencies (18)
F 0571: The facility failed to discontinue charges for disposable briefs for Resident #64 who no longer needed them, resulting in improper billing.
F 0580: The facility failed to notify Resident #16's physician of a 5-pound weight gain as ordered.
F 0584: The facility failed to maintain a safe, clean, and homelike environment, with observations of roaches, dirty rooms, disrepair, and inadequate housekeeping on Wing C and resident rooms.
F 0641: Resident #85's MDS assessment did not accurately reflect the use of antipsychotic medication.
F 0644: The facility failed to obtain a Level II PASARR screening after Resident #85 was newly diagnosed with Psychotic Disorder with Hallucinations.
F 0656: The facility failed to follow physician orders and care plans for Residents #2, #3, #62, and #82 including timely blood sugar checks, use of abdominal binder, anti-slip strips, and heel boots/hand roll.
F 0692: Resident #35 was not offered sufficient fluids to maintain hydration as ordered, with water pitcher often empty and out of reach.
F 0693: Resident #2's tube feeding formula was not labeled with start time and water flushes were inaccurately administered and documented.
F 0695: Resident #9's oxygen nasal cannula tubing was found on the floor unlabeled and not stored properly.
F 0726: The facility failed to ensure nursing staff had appropriate competencies, including administering expired insulin to Resident #42, inaccurate medication documentation for Resident #80, and Resident #16 being NPO without an order.
F 0759: The facility had a medication error rate of 63.33% due to late administration of medications and failure to implement effective corrective measures.
F 0761: Medication cart was left unlocked and unattended; expired insulin was stored and administered to Resident #42.
F 0812: Food items in walk-in refrigerator and freezer were improperly stored, undated, and freezer burnt, risking food safety for residents.
F 0814: Garbage and refuse were improperly stored outside with debris scattered around dumpsters, increasing risk of contamination.
F 0835: Facility failed to use resources effectively to reduce medication errors, with no effective interventions to address late medication administration.
F 0842: Resident #37's enteral feeding was administered too early and documented late; facility failed to ensure accurate clinical record documentation.
F 0880: Infection control failures included lack of chemicals in laundry water, improper PPE use by laundry staff, improper handling of isolation linen, and poor hand hygiene by nursing staff.
F 0885: Facility failed to notify residents and families of positive COVID-19 staff cases on multiple dates in 2023.
Report Facts
Medication error rate: 63.33
Number of medication errors: 19
Number of medication administration observations: 30
Number of residents affected by COVID-19 notification failure: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Named in multiple interviews regarding billing, housekeeping, medication errors, and COVID-19 notification |
| S2DON | Director of Nursing | Named in multiple interviews regarding medication errors, infection control, and resident care |
| S20LPN | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| S16LPN | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| S12LAUNDRY | Laundry Staff | Named in infection control and laundry chemical deficiencies |
| S28DM | Dietary Manager | Named in food storage and sanitation deficiencies |
| S5IP | Infection Preventionist | Named in infection control deficiencies |
| S15CP | Consultant Pharmacist | Named in medication administration and QAPI deficiencies |
| S13AIT | Administrator in Training | Named in medication error and QAPI deficiencies |
Inspection Report — Mar 13, 2023
Complaint Investigation CMS
Date: Mar 13, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to maintain a safe, clean, and homelike environment, and concerns about nursing staff competencies and medication administration.
Complaint Details
The complaint investigation substantiated issues with facility cleanliness, maintenance, and nursing staff competency. Specific complaints included pest infestation, unsafe and unsanitary conditions in resident rooms and common areas, failure to maintain equipment and fixtures, and improper medication administration including expired insulin use and lack of adherence to NPO orders.
Findings
The facility failed to maintain a clean and safe environment, with evidence of pest infestation, disrepair in resident rooms and common areas, and inadequate housekeeping and maintenance. Additionally, nursing staff failed to administer medications properly, including administering expired insulin and not following NPO orders.
Deficiencies (4)
F 0584: The facility failed to provide a safe, clean, and homelike environment as evidenced by pest infestation, dirty and disrepair conditions in resident rooms and Wing C, including rusty furniture, missing baseboards, cracked tiles, and water-stained ceilings.
F 0584: Maintenance failed to repair a hole in Resident #3's bathroom wall that allowed pests to enter, and failed to maintain the bathroom in good repair.
F 0584: Resident #14's toilet was easily moveable and coming off the floor, posing a safety risk, and maintenance failed to secure it properly.
F 0726: Nursing staff failed to ensure accurate medication administration documentation for Resident #80, administered expired insulin to Resident #42, and administered medications to Resident #16 without a valid NPO order.
Report Facts
Medication administration errors: 1
Residents in sample: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S10MAINT | Maintenance Supervisor | Interviewed regarding maintenance failures and lack of documentation of rounds |
| S1ADM | Administrator In Training | Interviewed and confirmed facility conditions and housekeeping issues |
| S2DON | Director of Nursing | Interviewed regarding medication administration errors and nursing competency |
| S16LPN | Licensed Practical Nurse | Interviewed regarding medication administration and documentation errors |
Viewing
Loading inspection reports...
