Inspection Reports for
Chateau St. James Rehab and Retirement
1980 JEFFERSON HWY, LUTCHER, LA, 70071
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Inspection Report — Dec 10, 2025
Annual Inspection CMS
Date: Dec 10, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, sanitation, feeding tube administration, and dialysis services at Chateau St. James Rehab and Retirement.
Findings
The facility was found deficient in maintaining sanitary conditions of resident equipment including enteral feeding pumps, weighted sandbags, and wheelchairs. Additionally, the facility failed to administer enteral feeding at the ordered rate and did not ensure proper communication and collaboration with the dialysis provider for a resident requiring dialysis.
Deficiencies (3)
F 0584: The facility failed to maintain the enteral feeding pump and weighted sandbag for Resident #12 and the wheelchair for Resident #43 in a sanitary manner, with dried unknown substances observed covering significant portions of the equipment.
F 0693: The facility failed to administer Resident #25's enteral feeding at the ordered rate of 50 milliliters per hour, with observations showing infusion at 53 milliliters per hour.
F 0698: The facility failed to ensure ongoing communication and collaboration with the dialysis provider for Resident #7, with missing dialysis communication sheets for multiple dialysis sessions.
Report Facts
Residents sampled: 61
Percentage coverage of dried substance: 80
Percentage coverage of dried substance: 25
Percentage coverage of dried substance: 25
Enteral feeding infusion rate: 53
Ordered enteral feeding infusion rate: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Indicated failures in sanitation and dialysis communication |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Noticed unsanitary conditions of Resident #12's equipment and lack of dialysis communication |
| S3 Assistant Director of Nursing | Assistant Director of Nursing | Indicated Resident #43's wheelchair was not cleaned as scheduled |
| S5 Licensed Practical Nurse | Licensed Practical Nurse | Indicated Resident #25's tube feeding was infusing at incorrect rate |
| S7 Licensed Practical Nurse | Licensed Practical Nurse | Indicated nursing staff responsibility to call dialysis provider if communication sheet missing |
| S6 Ward Clerk | Ward Clerk | Indicated nursing staff responsibility to ensure dialysis communication sheets were received |
Inspection Report — May 28, 2025
Annual Inspection CMS
Date: May 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans and respiratory care in the facility.
Findings
The facility failed to revise a resident's care plan to reflect significant changes in condition and failed to obtain proper CPAP settings and follow physician's oxygen orders for residents. Observations and interviews confirmed these deficiencies.
Deficiencies (2)
F 0657: The facility failed to revise Resident #2's care plan to reflect individualized needs following a significant change in condition. Observations showed missing fall mat and inaccessible call light.
F 0695: The facility failed to obtain CPAP settings for Resident #1 and did not follow physician's oxygen order for Resident #2, who was observed receiving oxygen at incorrect flow and improper nasal cannula placement.
Report Facts
Residents reviewed for quality of care: 5
Residents reviewed for respiratory care: 5
Residents affected by deficiencies: 1
Residents affected by respiratory care deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding Resident #2's fall mat and assistance needs | |
| Assistant Director of Nursing (ADON) | Interviewed regarding Resident #2's fall mat order and oxygen administration | |
| Licensed Practical Nurse | Interviewed regarding Resident #2's care plan and oxygen administration | |
| Quality Improvement (QI) Nurse | Confirmed lack of physician order for CPAP settings for Resident #1 |
Inspection Report — Nov 8, 2024
Annual Inspection CMS
Date: Nov 8, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, resident safety, infection control, staffing, and other standards.
Findings
The facility was found deficient in multiple areas including failure to post current Ombudsman contact information, failure to post previous survey results accessibly, unsafe smoking practices, inadequate fall prevention interventions, incomplete nurse staffing postings, improper hand hygiene during food preparation, and failure to include infection-causing organisms in infection surveillance.
Deficiencies (6)
F 0574: The facility failed to publicly post the required contact information for the current State Long-Term Care Ombudsman.
F 0577: The facility failed to post previous survey results in an area accessible to residents and their representatives.
F 0689: The facility failed to ensure an unsafe smoker did not have access to smoking materials unsupervised and failed to update fall prevention interventions after multiple falls for a resident.
F 0732: The facility failed to include required information such as facility name, daily census, and total nursing hours in daily posted nurse staffing information for 5 days.
F 0812: The facility failed to perform proper hand hygiene while preparing coffee for residents.
F 0880: The facility failed to identify and include infection-causing organisms in infection control surveillance for 4 of 5 residents reviewed.
Report Facts
Unwitnessed falls: 7
Daily nurse staffing postings missing required info: 5
Residents reviewed for infection surveillance: 5
Residents with infection-causing organisms not included in surveillance: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed failure to post current Ombudsman contact info and acknowledged missing nurse staffing info. |
| S2 Director of Nursing | Director of Nursing | Confirmed Resident #36 was an unsafe smoker and failure to update fall prevention care plans; instructed Infection Preventionist on culture follow-up. |
| S4 Clinical Quality Assurance Nurse | Clinical QA Nurse | Indicated Resident #1's care plan should have been updated after falls. |
| S6 Infection Preventionist | Infection Preventionist | Unaware of culture results and failed to follow-up on infection surveillance. |
| S8 Certified Nursing Assistant | Certified Nursing Assistant | Responsible for posting daily nurse staffing info but failed to document total nursing hours on several days. |
| S12 Dietary Manager | Dietary Manager | Indicated dietary aide should have performed hand hygiene before handling coffee. |
| S13 Dietary Aide | Dietary Aide | Failed to perform hand hygiene after touching garbage bin lid and before preparing coffee. |
Inspection Report — Apr 24, 2024
CMS
Date: Apr 24, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living for residents dependent on staff assistance.
Findings
The facility failed to ensure that a resident dependent on staff for activities of daily living received proper nail care. Observations and interviews revealed that Resident #3 had long fingernails with unknown substances underneath, which staff had not addressed due to combative behaviors.
Deficiencies (1)
F 0677: The facility failed to provide nail care for a resident dependent on staff for activities of daily living. Resident #3 had long fingernails with unknown substances underneath, which were not trimmed or cleaned due to combative behaviors.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 CNA | Indicated never attempted to trim or clean Resident #3's fingernails due to combative behaviors. | |
| S1 Assistant Director of Nursing (ADON) | Observed the condition of Resident #3's fingernails and indicated they should not have appeared as they did. |
Inspection Report — Dec 14, 2023
Complaint Investigation CMS
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident privacy, dignity, notification of hospital transfers to the Ombudsman, incontinence care, medication administration, infection control, hot water temperature safety, staffing adequacy, and medication cart security.
Complaint Details
The complaint investigation found substantiated issues including failure to protect resident privacy and dignity, failure to notify the Ombudsman timely of hospital transfers, inadequate incontinence care, medication administration errors, lack of hospice care coordination, unsafe hot water temperatures, staff sleeping on duty, unsecured medication carts, and infection control lapses.
Findings
The facility failed to protect residents' dignity and privacy during personal care, failed to notify the Ombudsman timely of hospital transfers, did not provide adequate incontinence care to a dependent resident, failed to administer insulin per physician orders, lacked coordination with hospice care, maintained unsafe hot water temperatures in multiple resident rooms and shower rooms, had a staff member sleeping on duty, left medication carts unlocked when unattended, and failed to follow infection prevention protocols including hand hygiene and proper linen handling.
Deficiencies (8)
F 0550: The facility failed to protect residents' dignity and privacy during personal care for 3 residents due to inadequate privacy curtains and exposure during care.
F 0623: The facility failed to notify the Ombudsman timely of hospital transfers/discharges for 2 residents as required.
F 0677: The facility failed to provide incontinence care every two hours as planned for 1 dependent resident, resulting in prolonged exposure to soiled briefs.
F 0684: The facility failed to administer insulin per physician's sliding scale orders for 1 resident and failed to coordinate hospice care for 1 resident.
F 0689: The facility failed to maintain hot water temperatures below 120°F in 4 resident rooms and 1 shower room, posing burn risks.
F 0725: The facility failed to ensure nursing staff availability as 1 CNA was observed sleeping during the night shift.
F 0761: The facility failed to ensure a medication cart was locked when unattended for 1 of 3 medication carts observed.
F 0880: The facility failed to handle and store linen properly, failed to perform hand hygiene during peri-care and medication administration for observed staff.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Rooms with hot water >120°F: 5
Medication carts observed: 3
Medication carts unlocked: 1
CNAs observed on night shift: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S21 CNA | Certified Nursing Assistant | Named in findings related to failure to provide privacy and incontinence care for Resident #18 and Resident #75 |
| S23 CNA | Certified Nursing Assistant | Observed sleeping during night shift and terminated for this conduct |
| S10 Agency LPN | Licensed Practical Nurse | Observed failing to lock medication cart and failing hand hygiene during medication administration |
| S11 Director of Nursing | Director of Nursing | Provided interviews confirming failures in insulin administration, hospice coordination, hand hygiene, and medication cart security |
| S17 CNA | Certified Nursing Assistant | Observed failing hand hygiene during peri-care for Resident #59 |
| S13 Social Worker | Social Worker | Interviewed regarding failure to notify Ombudsman timely |
| S1 Administrator | Administrator | Interviewed regarding privacy, Ombudsman notification, and staff sleeping incident |
| S20 Quality Improvement Nurse | Quality Improvement Nurse | Interviewed regarding privacy and incontinence care standards |
| S27 Resource Staff | Resource Staff | Confirmed lack of privacy curtain for Resident #18 |
| S5 Laundry | Laundry Staff | Interviewed regarding improper linen storage |
| S6 Housekeeping | Housekeeping Staff | Observed handling dirty laundry without gloves |
| S8 Housekeeping Laundry Supervisor | Laundry Supervisor | Confirmed improper linen handling and storage practices |
Inspection Report — Jun 27, 2023
Complaint Investigation CMS
Date: Jun 27, 2023
Visit Reason
The inspection was conducted due to a complaint alleging the facility failed to notify the responsible party of medication changes for Resident #1.
Complaint Details
The complaint was substantiated. The facility failed to notify the responsible party of medication changes for Resident #1 as required.
Findings
The facility failed to notify the responsible party of medication changes for Resident #1 on 04/26/2023, despite policy requiring prompt notification. Interviews with the Social Worker and Director of Nursing confirmed the responsible party was not informed.
Deficiencies (1)
F 0580: The facility did not notify the responsible party of medication changes for Resident #1 on 04/26/2023 as required by policy.
Report Facts
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding notification responsibility for Resident #1 | |
| Director of Nursing | Interviewed and acknowledged notification failure for Resident #1 |
Inspection Report — Apr 5, 2023
Complaint Investigation CMS
Date: Apr 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident caused by staff negligence during personal care.
Complaint Details
The complaint investigation substantiated that the CNA disregarded Resident #1's request to stop turning him, which caused the resident to fall out of bed and sustain injuries including a fractured tooth, contusion, and skin tears.
Findings
The facility failed to ensure a resident was free from accident hazards when a Certified Nursing Assistant disregarded the resident's request to stop turning him, resulting in the resident falling out of bed and sustaining multiple injuries including a fractured tooth and skin tears. The incident caused actual harm and required medical and dental treatment.
Deficiencies (1)
F 0689: The facility failed to ensure a resident was free from accident hazards when a CNA did not properly position the resident and ignored his request to stop turning, causing the resident to fall out of bed and sustain injuries including a fractured tooth and skin tears.
Report Facts
Residents sampled for accident review: 5
Incident date: Feb 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Staff member who failed to ensure resident safety during turning, causing the fall. | |
| Licensed Practical Nurse (LPN) | Provided care to Resident #1 after the incident and reported on resident condition. | |
| Director of Nursing (DON) | Stated that CNA should have stopped and assessed resident position or called for assistance. | |
| Regional Nurse Consultant (RNC) | Confirmed CNA disregarded resident's request and resident experienced harm. |
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