Inspection Reports for
Consolata Rehab and Wellness Center on the Teche
2319 EAST MAIN STREET, NEW IBERIA, LA, 70560
Back to Facility Profile8 Reports
Inspection Report — Apr 2, 2025
Routine CMS
Date: Apr 2, 2025
Visit Reason
Routine inspection of Consolata Rehab and Wellness Center on the Teche to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly care plan meetings, inadequate resident council responsiveness, privacy breaches of medical records, unresolved maintenance issues, inaccurate resident assessments, incomplete restorative services, poor personal care, improper enteral feeding practices, inadequate respiratory care, failure to monitor dialysis weights as ordered, improper medication storage and handling, and food service safety violations.
Deficiencies (12)
F 0553: Facility failed to ensure quarterly care plan meetings were conducted for Resident #47, with no meeting held in March 2025 due to lack of staff.
F 0565: Facility failed to address resident council grievances over multiple months, including issues with staff phone use, parking, whirlpool access, and housekeeping.
F 0583: Facility failed to maintain privacy and confidentiality of medical records by leaving resident information visible on an unattended laptop.
F 0584: Facility failed to repair Resident #11's bed for over two months despite reports, causing discomfort.
F 0641: Facility failed to accurately code Resident #7's MDS assessment regarding serious mental illness status.
F 0656: Facility failed to provide restorative nursing services as ordered for Resident #14 due to staffing and management issues.
F 0677: Facility failed to provide adequate nail care for Resident #39, whose fingernails remained long and unclean despite orders.
F 0693: Facility failed to ensure Resident #51 received enteral feedings as ordered, with feeding pump observed turned off multiple times.
F 0695: Facility failed to provide appropriate respiratory care for Residents #11, #14, and #19, including improper oxygen tubing labeling, empty humidifier bottles, and improper storage of respiratory equipment.
F 0698: Facility failed to monitor and document weights as ordered for Resident #260 receiving dialysis, missing weights on multiple days.
F 0761: Facility failed to ensure medication carts were locked when unattended, free of loose and expired medications, and properly stored Ozempic syringes.
F 0812: Facility failed to maintain kitchen food safety standards including uncovered food in cooler, expired dry goods, dishwasher not reaching required temperature, and improper storage of clean dishes.
Report Facts
Residents sampled: 28
Residents affected by care plan meeting deficiency: 1
Residents affected by resident council grievance deficiency: 3
Residents affected by privacy breach: 4
Residents affected by bed repair deficiency: 1
Residents affected by inaccurate assessment: 1
Residents affected by restorative care deficiency: 1
Residents affected by nail care deficiency: 1
Residents affected by enteral feeding deficiency: 1
Residents affected by respiratory care deficiency: 3
Residents affected by dialysis care deficiency: 1
Medication carts reviewed: 2
Loose pills found: 65
Expired medications found: 6
Uncovered food items: 10
Expired food packages: 3
Dishwasher temperature: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3ADON | Assistant Director of Nursing | Interviewed regarding care plan meetings, medication cart issues, respiratory care, and dialysis weight monitoring |
| S17AD | Activities Director | Provided resident council meeting minutes and confirmed lack of response to grievances |
| S2DON/FormerNFA | Director of Nursing/Former Nursing Facility Administrator | Interviewed regarding care plan meetings and staffing issues |
| S7RN | Registered Nurse | Responsible for Med Cart A, confirmed medication storage deficiencies |
| S6LPN | Licensed Practical Nurse | Responsible for Med Cart B, confirmed medication storage deficiencies |
| S14DM | Dietary Manager | Observed kitchen deficiencies including uncovered food and dishwasher temperature |
| S15Dietary | Dietary Staff | Observed washing dishes and storing clean dishes improperly |
| S8TXLPN | Treatment Licensed Practical Nurse | Responsible for nail care, confirmed Resident #39's nails were untrimmed |
| S6LPN | Licensed Practical Nurse | Confirmed medication cart deficiencies |
| S12LPN | Licensed Practical Nurse | Confirmed improper storage of respiratory equipment |
Inspection Report — Nov 25, 2024
Complaint Investigation CMS
Date: Nov 25, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, failure to develop and implement appropriate care plans, improper use and monitoring of side rails, and incomplete medical record documentation.
Complaint Details
The complaint investigation substantiated that the facility failed to timely report an injury of unknown origin, failed to develop and implement appropriate care plans, failed to assess and monitor side rail use including obtaining consent, and failed to maintain accurate medication administration records.
Findings
The facility failed to timely report an injury of unknown origin involving Resident #1, did not develop or implement a care plan including side rail use for Resident #2, failed to assess risks and obtain consent for side rail use for Residents #2 and #3, and did not maintain accurate medication administration records for Resident #1.
Deficiencies (4)
F 0609: The facility failed to timely report suspected abuse involving an injury of unknown origin resulting in serious bodily injury for Resident #1 to the state survey agency within 2 hours as required.
F 0656: The facility failed to develop and implement a person-centered care plan that included the use of side rails for Resident #2.
F 0700: The facility failed to assess risk of entrapment, obtain informed consent, and provide ongoing monitoring and supervision for side rail use for Residents #2 and #3.
F 0842: The facility failed to maintain accurate medical records by not documenting administration of Tylenol for Resident #1 in the EMAR on 10/23/2024 at 7:25 PM.
Report Facts
Residents sampled: 3
Date of injury incident: Oct 23, 2024
Date of survey completion: Nov 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | S2DON interviewed regarding failure to report injury, care plan deficiencies, and side rail monitoring. | |
| Administrator | S1ADM interviewed regarding notification and failure to report injury to state survey agency. | |
| Licensed Practical Nurse | S3LPN documented Resident #1's injury and medication administration notes. | |
| Certified Nursing Assistant | S4CNA notified nurse of Resident #1's injury. | |
| Certified Nursing Assistant | S6CNA interviewed about side rail use for Resident #2. | |
| Licensed Practical Nurse | S5LPN interviewed about Resident #2's entrapment incident and medication documentation. | |
| Certified Nursing Assistant | S7CNA interviewed about Resident #2's entrapment incident. |
Inspection Report — Nov 13, 2024
Routine CMS
Date: Nov 13, 2024
Visit Reason
Routine inspection to assess compliance with regulatory requirements including medication self-administration, resident rights, privacy, care planning, nurse aide competency, and medication cart security.
Findings
The facility was found deficient in allowing a resident to self-administer medications safely, respecting a resident's right to refuse care, maintaining privacy of medical records, updating care plans to reflect resident wishes, ensuring nurse aides' competency in feeding techniques, and securing medication carts when unattended.
Deficiencies (6)
F 0554: The facility failed to ensure one resident was safe to self-administer medications as there was no clinical assessment or physician order for self-administration, and medications were left at the bedside.
F 0561: The facility failed to support resident self-determination by not accommodating a resident's choice to refuse bed baths.
F 0583: The facility failed to maintain privacy and confidentiality of medical records when a medication cart was left unattended and unlocked with resident information visible.
F 0657: The facility failed to revise a resident's care plan to reflect the resident's wish to transfer to another facility despite multiple transfer requests.
F 0726: Nurse aides lacked competency in administering pleasure feedings safely, failing to cue chin tuck, double swallow, and proper positioning, and untrained staff administered feedings.
F 0761: Medication carts were left unlocked and unattended on multiple occasions, violating facility policy for medication security.
Report Facts
Sampled residents: 3
Medication carts observed: 3
Medication carts unlocked: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Interviewed regarding medication cups left at resident bedside and medication cart security |
| S2DON | Director of Nursing | Interviewed regarding medication self-administration and restorative feeding program |
| S9CNA | Certified Nursing Assistant | Interviewed about resident refusal of bed baths |
| S11SSD | Social Service Director | Interviewed about resident transfer requests |
| S8MDS | Minimum Data Set Coordinator | Interviewed about care plan revisions |
| S6CNA | Certified Nursing Assistant | Observed and interviewed regarding improper administration of pleasure feedings |
| S7ST | Speech Therapist | Interviewed about restorative feeding plan |
| S12RCNA | Restorative Certified Nursing Assistant | Interviewed about training and administration of pleasure feedings |
| S1ADM | Administrator | Interviewed about restorative program training feasibility |
| S4LPN | Licensed Practical Nurse | Interviewed about medication cart security |
| S10ADON | Assistant Director of Nursing | Interviewed about medication cart security |
| S5LPN | Licensed Practical Nurse | Interviewed about medication cart security |
Inspection Report — Jul 9, 2024
Annual Inspection CMS
Date: Jul 9, 2024
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident safety and facility operations.
Findings
The facility failed to ensure the call light system in Resident #1's bathroom was functioning, posing a risk to timely staff response. Interviews and observations confirmed the call light did not work and staff were not promptly notified.
Deficiencies (1)
F 0919: The facility failed to ensure a working call system was available in Resident #1's bathroom. The call light did not activate the front desk or alert staff, and the issue was not promptly reported or addressed.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and confirmed call light did not work | |
| Maintenance Supervisor | Interviewed and confirmed call light did not work | |
| Director of Nursing | Interviewed and stated she was not notified about the call light issue |
Inspection Report — Jun 6, 2024
Complaint Investigation CMS
Date: Jun 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's physician about changes in the resident's plan of care and failure to complete a required preadmission screening for a resident with a qualifying mental disorder.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify the physician about changes in Resident #1's care plan and failure to complete required PASRR screening before admission.
Findings
The facility failed to notify Resident #1's physician about revoking smoking privileges and administering nicotine replacement without a physician's order, potentially affecting 9 residents who smoked. Additionally, the facility admitted Resident #1 without completing a required PASRR preadmission screening for mental disorders.
Deficiencies (2)
F 0580: The facility failed to notify Resident #1's physician of revoked smoking privileges and administration of nicotine replacement without a physician's order. This affected 9 residents who smoked and posed potential harm.
F 0645: The facility admitted Resident #1 without completing a required PASRR preadmission screening for mental disorders. The level 1 screening did not include the resident's diagnosis of Major Depressive Disorder.
Report Facts
Residents affected: 9
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2SSD | Social Service Director | Interviewed regarding Resident #1's nicotine replacement and PASRR screening |
| S4NP | Nurse Practitioner | Interviewed regarding lack of notification about Resident #1's smoking privilege revocation and nicotine replacement orders |
| S1ADM | Administrator | Interviewed regarding expectations for notifying physician about changes in Resident #1's care plan |
| S3ADON | Assistant Director of Nursing | Interviewed regarding failure to notify physician about Resident #1's care plan changes |
Inspection Report — Apr 3, 2024
Annual Inspection CMS
Date: Apr 3, 2024
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements and evaluate the facility's care and services.
Findings
The facility was found deficient in multiple areas including failure to post the most recent survey results, inadequate maintenance of a homelike environment, incomplete care plans for several residents, insufficient pressure ulcer care, inadequate fall prevention supervision, improper respiratory equipment storage, medication management issues, and lapses in infection prevention practices.
Deficiencies (10)
F 0577: The facility failed to post the most recent complaint survey results from 04/11/2023 in a place readily accessible to residents and families.
F 0584: The facility failed to provide a homelike environment for Resident #30, evidenced by copper stains on bathroom fixtures, paint blister, and dust on ceiling vent.
F 0656: The facility failed to develop comprehensive care plans for Residents #13 and #17, not addressing family refusal of positioning device and limited range of motion respectively.
F 0657: The facility failed to develop comprehensive person-centered care plans within 7 days of assessment for Residents #4, 12, 16, 21, and 31.
F 0686: The facility failed to provide appropriate pressure ulcer care for Resident #13 by not assessing a pressure ulcer on the date it was identified.
F 0689: The facility failed to ensure adequate supervision and use of fall prevention devices for Resident #42, resulting in falls with injury and malfunctioning alarms.
F 0695: The facility failed to properly store and label respiratory equipment for Residents #9 and #16, including oxygen tubing on the floor and unlabeled nebulizer equipment.
F 0755: The facility failed to ensure Resident #25's Plavix was reordered and administered timely and failed to maintain accurate controlled medication reconciliation for Resident #31.
F 0761: The facility failed to ensure medications were not left unattended on medication carts or at bedside, failed to properly store controlled medications, and failed to label medications and supplements appropriately.
F 0880: The facility failed to maintain an effective infection prevention program by not performing hand hygiene before medication preparation and after glove removal.
Report Facts
Residents investigated: 31
Percocet pills: 76
Percocet pills: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S14LPN | Licensed Practical Nurse | Observed during medication pass, discovered missing Plavix, left medications unattended on cart, and failed hand hygiene |
| S3ADONIP | Assistant Director of Nursing, Infection Preventionist | Interviewed regarding infection control, medication storage, and respiratory equipment handling |
| S2DON | Director of Nursing | Interviewed regarding medication management, care planning, and fall prevention |
| S17LPN | Licensed Practical Nurse | Observed narcotic reconciliation discrepancy for Resident #31 |
| S18RN | Registered Nurse | Observed narcotic reconciliation discrepancy for Resident #31 |
Inspection Report — Apr 11, 2023
Annual Inspection CMS
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident care, clinical record accuracy, and hospice service coordination.
Findings
The facility failed to ensure bed sensor alarms were in place as ordered for two residents, failed to document bed sensor alarm checks on the eMAR for one resident, and failed to collaborate with hospice to ensure a hospice plan of care was in place for one resident.
Deficiencies (3)
F 0656: The facility failed to ensure that a bed sensor alarm was placed on the beds of 2 residents as outlined in their care plans.
F 0842: The facility failed to document on the eMAR that the bed sensor alarm was checked every shift for 1 resident.
F 0849: The facility failed to collaborate with a hospice agency to ensure a hospice plan of care was in place for 1 resident receiving hospice services.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nursing | Interviewed regarding bed alarm discontinuation and hospice plan of care |
| S2LPN | Licensed Practical Nurse | Interviewed and observed regarding bed sensor alarms and hospice plan of care |
Inspection Report — Mar 22, 2023
Routine CMS
Date: Mar 22, 2023
Visit Reason
Routine inspection of Consolata Rehab and Wellness Center on the Teche to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to notify the State Long-Term Care Ombudsman of discharges, incomplete RN assessments, inadequate pressure ulcer care, insufficient supervision for fall prevention, improper respiratory equipment storage, food safety violations, infection control lapses including improper PPE use and hand hygiene, lack of COVID-19 vaccination exemption processing, and failure to use nationally recognized infection surveillance criteria.
Deficiencies (8)
F 0623: The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated discharges for 1 resident, potentially affecting 57 residents.
F 0642: The facility failed to have an RN conduct, certify, and sign assessments for 6 residents; LPNs signed instead.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 1 resident with a left heel unstageable pressure ulcer.
F 0689: The facility failed to ensure adequate supervision and monitoring for 1 resident at risk for falls, with incomplete close monitoring documentation.
F 0695: The facility failed to ensure respiratory equipment (CPAP mask) was properly stored when not in use for 1 resident.
F 0812: The facility failed to remove scoops from dried food bins, remove expired food, and label opened food items in the kitchen, risking food safety for 40 residents.
F 0880: The facility failed to maintain an effective infection prevention and control program, including improper PPE use, handling of contaminated linens, failure to use surveillance criteria, and improper hand hygiene, affecting many residents.
F 0888: The facility failed to implement its COVID-19 vaccination policy by not approving or denying an employee's vaccination exemption request.
Report Facts
Residents affected: 57
Residents sampled: 32
Residents with pressure ulcers: 4
Residents monitored for falls: 3
Residents positive for COVID-19: 6
Residents affected by infection control deficiencies: 57
Residents affected by respiratory equipment storage deficiency: 1
Residents affected by pressure ulcer care deficiency: 1
Residents affected by fall supervision deficiency: 1
Residents affected by COVID-19 vaccination exemption deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5SSD | Confirmed failure to notify Ombudsman of resident discharges | |
| S9MDS | LPN | Signed MDS assessments without RN signature |
| S16TXN | Treatment Nurse | Documented wound care completion in error |
| S2ADON | Assistant Director of Nursing | Confirmed monitoring and infection control deficiencies |
| S15LPN | Licensed Practical Nurse | Confirmed improper CPAP mask storage |
| S4DS | Dietary Supervisor | Confirmed food safety violations |
| S11CNA | Certified Nursing Assistant | Observed improper PPE use and handling of contaminated items |
| S13CNA | Certified Nurse Assistant | Had incomplete COVID-19 vaccination exemption form |
| S3ADON | Assistant Director of Nursing | Confirmed employee vaccination exemption status |
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