Inspection Reports for
Courtyard Retirement & Assisted Living
308 Sidney Martin Rd, Lafayette, LA 70507, United States, LA, 70507
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 8
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to notify representatives of significant condition changes, failure to provide care as outlined in care plans, inadequate respiratory care, nursing staff competency issues, inaccurate nurse staffing postings, and failure to accommodate resident food preferences.
Deficiencies (8)
F 0558: The facility failed to ensure reasonable accommodation of resident's needs for 1 of 29 sampled residents as Resident #12's call light device was outside of her reach.
F 0580: The facility failed to notify a resident's representative of a significant change in condition for 1 of 29 sampled residents as Resident #18's vomiting episodes were not reported.
F 0656: The facility failed to ensure services were provided as outlined in the care plan for 1 of 29 sampled residents as staff failed to turn Resident #12 every two hours.
F 0677: The facility failed to ensure a resident unable to carry out ADLs received necessary services for 1 of 3 residents reviewed as Resident #57 did not receive timely perineal care.
F 0695: The facility failed to provide respiratory care consistent with professional standards for 1 of 1 residents by failing to label and properly store Resident #46's CPAP mask.
F 0726: The facility failed to ensure nursing staff possessed competencies to provide nursing services safely for 1 of 12 sampled residents as staff failed to properly maintain and record output from a Jackson Pratt drain for Resident #12.
F 0732: The facility failed to ensure daily posted nurse staffing information was accurate and current; staffing information posted was from the previous day while census was 83.
F 0806: The facility failed to accommodate food preferences for 2 of 6 residents reviewed as Resident #23 did not receive milk with lunch and Resident #17 was served iceberg lettuce despite dietary restrictions.
Report Facts
Residents sampled: 29
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 83
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S15LPN | Licensed Practical Nurse | Named in failure to notify resident representative finding for Resident #18 |
| S2DON | Director of Nursing | Confirmed failure to notify representative and lack of in-service training on JP drain care |
| S3ADON | Assistant Director of Nursing | Confirmed failure to label CPAP mask and improper JP drain care |
| S5LPN | Licensed Practical Nurse | Failed to empty JP drain and maintain proper care for Resident #12 |
| S7LPN | Licensed Practical Nurse | Interviewed regarding JP drain care and staff training |
| S6LPN | Licensed Practical Nurse | Observed not compressing JP drain bulb after emptying |
| S14WC | Ward Clerk | Responsible for posting nurse staffing information |
| S4DM | Dietary Manager | Confirmed food preference deficiencies for Residents #17 and #23 |
| S8LPN | Licensed Practical Nurse | Confirmed failure to provide milk with lunch for Resident #23 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify residents' responsible parties of significant changes in condition and to assess the provision of respiratory care.
Complaint Details
The complaint investigation found substantiated failures in notifying responsible parties of significant changes and falls, and deficiencies in respiratory care for two residents.
Findings
The facility failed to notify the responsible parties of two residents about significant changes in condition and an unwitnessed fall. Additionally, the facility failed to provide respiratory care consistent with professional standards for two residents, including improper storage of respiratory equipment and incorrect oxygen administration.
Deficiencies (2)
F 0580: The facility failed to notify Resident #6's responsible party of the resident's transfer to the hospital and failed to notify Resident #69's responsible party of an unwitnessed fall.
F 0695: The facility failed to ensure respiratory equipment was properly stored and Resident #65 received oxygen as ordered by the physician.
Report Facts
Residents reviewed: 41
Residents affected: 2
Residents affected: 2
Oxygen order rate: 3
Oxygen delivery rate observed: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | S8LPN confirmed no notification to Resident #6's responsible party | |
| Director of Nursing | S2DON confirmed no notification to Resident #69's responsible party | |
| Licensed Practical Nurse | S9LPN confirmed respiratory care deficiencies and oxygen order discrepancy for Resident #65 |
Inspection Report
Annual Inspection
Capacity: 79
Deficiencies: 8
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to properly manage residents' personal funds, inaccurate documentation of advance directives, failure to notify responsible parties of significant changes, incomplete PASARR referrals, incomplete implementation of care plans, improper respiratory care, food service hygiene violations, and inadequate infection control practices.
Deficiencies (8)
F 0568: The facility failed to provide quarterly statements for residents' personal funds, as evidenced by Resident #49 not receiving statements in 2023 until prompted by the survey team.
F 0578: The facility failed to ensure Resident #65's plan of care and clinical record accurately reflected his advance directive with DNR status.
F 0580: The facility failed to notify responsible parties of significant changes in condition for Residents #6 and #69, including hospital transfer and unwitnessed fall.
F 0644: The facility failed to refer Residents #1 and #18 for Level II PASARR evaluation after new mental disorder diagnoses.
F 0656: The facility failed to follow physician's standing orders for Resident #6's low blood sugar and failed to provide Resident #49 with a renal diet as ordered.
F 0695: The facility failed to properly store respiratory equipment and failed to provide Resident #65 oxygen at the ordered rate of 3L via nasal cannula.
F 0812: The facility failed to ensure dietary staff wore beard restraints to prevent hair contamination of food, affecting all 79 residents.
F 0880: The facility failed to perform hand hygiene after glove removal during wound care for Resident #7, risking infection transmission.
Report Facts
Residents sampled: 41
Facility census: 79
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4BOM | Business Office Manager | Named in deficiency related to resident personal funds statements |
| S5SSD | Social Service Director | Named in deficiencies related to advance directives and PASARR referrals |
| S8LPN | Licensed Practical Nurse | Named in deficiency related to failure to notify responsible party and blood sugar management |
| S2DON | Director of Nursing | Named in deficiency related to failure to notify responsible party of fall |
| S6DM | Dietary Manager | Named in deficiency related to food service hygiene and diet errors |
| S11DA | Dietary Aide | Named in deficiency related to serving incorrect diet and food hygiene |
| S9LPN | Licensed Practical Nurse | Named in deficiency related to respiratory care and oxygen administration |
| S13LPNWC | Licensed Practical Nurse, Wound Care | Named in deficiency related to failure to perform hand hygiene during wound care |
| S3ADONIP | Assistant Director of Nursing, Infection Preventionist | Named in deficiency related to infection control oversight |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 10, 2023
Visit Reason
The inspection was conducted due to an alleged staff to resident physical abuse and failure to provide appropriate pressure ulcer care as reported in complaints and investigations.
Complaint Details
The complaint involved an allegation of staff to resident physical abuse where a resident had a bruise on her foot and reported being hit by a CNA. The facility did not report the allegation to the State Survey Agency, concluding there was no evidence of abuse after investigation.
Findings
The facility failed to timely report suspected staff to resident physical abuse and failed to follow physician's orders for wound care for residents. The alleged abuse was not reported to the State Survey Agency because the facility determined there was no evidence of abuse. Additionally, wound care treatment was not fully administered as ordered for one resident with pressure ulcers.
Deficiencies (2)
F 0609: The facility failed to timely report suspected staff to resident physical abuse to the State Survey Agency for one resident. The alleged abuse involved a bruise on the resident's foot and was not reported within the required 2-hour timeframe.
F 0686: The facility failed to provide appropriate pressure ulcer care by not applying Calmoseptine to the surrounding skin of a resident's wound as ordered by the physician.
Report Facts
Residents sampled for abuse allegation: 5
Residents investigated with pressure ulcers: 3
Residents affected by deficiencies: 1
Bruise size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Conducted assessment and investigation of alleged abuse and confirmed wound care noncompliance |
| S1Administrator | Administrator | Explained rationale for not reporting alleged abuse to State Survey Agency |
| S3ADON | Assistant Director of Nursing | Performed wound care and confirmed failure to apply ordered treatment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 25, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding resident-to-resident physical abuse involving Resident #6 slapping Resident #3 in the face.
Complaint Details
The complaint investigation substantiated resident-to-resident physical abuse. Resident #6 slapped Resident #3 unprovoked on 02/26/23. Resident #6 was separated from other residents and transferred to a behavioral health facility. Resident #3 had no visible injuries and denied being hit since admission.
Findings
The facility failed to protect Resident #3 from physical abuse by Resident #6. The incident was substantiated by facility staff and involved Resident #6 exhibiting aggressive behavior and being transferred to a behavioral health facility.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Resident #6 slapped Resident #3 in the face, constituting resident-to-resident physical abuse.
Report Facts
Residents affected: 1
Incident date: Feb 26, 2023
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly monitor and report critical blood glucose levels for a resident with diabetes.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify the physician of critical lab results and failure to perform and document blood glucose checks, resulting in actual harm to a resident.
Findings
The facility failed to ensure nurses performed and documented blood glucose checks accurately and notify the physician of critical results, resulting in actual harm to one resident who was transferred to the hospital with hyperosmolar hyperglycemic state. The facility implemented corrective actions including staff in-service training and termination of the nurse involved.
Deficiencies (2)
F 0580: The facility failed to notify the physician of a critical blood glucose result for one resident with diabetes. The nurse did not document notifying the physician of the critical blood glucose level of 656 on 1/2/2023.
F 0684: The facility failed to ensure all residents received care according to orders as a nurse did not perform a blood glucose check on 1/2/2023 and documented a false result of 137. This resulted in actual harm to the resident who was hospitalized with hyperosmolar hyperglycemic state.
Report Facts
Blood glucose level: 656
Blood glucose level: 137
Blood glucose level: 780
Dates of false documentation: 8
Date of blood glucose lab draw: Jan 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2LPN | Licensed Practical Nurse | Nurse who failed to perform blood glucose check and documented false results; terminated from facility |
| S3LPN | Licensed Practical Nurse | Nurse who received critical blood glucose lab call but did not notify physician or document notification |
| S1DON | Director of Nurses | Interviewed regarding failure to notify physician and nurse documentation; oversaw corrective actions |
Inspection Report
Routine
Census: 69
Deficiencies: 8
Date: Sep 21, 2022
Visit Reason
Routine inspection to assess compliance with Medicare/Medicaid regulations including resident notifications, assessments, staff training, and medication administration.
Findings
The facility was found deficient in providing required written notices to residents and representatives regarding Medicare coverage, transfers, and bed-hold policies. Several Minimum Data Set (MDS) assessments were incomplete or untimely. Staff training on dementia, abuse/neglect, and workplace violence was not current for some employees. Medication administration documentation was incomplete for two residents.
Deficiencies (8)
F 0582: Facility failed to inform resident or legal representative in writing about Medicare non-coverage and potential liability for non-covered services for 1 of 3 sampled residents.
F 0623: Facility failed to provide timely written notification to resident and representative about transfer/discharge reasons for 1 of 3 residents investigated for hospitalizations.
F 0625: Facility failed to provide written notice specifying duration of bed-hold policy to resident and representative for 1 of 3 residents investigated for hospitalizations.
F 0636: Facility failed to complete annual, significant change, and death-in-facility MDS assessments timely for 4 of 42 sampled residents.
F 0638: Facility failed to complete quarterly MDS assessments timely for 3 of 41 sampled residents.
F 0641: Facility failed to ensure accurate MDS completion for 1 resident by omitting required elopement risk assessment.
F 0741: Facility failed to ensure 3 staff members received annual dementia, abuse/neglect, and workplace violence training, affecting all 52 employees.
F 0842: Facility failed to ensure accurate medication administration documentation on MAR for 2 residents, with multiple missing entries across several dates.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 1
Staff affected: 3
Residents affected: 2
Facility census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Interviewed regarding MDS assessments and medication administration documentation |
| S5SSD | Interviewed regarding transfer notifications and beneficiary notices | |
| S1ADM | Administrator | Interviewed regarding facility policies on transfer notifications |
| S6LPN | Licensed Practical Nurse | Personnel record reviewed for training deficiencies |
| S7LPN | Licensed Practical Nurse | Personnel record reviewed for training deficiencies |
| S8CNA | Certified Nursing Assistant | Personnel record reviewed for training deficiencies |
| S3BOM | Business Office Manager | Interviewed regarding staff training records |
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