Inspection Reports for
Lacombe Nursing Centre
28119 HWY 190, LACOMBE, LA, 70445
Back to Facility Profile8 Reports
Inspection Report — Jul 30, 2025
Routine CMS
Date: Jul 30, 2025
Visit Reason
Routine inspection of Lacombe Nursing Centre to assess compliance with regulatory requirements including resident rights, abuse prevention, respiratory care, food safety, and medical record accuracy.
Findings
The facility was found deficient in posting required ombudsman contact information, inconsistent documentation of residents' code status, failure to protect a resident from physical abuse by another resident, delayed reporting of abuse to the State Agency, failure to refer a resident for PASRR Level II evaluation, improper oxygen administration, unsanitary food storage practices, and incomplete documentation of wound care, medication administration, and catheter care.
Deficiencies (8)
F 0575: The facility failed to post the name, address, and telephone numbers of the Office of the State Long-Term Care Ombudsman program in an accessible manner, affecting 71 residents.
F 0578: The facility failed to ensure medical records consistently reflected residents' code status for 2 of 25 residents reviewed.
F 0600: The facility failed to protect a resident from physical abuse by another resident and failed to recognize the incident as abuse.
F 0609: The facility failed to timely report allegations of physical abuse to the State Agency for 1 of 24 residents reviewed.
F 0644: The facility failed to refer a resident with new mental health diagnoses for a PASRR Level II evaluation as required.
F 0695: The facility failed to provide respiratory care by administering oxygen at a lower rate than ordered for 1 resident.
F 0812: The facility failed to store and label food properly in the kitchen, risking all 69 residents served.
F 0842: The facility failed to maintain accurate and complete medical records for wound care, medication administration, and catheter care for 4 residents reviewed.
Report Facts
Residents affected: 71
Residents reviewed for advanced directives: 25
Residents reviewed for abuse: 24
Residents reviewed for PASRR: 3
Residents affected: 69
Residents reviewed for medical records: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3ADON | Confirmed no ombudsman information posted and oxygen administration standards | |
| S2DON | Confirmed oxygen administration standards and documentation expectations | |
| S9RN | Registered Nurse | Assessed resident after abuse incident and reported findings |
| S10WS | Notified about abuse incident and reported to administration | |
| S1ADM | Administrator | Notified of abuse incident and interviewed regarding incident |
| S7SSD | Responsible for PASRR resubmission | |
| S8LPN | Licensed Practical Nurse | Confirmed oxygen administration order and observed oxygen settings |
| S4SFD | Responsible for kitchen staff and meal preparation, confirmed food labeling deficiencies | |
| S11LPN | Licensed Practical Nurse | Performed wound and catheter care, confirmed documentation deficiencies |
| S12LPN | Licensed Practical Nurse | Confirmed medication administration documentation deficiencies |
Inspection Report — Jan 29, 2025
Annual Inspection CMS
Date: Jan 29, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and care plan updates, specifically focusing on accurate Minimum Data Set (MDS) assessments and timely revision of care plans after resident falls.
Findings
The facility failed to ensure that Resident #3's MDS assessment accurately reflected her fall history and failed to update the care plan with fall interventions after a fall on 12/08/2024. Interviews confirmed these deficiencies and the need for correction.
Deficiencies (2)
F0641: The facility failed to ensure the MDS assessment accurately reflected Resident #3's fall history, as Section J1700 was left blank despite a documented fall and fracture.
F0657: The facility failed to revise Resident #3's care plan to include fall interventions after an unwitnessed fall on 12/08/2024, despite policy requiring updates within 7 days.
Report Facts
Residents reviewed for falls: 3
Resident #3 fall date: Dec 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3RN | Responsible for completing MDS assessments and updating Resident #3's care plan. | |
| S2DON | Director of Nursing who confirmed deficiencies in MDS coding and care plan updates. |
Inspection Report — Aug 21, 2024
CMS
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, professional standards of care, life support, respiratory care, staffing documentation, food safety, and infection control at Lacombe Nursing Centre.
Findings
The facility was found deficient in multiple areas including failure to complete and transmit discharge/transfer assessments timely, lack of device site care orders, inconsistent resident code status documentation, improper labeling of oxygen equipment, incomplete nurse staffing data postings, expired dietary supplements in use, and failure to maintain infection control protocols including PPE use.
Deficiencies (7)
F 0640: The facility failed to ensure a Discharge/Transfer MDS assessment was completed and transmitted timely for 1 resident reviewed for Resident Assessment.
F 0658: The facility failed to ensure device site care orders were obtained for 1 of 3 residents reviewed for indwelling devices, with no documentation of site monitoring or dressing changes for a midline catheter.
F 0678: The facility failed to ensure a resident's code status matched and was maintained throughout the clinical record for 1 of 25 residents reviewed for code status.
F 0695: The facility failed to ensure oxygen tubing and humidifier bottles were properly labeled with the date last changed for 4 residents reviewed for oxygen therapy.
F 0732: The facility failed to document nurse staffing data requirements including facility census and actual hours worked on daily postings, affecting all 71 residents.
F 0812: The facility failed to store, prepare, and distribute foods and dietary supplements under sanitary conditions, with expired supplements available for resident consumption.
F 0880: The facility failed to maintain an infection prevention and control program by not ensuring staff wore proper Personal Protective Equipment while providing care to a resident on Enhanced Barrier Precautions.
Report Facts
Residents affected: 1
Residents affected: 1
Residents reviewed: 25
Residents affected: 4
Residents affected: 71
Expired dietary supplements: 4
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S9RN | Responsible for completing and transmitting MDS assessments; confirmed missing discharge/transfer MDS assessment for Resident #65 | |
| S2DON | Director of Nursing; confirmed missing discharge/transfer MDS assessment for Resident #65, midline catheter care orders missing for Resident #56, oxygen tubing labeling policy and deficiencies, infection control PPE requirements, and nurse staffing data documentation issues | |
| S7LPN | Confirmed no order obtained for midline catheter site monitoring for Resident #56 | |
| S5LPN | Confirmed Resident #63's code status was DNR and protocol for verifying code status | |
| S4SW | Responsible for updating code statuses; confirmed electronic record did not match DNR status for Resident #63 | |
| S6RN | Confirmed oxygen tubing was not labeled with date last changed for Resident #11 | |
| S3LPN | Observed unlabeled oxygen tubing and expired dietary supplements; confirmed expired supplements should have been discarded | |
| S8ADON | Unaware of nurse staffing data sheet requirements; confirmed missing census and hours worked documentation | |
| S1ADM | Confirmed missing nurse staffing data documentation and expired dietary supplements |
Inspection Report — May 6, 2024
Annual Inspection CMS
Date: May 6, 2024
Visit Reason
The inspection was conducted as part of a regulatory annual survey to assess compliance with healthcare regulations and resident care standards at Lacombe Nursing Centre.
Findings
The facility was found deficient in accommodating residents with hand contractures by not providing an appropriate call light for assistance. Additionally, resident assessments did not accurately reflect fall injuries, and fall prevention interventions were inadequate, including failure to keep the bed in a low position and to implement effective safety measures after falls.
Deficiencies (3)
F 0558: The facility failed to ensure residents with hand contractures had an appropriate call light to notify staff for assistance for 1 of 2 residents reviewed with contractures.
F 0641: The facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 3 residents reviewed, specifically not coding a fall with injury despite documented skin tears.
F 0689: The facility failed to implement appropriate interventions, monitor effectiveness, and modify interventions following a fall for 1 of 3 residents reviewed, including not keeping the bed in the low position and lacking other safety measures.
Report Facts
Residents affected: 1
Residents reviewed: 3
Falls on 03/10/2024: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Licensed Practical Nurse | Verified Resident #1 fall and skin tears |
| S1DON | Director of Nursing | Confirmed deficiencies and expectations regarding call light reporting and fall prevention |
| S4RN | Registered Nurse | Observed Resident #2 unable to use call light and bed in high position |
| S2ADON | Assistant Director of Nursing | Responsible for fall interventions and confirmed bed position and call light issues |
Inspection Report — Jan 30, 2024
Complaint Investigation CMS
Date: Jan 30, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding failure to notify a resident's physician and responsible party after a resident fall.
Complaint Details
The complaint investigation found that the falls of Resident #3 on 12/30/2023 and 12/31/2023 were not reported to nursing staff, the physician/physician's representative, or the responsible party as required. Interviews with multiple staff confirmed the failure to notify and follow protocol.
Findings
The facility failed to ensure that the physician/physician's representative and responsible party were notified after Resident #3 experienced falls on 12/30/2023 and 12/31/2023. Interviews confirmed that nursing staff did not follow the fall reporting process and failed to notify appropriate parties.
Deficiencies (1)
F 0580: The facility failed to notify the resident's physician/physician's representative and responsible party after Resident #3's falls on 12/30/2023 and 12/31/2023. Nursing staff did not follow the fall reporting process and moved the resident without notifying nursing or medical staff.
Inspection Report — Sep 27, 2023
Routine CMS
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication storage and labeling, PASRR Level II evaluations, food safety, and overall facility operations.
Findings
The facility was found deficient in multiple areas including failure to accurately complete resident assessments, failure to submit required PASRR Level II evaluations, improper medication storage and labeling including expired medications, failure to maintain food temperature logs, and improper food storage and handling practices.
Deficiencies (5)
F 0641: The facility failed to ensure resident assessments accurately reflected the resident's BIMS score for 1 of 18 residents reviewed.
F 0644: The facility failed to ensure that residents with identified mental health diagnoses were referred for PASRR Level II evaluations as required for 2 of 3 sampled residents.
F 0761: The facility failed to ensure medications were properly stored and labeled, including expired medications available for use in medication rooms and carts.
F 0800: The facility failed to maintain food temperature logs for all meals, risking foodborne illness for 72 residents.
F 0812: The facility failed to ensure food was properly labeled and stored, and proper food handling practices were not followed, risking foodborne illness for all 72 residents.
Report Facts
Residents reviewed for Resident Assessment: 18
Residents reviewed for PASRR Level II: 3
Residents affected by food safety deficiencies: 72
Expired medication vials observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7SSD | Responsible for assessing and entering residents' BIMS scores and submitting PASRR Level II forms; named in findings for failure to enter BIMS score and submit PASRR forms. | |
| S4MDS | Responsible for ensuring accuracy of MDS submissions; named in findings for failure to ensure BIMS score entry and PASRR notification. | |
| S2DON | Director of Nursing; interviewed regarding MDS and PASRR responsibilities and medication expiration issues. | |
| S1ADM | Administrator; confirmed responsibilities and verified expired medication and food safety issues. | |
| S6LPN | Nurse | Observed expired medications and medication cart conditions. |
| S8LPN | Observed medication labeling and expiration issues on insulin and medication carts. | |
| S9Cook | Observed food temperature checks and food storage practices; confirmed expired and improperly stored food items. |
Inspection Report — Mar 2, 2023
Complaint Investigation CMS
Date: Mar 2, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to develop and implement policies and procedures for vaccination education and documentation, specifically for influenza, pneumococcal, and COVID-19 vaccines.
Complaint Details
The investigation was complaint-driven, focusing on vaccination education and documentation failures for influenza, pneumococcal, and COVID-19 vaccines. The complaint was substantiated with findings of missing education documentation and declination forms for multiple residents.
Findings
The facility failed to ensure medical records included documentation of education about vaccine benefits and potential side effects, as well as rationales for residents not receiving influenza, pneumococcal, and COVID-19 vaccinations. Declination forms and education documentation were inconsistently or not provided for several residents.
Deficiencies (2)
F 0883: The facility failed to develop and implement policies and procedures ensuring medical records documented education on influenza and pneumococcal vaccines and rationales for residents not receiving these vaccines.
F 0887: The facility failed to implement policies and procedures ensuring COVID-19 vaccination education, consent, and documentation of declinations or rationales for residents not receiving the vaccine.
Report Facts
Residents reviewed for vaccination status: 5
Residents affected: 3
Inspection Report — Mar 2, 2023
Annual Inspection CMS
Date: Mar 2, 2023
Visit Reason
Annual inspection survey of Lacombe Nursing Centre to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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