Inspection Reports for Lafon Nursing Facility
6900 Chef Menteur Hwy, New Orleans, LA 70126, LA, 70126
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
208% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 22, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards related to resident care, infection control, and privacy in the nursing facility.
Findings
The facility was found deficient in maintaining accurate medical records for a resident's enteral feeding documentation, ensuring proper infection prevention practices including posting Enhanced Barrier Precaution signage and staff use of personal protective equipment, and providing adequate privacy curtains in semi-private rooms.
Deficiencies (3)
Failed to maintain accurate records for Resident #3's enteral feeding times and residual checks.
Failed to post Enhanced Barrier Precaution signage and ensure staff wore proper protective equipment during high contact care for Resident #3.
Failed to provide ceiling suspended privacy curtains for residents in semi-private rooms (Residents #3 and #R4).
Report Facts
Deficiencies cited: 3
Residents sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6 LPN | Licensed Practical Nurse | Named in findings related to inaccurate documentation and failure to wear gown during PEG tube care. |
| S3 Director of Nursing | Director of Nursing | Confirmed documentation and infection control deficiencies. |
| S7 CNA | Certified Nursing Assistant | Interviewed regarding lack of EBP signage and failure to wear gown during resident care. |
| S8 RA | Restorative Aide | Interviewed regarding failure to wear gown during resident transfer and repositioning. |
| S4 Assistant Director of Nursing/Infection Preventionist | Assistant Director of Nursing/Infection Preventionist | Confirmed infection control protocol deficiencies. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The inspection was conducted to assess the accuracy of resident Minimum Data Set (MDS) assessments and compliance with food sanitation procedures at Lafon Nursing Facility of the Holy Family.
Findings
The facility failed to ensure accurate MDS assessments for two residents, Resident #6 and Resident #9, with documented inaccuracies regarding falls and oral/dental status. Additionally, the facility failed to ensure staff followed manufacturer's instructions for sanitizing dishware in the 3 compartment sink.
Deficiencies (2)
Failed to ensure resident MDS assessments were completed accurately and reflected the resident's status for Resident #6 and Resident #9.
Failed to ensure staff followed the manufacturer's instructions for the 3 compartment sink to correctly sanitize dishware.
Report Facts
Residents sampled for MDS accuracy: 19
Residents with inaccurate MDS assessments: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Interviewed regarding Resident #6's fall documentation |
| S3 Minimum Data Set Nurse Coordinator | MDS Nurse Coordinator | Confirmed inaccurate MDS assessments for Resident #6 and Resident #9 |
| S1 Administrator | Administrator | Acknowledged inaccurate MDS documentation for Resident #9 and confirmed sanitization procedure noncompliance |
| S4 Dietary | Dietary Staff | Interviewed regarding dishwashing procedures in the 3 compartment sink |
| S5 Dietary Manager | Dietary Manager | Confirmed staff should have followed manufacturer's sanitization instructions |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 21, 2025
Visit Reason
The inspection was conducted to investigate complaints related to discharge and transfer procedures for sampled residents, specifically focusing on whether referrals to home health were completed prior to discharge and whether discharge orders ensured residents had necessary supplies and equipment.
Complaint Details
The complaint investigation focused on discharge requirements for Residents #1, #2, and #3. Resident #1's home health referral was not accepted prior to discharge, and necessary PEG tube feeding supplies were delayed. Transfer/discharge reports for all three residents were incomplete. The complaint was substantiated with findings of minimal harm or potential for harm.
Findings
The facility failed to ensure a home health referral was completed prior to discharge for Resident #1 and did not clarify discharge orders to ensure necessary PEG tube feeding supplies were provided. Additionally, transfer/discharge reports were incomplete for Residents #1, #2, and #3, lacking chief complaints, relevant information, and final summaries of resident status at discharge.
Deficiencies (3)
Failed to ensure a referral to home health was completed prior to Resident #1's discharge as ordered.
Failed to clarify Resident #1's discharge order to ensure all necessary PEG tube feeding supplies and equipment were ordered and provided upon discharge.
Failed to complete transfer or discharge reports for Residents #1, #2, and #3, lacking chief complaint, relevant information, and final summary of resident status at discharge.
Report Facts
Residents investigated for discharge requirements: 3
Date of Resident #1's Physician's Telephone Order: Apr 7, 2025
Date of Resident #1's Transfer/Discharge Report: Apr 10, 2025
Date of Resident #1's Physician's Orders for PEG tube pump and formula: Apr 11, 2025
Date referral made to infusion company: Apr 25, 2025
Date Resident #1 received PEG tube feeding pump: Apr 30, 2025
Date Resident #1 received Isosource 1.5 formula: May 1, 2025
Discharge dates for Residents: Apr 10, 2025
Discharge dates for Residents: May 7, 2025
Discharge dates for Residents: Apr 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Indicated no documented evidence of home health referral acceptance prior to Resident #1's discharge and that transfer/discharge reports were incomplete for Residents #1, #2, and #3. |
| S2 Speech Therapist | Rehabilitation Director | Participated in Resident #1's discharge planning meeting and indicated Resident #1 needed to continue PEG tube feedings at home. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 19, 2025
Visit Reason
The inspection was conducted to investigate complaints related to employee rights signage, timely reporting of abuse allegations, and personnel performance reviews at Lafon Nursing Facility of the Holy Family.
Complaint Details
The complaint investigation found that the facility did not post required employee rights signage, failed to report an abuse allegation involving Resident #1 within two hours as required, and did not complete a timely performance review for a Certified Nursing Assistant. The abuse allegation involved a delay in reporting to the State Survey Agency and suspension of the involved CNA pending investigation.
Findings
The facility failed to post required employee rights signage against retaliation, did not report an allegation of abuse within the required two-hour timeframe, and failed to complete a required annual performance review for a Certified Nursing Assistant.
Deficiencies (3)
Failed to ensure a notice of employees' rights against retaliation for reporting crimes against residents was posted in a conspicuous location.
Failed to timely report an allegation of abuse to the State Survey Agency within the required two hours for one resident.
Failed to complete a performance review within 12 months for one Certified Nursing Assistant.
Report Facts
Residents investigated for abuse: 3
Residents affected by abuse reporting deficiency: 1
Personnel records reviewed: 5
Personnel affected by missing performance review: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed lack of signage, delayed abuse reporting, and missing performance review |
| S2 Chief Operations Officer | Chief Operations Officer | Confirmed no signage evidence |
| S3 Assistant Chief Operations Officer | Assistant Chief Operations Officer | Reported suspension of CNA pending investigation |
| S4 Compliance Executive Nurse | Compliance Executive Nurse | Unaware of signage requirement |
| S5 Human Resources Director | Human Resources Director | Confirmed no documented performance review for CNA |
| S6 Licensed Practical Nurse | Licensed Practical Nurse | Reported no signage displayed for employee rights |
| S8 Certified Nursing Assistant | Certified Nursing Assistant | Subject of missing performance review and suspension pending abuse investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to the facility's failure to document monthly weights for residents as required for nutrition monitoring.
Complaint Details
The visit was complaint-related, investigating failure to document monthly weights for nutrition monitoring. The deficiency was substantiated based on record review and interviews.
Findings
The facility failed to ensure monthly weights were documented for Resident #1 for November and December 2024, which prevented proper nutritional assessment. Interviews with the dietitian and compliance nurse confirmed the absence of documented weights and the facility policy requiring monthly weight documentation.
Deficiencies (1)
Failure to ensure monthly weights were documented for Resident #1 for November and December 2024.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietitian | Interviewed regarding inability to assess Resident #1's weight loss due to missing documentation. | |
| Compliance Executive Nurse (CEN) | Interviewed confirming facility policy and missing weight documentation for Resident #1. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, accuracy of Minimum Data Set (MDS) assessments, and staff performance evaluations at Lafon Nursing Facility of the Holy Family.
Findings
The facility failed to complete and transmit a discharge/transfer MDS assessment timely for one resident, inaccurately coded restraints in another resident's MDS, and did not conduct annual performance evaluations or provide in-service education for certain unlicensed personnel.
Deficiencies (3)
Failed to ensure a Discharge/Transfer Minimum Data Set (MDS) assessment was completed and transmitted timely for Resident #66.
Failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for Resident #12, including incorrect coding of restraints.
Failed to complete performance reviews and provide in-service education annually for 2 of 3 sampled unlicensed personnel (S5 Certified Nursing Assistant and S6 Receptionist).
Report Facts
Residents reviewed for assessment: 3
Residents affected by discharge MDS deficiency: 1
Residents affected by MDS accuracy deficiency: 1
Unlicensed personnel sampled: 3
Unlicensed personnel affected by missing performance evaluations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 License Practical Nurse | Minimum Data Set Nurse | Confirmed Resident #66's discharge MDS was not completed and Resident #12's MDS was coded for restraints in error |
| S7 Director of Nursing | Director of Nursing | Confirmed Resident #66 did not have a discharge MDS and that the facility did not use restraints |
| S2 Human Resource Director | Human Resource Director | Confirmed S4 CNA, S5 CNA, and S6 Receptionist had not had performance evaluations |
| S1 Director of Operations | Director of Operations | Confirmed personnel performance evaluations had not been conducted for S4 CNA, S5 CNA, or S6 Receptionist |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Jul 31, 2024
Visit Reason
The inspection was conducted due to an Immediate Jeopardy situation related to the facility's failure to ensure mechanical lift slings were in good condition, which resulted in resident injuries during transfers.
Findings
The facility failed to keep residents safe by using mechanical lift slings that were worn, altered, or defective, leading to a resident falling and sustaining a head injury. The Immediate Jeopardy was removed after the facility implemented an acceptable Plan of Removal.
Deficiencies (2)
Failure to ensure mechanical lift slings were in good condition, resulting in a resident fall and head injury due to a broken sling strap.
Use of a mechanical lift sling with altered/removed blue straps to transfer a resident.
Report Facts
Residents affected: 2
Date of Immediate Jeopardy start: Apr 12, 2024
Date of Immediate Jeopardy removal: Jul 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Wrote nurse's note documenting Resident #3's injury |
| S6 Certified Nursing Assistant | Certified Nursing Assistant | Involved in transferring Resident #3 when sling strap broke |
| S10 Certified Nursing Assistant | Certified Nursing Assistant | Involved in transferring Resident #3 when sling strap broke |
| S4 Certified Nursing Assistant | Certified Nursing Assistant | Observed transferring Resident #R4 using altered sling |
| S5 Certified Nursing Assistant | Certified Nursing Assistant | Assisted in transferring Resident #R4 using altered sling |
| S11 Licensed Practical Nurse | Licensed Practical Nurse | Indicated CNAs were to check mechanical lift slings for defects |
| S9 Licensed Practical Nurse | Licensed Practical Nurse | Inspected altered mechanical lift sling used for Resident #R4 |
| S1 Administrator | Administrator | Notified of Immediate Jeopardy and confirmed policy on sling use |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Mar 1, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to identify any deficiencies in care and facility operations.
Findings
The facility was found deficient in ensuring a floor mat was placed at the bedside for a high fall-risk resident as per the care plan, and in properly transcribing a physician's order for pain medication into the medical record, which could affect medication administration.
Deficiencies (2)
Failed to ensure staff placed a floor mat on the floor while a resident was in bed per the resident's plan of care as a safety precaution.
Failed to ensure a physician's order for pain medication was transcribed to the medical record.
Report Facts
Fall risk score: 75
Medication quantity: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed failure to place floor mat and failure to enter medication order |
| S5 Licensed Practical Nurse | Licensed Practical Nurse | Received medication but did not enter the order into the electronic record |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to evaluate compliance with Medicare and Medicaid regulations, including review of resident care, safety, infection control, staffing, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to complete required Medicare beneficiary notices, inadequate pressure ulcer care and assessments, unsafe water temperatures, poor communication with dialysis providers, incomplete CNA registry verification, unsanitary food storage practices, inaccurate staffing data submission, and lapses in infection prevention and control practices.
Deficiencies (8)
Failed to ensure Skilled Nursing Facility Advance Beneficiary Notice (CMS-10055) was completed prior to discontinuation of Medicare Part A services for 2 residents.
Failed to ensure weekly pressure ulcer wound assessments and appropriate wound care per physician orders for 2 residents.
Water accessible to residents exceeded 120 degrees Fahrenheit in 2 rooms.
Failed to establish and maintain communication with contracted dialysis facility for 1 resident.
Failed to have documented evidence of Certified Nursing Assistant Registry check prior to hire for 1 employee.
Failed to maintain clean freezer floor, prevent food storage on floor, and ensure food was labeled, dated, and sealed.
Failed to electronically submit accurate payroll information for direct care staffing.
Failed to implement infection prevention and control program including proper hand hygiene, glove changes, and disinfection of reusable equipment.
Report Facts
Residents reviewed for Medicare Part A termination: 3
Residents with pressure ulcer deficiencies: 4
Rooms with water temperature exceeding 120°F: 2
Dialysis communication forms missing: 9
Personnel records reviewed for CNA registry verification: 5
Dates with no RN hours reported in PB&J: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed wound assessment deficiencies, dialysis communication process, staffing reporting issues, and infection control lapses. |
| S5 Wound Care LPN | Licensed Practical Nurse | Observed performing wound care with improper glove use and hand hygiene. |
| S15 CNA | Certified Nursing Assistant | Observed providing incontinence care with improper towel use and glove hygiene. |
| S4 Engineering | Engineering Staff | Measured water temperatures exceeding 120°F and acknowledged failure to monitor temperatures. |
| S8 Facility Director | Facility Director | Acknowledged deficiencies in CNA registry verification, food storage, and staffing data submission. |
| S6 LPN | Licensed Practical Nurse | Observed failing to disinfect blood pressure cuff between residents. |
| S7 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed dialysis communication form deficiencies. |
| S3 Social Worker | Social Worker | Unaware of Skilled Nursing Facility Advance Beneficiary Notice process. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 22, 2023
Visit Reason
The inspection was conducted due to a complaint alleging the facility failed to immediately notify the responsible party of a change in skin condition for Resident #1.
Complaint Details
The complaint investigation found the facility did not immediately notify Resident #1's responsible party of a skin condition change as required. The issue was substantiated based on record review and staff interview.
Findings
The facility failed to immediately notify Resident #1's responsible party of a reddened area on the resident's right foot identified on 09/01/2023. Documentation showed notification did not occur until 09/05/2023.
Deficiencies (1)
Failure to immediately notify the resident's responsible party of a change in skin condition to Resident #1's right lower extremity.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Named in wound assessment and interview regarding notification failure. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to immediately notify the responsible party when there was a significant change in a resident's condition requiring hospital transportation.
Complaint Details
The complaint investigation found that the facility did not immediately notify the responsible party of Resident #1's decline in condition which required transportation by Emergency Medical Services to a local hospital.
Findings
The facility failed to immediately notify the responsible party when Resident #1 experienced a significant change in level of consciousness and decreased blood pressure requiring hospital transport. Documentation confirming immediate notification was not found during interviews with facility staff.
Deficiencies (1)
Failure to immediately notify the resident, the resident's doctor, and a family member of situations affecting the resident, specifically a significant change in Resident #1's condition requiring hospital transport.
Report Facts
Residents sampled: 5
Residents affected: 1
Vital signs: 61
Vital signs: 33
Vital signs: 109
Vital signs: 34
Vital signs: 96.6
Date of incident: Jun 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Noted change in Resident #1's condition and documented vital signs |
| S2 Director of Nurses | Director of Nurses | Interviewed and stated no documented evidence of immediate notification |
| S1 Administrator | Administrator | Interviewed and stated no documented evidence of immediate notification |
Inspection Report
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
This document is a statement of deficiencies and plan of correction for Lafon Nursing Facility of the Holy Family, summarizing the results of a survey completed on 2023-02-02.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 79
Deficiencies: 8
Date: Feb 1, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, including COVID-19 protocols, and to evaluate staff vaccination status.
Findings
The facility failed to maintain an effective infection prevention and control program, including improper hand hygiene and PPE use by staff, failure to clean and store PPE properly, and improper use of N95 masks across isolation and non-isolation rooms. Additionally, the facility lacked a process to monitor COVID-19 vaccination status of employees, volunteers, and contractors.
Deficiencies (8)
Staff failed to perform hand hygiene and/or wore PPE improperly when handling medications for one resident.
Staff did not properly clean and store PPE used in rooms with COVID-19 positive residents.
Staff failed to perform hand hygiene after handling PPE used in COVID-19 positive residents' rooms.
Certified Nurse Assistants failed to follow infection control practices in multiple rooms housing COVID-19 positive residents.
Staff wore the same N95 mask in both isolation and non-isolation rooms, contrary to policy.
Staff failed to wear protective eye equipment and gloves when required.
Staff placed uncleaned blood pressure cuff into scrub pocket after use in isolation room.
Facility failed to have a process to monitor COVID-19 vaccination status of employees, volunteers, and contractors.
Report Facts
Residents affected: 79
Residents receiving medications on Hall X: 17
Rooms observed with COVID-19 positive residents: 8
Certified Nurse Assistants observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Licensed Practical Nurse | Named in medication handling and hand hygiene deficiency. |
| S15CNA | Certified Nursing Assistant | Named in PPE handling and hand hygiene deficiencies. |
| S7Restorative CNA | Certified Nursing Assistant | Named in PPE donning deficiencies. |
| S9CNA | Certified Nursing Assistant | Named in improper N95 mask use. |
| S11CNA | Certified Nursing Assistant | Named in improper N95 mask use. |
| S13CNA | Certified Nursing Assistant | Named in PPE and glove use deficiencies. |
| S14CNA | Certified Nursing Assistant | Named in PPE and glove use deficiencies. |
| S3Infection Preventionist | Infection Preventionist | Provided confirmation and statements regarding infection control deficiencies. |
| S5Contracted Cleaner | Contracted Cleaner | Named in vaccination status deficiency. |
| S6Hospice Nurse | Hospice Nurse | Named in vaccination status deficiency. |
| S8Management | Management | Named in vaccination status deficiency. |
| S10Priest | Volunteer | Named in vaccination status deficiency. |
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