Inspection Reports for
Legacy Nursing and Rehabilitation of Morgan City
740 Justa Street, Morgan City, LA, 70380
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Inspection Report — Dec 30, 2025
Annual Inspection CMS
Date: Dec 30, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards for activities of daily living documentation and medical record completeness.
Findings
The facility failed to ensure complete documentation of Resident #1's activities of daily living care and refusals, with multiple instances of missing or incomplete records despite care being provided. Interviews with staff and supervisors confirmed the lack of proper documentation in the electronic medical record system.
Deficiencies (1)
F 0842: The facility failed to maintain complete medical records for Resident #1, with missing documentation of activities of daily living care and refusals in October and November 2025. Staff interviews confirmed care was provided but not documented due to system limitations and assignment restrictions.
Report Facts
Residents reviewed: 3
Dates with no documented morning care: 12
Dates with refused baths/showers: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Reviewed documentation and confirmed missing care records for Resident #1 |
| S4 Assistant Director of Nursing | Assistant Director of Nursing | Reviewed documentation and confirmed missing care records for Resident #1 |
| S1 Administrator | Administrator | Informed of findings and confirmed documentation deficiencies |
| S3 Previous Director of Nursing | Previous Director of Nursing | Indicated facility had computer software changes but no documentation of corrections |
Inspection Report — Aug 7, 2025
Complaint Investigation CMS
Date: Aug 7, 2025
Visit Reason
The inspection was conducted as a complaint survey triggered by allegations of verbal and mental abuse between residents, failure to report abuse, failure to investigate abuse allegations, and other care and safety concerns.
Complaint Details
The complaint investigation was substantiated. The facility failed to protect Resident #30 from verbal and mental abuse by Resident #15, failed to report the abuse to the state agency, and failed to conduct a thorough investigation. Resident #30 was exposed to racial slurs and verbal aggression causing emotional distress. The facility was aware of the incidents but did not intervene adequately.
Findings
The facility failed to protect a resident from verbal and mental abuse by another resident, failed to report the abuse to the state agency, and failed to conduct a thorough investigation. Additional deficiencies included failure to implement fall risk interventions, improper oxygen administration and tubing maintenance, expired medications on medication carts, incomplete narcotic counts, undocumented medication administration, improper food storage, and lapses in infection prevention practices.
Deficiencies (9)
F0577: The facility failed to post the most recent survey results in a place readily accessible to residents.
F0600: The facility failed to protect a resident from verbal and mental abuse by another resident, resulting in actual harm.
F0609: The facility failed to timely report an allegation of verbal and mental abuse to the state agency for one resident.
F0610: The facility failed to document a thorough investigation following allegations of verbal and mental abuse.
F0656: The facility failed to implement fall risk interventions for two residents, including use of auto lock brakes on a wheelchair and a wheelchair pocket attachment.
F0695: The facility failed to follow physician orders for oxygen administration and failed to change and date oxygen tubing weekly for two residents.
F0755: The facility failed to ensure expired medications were not available for resident use, failed to complete shift verification of controlled substances count sheets, and failed to document medication administration.
F0812: The facility failed to ensure food stored in the refrigerator was labeled with an opened date and discarded prior to expiration, and failed to ensure scoops were not stored inside dry goods bins.
F0880: The facility failed to ensure the ice scoop handle was not submerged in ice water, failed to ensure proper handling of soiled linen, and failed to implement Enhanced Barrier Precautions for a resident with a PICC line.
Report Facts
Deficiencies cited: 9
Residents affected: 1
Oxygen flow rate: 2
Oxygen flow rate observed: 3.5
Fall risk score: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Named in relation to awareness and response to abuse incidents between residents |
| S2 Director of Nursing | Director of Nursing | Named in relation to oxygen administration, narcotic counts, and infection control findings |
| S3 Social Services | Social Services | Named in relation to reporting and investigation of abuse allegations |
| S9 Certified Nursing Assistant | Certified Nursing Assistant | Named in relation to witnessing and reporting verbal abuse incidents |
| S11 Licensed Practical Nurse | Licensed Practical Nurse | Named in relation to abuse incidents and infection control breach |
| S13 Licensed Practical Nurse | Licensed Practical Nurse | Named in relation to oxygen administration and medication documentation |
| S16 Licensed Practical Nurse | Licensed Practical Nurse | Named in relation to narcotic count documentation and fall risk interventions |
| S4 Infection Preventionist | Infection Preventionist | Named in relation to infection control policy and practice |
| S10 Certified Nursing Assistant Supervisor | Certified Nursing Assistant Supervisor | Named in relation to reporting abuse incidents |
| S12 Certified Nursing Assistant | Certified Nursing Assistant | Named in relation to improper handling of soiled linen |
| S14 Dietary Manager | Dietary Manager | Named in relation to food storage deficiencies |
| S15 Chief Nursing Officer | Chief Nursing Officer | Named in relation to awareness of abuse incidents |
| S17 MDS Coordinator | MDS Coordinator | Named in relation to care plan implementation |
Inspection Report — Apr 3, 2025
Complaint Investigation CMS
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding insufficient nursing staff and failure to provide required physical therapy services to residents.
Complaint Details
The complaint investigation found substantiated issues with staffing shortages causing delays in resident care and failure to provide ordered physical therapy services to a resident.
Findings
The facility failed to maintain adequate nursing staff levels on multiple days, resulting in insufficient care for residents. Additionally, the facility did not provide required physical therapy services to one resident due to lack of available physical therapist after insurance changes.
Deficiencies (2)
F 0725: The facility failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift. Staffing hours were below required levels on multiple dates between October 2024 and March 2025.
F 0825: The facility failed to ensure a resident received required physical therapy services between 02/27/2025 and 03/06/2025 due to unavailability of a physical therapist after insurance changes.
Report Facts
Nursing staff hours deficit: 29.9
Nursing staff hours deficit: 33.66
Nursing staff hours deficit: 30.03
Nursing staff hours deficit: 8.03
Nursing staff hours deficit: 19.11
Nursing staff hours deficit: 11.27
Nursing staff hours deficit: 7.24
Nursing staff hours deficit: 30.6
Nursing staff hours deficit: 25.45
Nursing staff hours deficit: 8.94
Nursing staff hours deficit: 9.77
Nursing staff hours deficit: 30.28
Nursing staff hours deficit: 9.06
Nursing staff hours deficit: 27.2
Nursing staff hours deficit: 28.92
Nursing staff hours deficit: 21.48
Nursing staff hours deficit: 9.85
Nursing staff hours deficit: 2.19
Nursing staff hours deficit: 10.62
Nursing staff hours deficit: 22.92
Nursing staff hours deficit: 29.03
Nursing staff hours deficit: 11.29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Rehabilitation | Director of Rehabilitation | Indicated Resident #1 did not receive PT services due to lack of physical therapist availability. |
| S8 Medical Director | Medical Director | Acknowledged Resident #1 should have been evaluated for physical therapy after insurance change. |
| S1 Administrator | Administrator | Signed staffing pattern reports and offered no evidence disputing deficient practice. |
Inspection Report — Aug 22, 2024
Complaint Investigation CMS
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to investigate complaints related to delayed transmission of Minimum Data Set (MDS) assessments, pressure ulcer care, resident supervision to prevent burns, medication administration practices, hospice service coordination, infection prevention and control, and other care concerns at Legacy Nursing and Rehabilitation of Morgan City.
Complaint Details
The investigation was complaint-driven, focusing on issues such as delayed MDS transmissions, pressure ulcer care, resident supervision to prevent burns, medication handling, hospice service coordination, and infection control practices. Substantiation status is not explicitly stated.
Findings
The facility failed to transmit MDS assessments within 14 days for multiple residents, did not ensure pressure reducing wheelchair cushions for a high-risk resident, failed to supervise residents adequately leading to thermal burns, improperly handled medication disposal and hand hygiene, lacked current hospice care documentation, and did not properly implement infection prevention measures including hand hygiene and cluster infection identification.
Deficiencies (6)
F0640: The facility failed to transmit Minimum Data Set (MDS) assessments within 14 days of completion for 3 of 5 residents reviewed.
F0686: The facility failed to ensure a pressure reducing wheelchair cushion was used for a resident at high risk for skin breakdown.
F0689: The facility failed to ensure residents were supervised to prevent thermal burns, resulting in actual harm to 2 residents from spilled hot coffee.
F0761: The facility failed to ensure a licensed practical nurse disposed of a resident's medication properly and did not place unused medication back into the blister pack.
F0849: The facility failed to obtain and maintain current hospice plans of care and ensure staff awareness of hospice responsibilities for a resident receiving hospice services.
F0880: The facility failed to ensure proper infection prevention practices including hand hygiene by staff, proper storage of clean laundry, and identification and response to a cluster of urinary tract infections.
Report Facts
Residents with delayed MDS transmissions: 3
Residents affected by pressure cushion deficiency: 1
Residents affected by thermal burns: 2
Temperature of coffee dispenser: 150.8
Residents with urinary tract infections caused by Proteus Mirabilis: 3
BIMS score for Resident #19: 6
BIMS score for Resident #49: 12
Braden Scale score for Resident #5: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Failed to properly dispose of medication and did not perform hand hygiene during medication administration. |
| S2 Director of Nursing | Director of Nursing (DON) | Acknowledged failures in medication disposal and infection control oversight. |
| S3 Assistant Director of Nursing/Infection Preventionist | Assistant Director of Nursing/Infection Preventionist (ADON/IP) | Did not identify infection cluster or implement corrective infection control measures. |
| S8 Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Failed to perform hand hygiene after incontinence care. |
| S5 Treatment Nurse | Treatment Nurse (TN) | Failed to perform hand hygiene between wound care procedures. |
| S1 Administrator | Administrator | Designated to ensure hospice agreement compliance; unaware of outdated hospice documentation. |
Inspection Report — Oct 5, 2023
Annual Inspection CMS
Date: Oct 5, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey of Legacy Nursing and Rehabilitation of Morgan City to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to develop timely baseline care plans, incomplete care plans, improper medication administration, inadequate respiratory care, insufficient RN coverage, inaccurate medication dispensing, expired medications and food, failure to safeguard resident medical records, lack of an effective Quality Assurance program, inadequate infection control practices including improper PPE use and COVID-19 testing, and insufficient nurse aide training.
Deficiencies (14)
F0655: The facility failed to initiate baseline care plans within 48 hours of admission for 3 residents with diagnoses including anxiety, depression, and renal disease.
F0656: The facility failed to develop and implement comprehensive person-centered care plans with measurable goals and interventions for 3 residents, including those with dementia and unsafe smoking behavior.
F0693: The facility failed to administer a resident's enteral feeding water flush per physician orders, delivering it at the wrong rate.
F0695: The facility failed to ensure a resident's CPAP mask was properly contained and clean, posing a risk for respiratory care.
F0727: The facility failed to ensure registered nurse coverage for eight consecutive hours on two days within the review period.
F0732: The facility failed to post nurse staffing information in a prominent and accessible location for residents and visitors.
F0755: The facility failed to ensure accurate dispensation and documentation of controlled medications, with discrepancies found in narcotic records.
F0761: The facility failed to ensure expired medications and dressings were removed and not available for resident use.
F0812: The facility failed to ensure expired food was not available for resident consumption and failed to appropriately date and label opened food items.
F0842: The facility failed to safeguard resident-identifiable information by altering a medical record after a resident's death.
F0865: The facility failed to develop, implement, and maintain an effective Quality Assurance and Performance Improvement program.
F0868: The facility failed to ensure the Quality Assessment and Assurance committee met quarterly and included required members.
F0880: The facility failed to implement infection prevention and control measures including hand hygiene during catheter care, proper PPE use for COVID-19 positive residents, COVID-19 testing of exposed residents and staff, and posting outbreak signage.
F0947: The facility failed to provide required in-service training for nurse aides to ensure continuing competence and education in dementia care and abuse prevention.
Report Facts
Controlled medication discrepancies: 9
Expired medication: 14
Expired dressing: 1
RN coverage hours: 2
Nurse aide training hours: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S11 CNA Coordinator | Certified Nurse Assistant Coordinator | Failed to complete required in-service training and involved in medication administration deficiencies. |
| S8 Director of Nursing | Director of Nursing | Confirmed deficiencies related to CPAP care, RN coverage, PPE use, and infection control. |
| S2 Administrator | Administrator | Confirmed RN coverage deficiencies, medication administration issues, and lack of Quality Assurance program. |
| S9 Infection Preventionist | Infection Preventionist | Reported overwhelmed status and lack of clarity on COVID-19 testing and outbreak control. |
| S21 Unit Manager | Unit Manager | Reported medication reconciliation deficiencies for controlled substances. |
Inspection Report — Aug 2, 2023
CMS
Date: Aug 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements and identify deficiencies related to resident care and facility operations.
Findings
The facility failed to provide a nutritional supplement (magic cup) as ordered for one resident (Resident #1) during multiple meal observations. Interviews with staff confirmed the supplement was not provided despite physician orders.
Deficiencies (1)
F 0692: The facility failed to provide a nutritional supplement as ordered for Resident #1. Observations and interviews confirmed the magic cup supplement was not provided at lunch and breakfast on specified dates.
Report Facts
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | S3 CNA served Resident #1 lunch tray without supplement | |
| Dietary Manager | S2 DM confirmed supplement order but not listed on meal ticket | |
| Certified Nursing Assistant | S4 CNA confirmed supplement not provided at breakfast | |
| Director of Nursing | S1 DON confirmed physician order for supplement with every meal |
Inspection Report — Mar 9, 2023
CMS
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to assess compliance with facility policies regarding staff certification in Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR).
Findings
The facility failed to ensure that five Licensed Practical Nurses (LPNs) maintained current CPR certifications as required by policy. Personnel records showed expired or missing CPR certifications for these nurses.
Deficiencies (1)
F 0678: The facility failed to ensure five Licensed Practical Nurses were certified in Basic Life Support (BLS)/CPR as required by facility policy. Personnel records showed expired or absent CPR certifications for these nurses.
Report Facts
Licensed Practical Nurses without current CPR certification: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Director of Nurses | Director of Nurses | Interviewed and confirmed awareness of LPNs lacking current CPR certification |
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