Inspection Reports for
Legacy Nursing and Rehabilitation of Port Allen
403 15TH STREET, PORT ALLEN, LA, 70767
Back to Facility Profile9 Reports
Inspection Report — Dec 16, 2025
CMS
Date: Dec 16, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with fall prevention protocols and to assess whether the care plans were updated following resident falls.
Findings
The facility failed to ensure Resident #5, identified as high risk for falls, had updated care plans reflecting his falls on 08/31/2025 and 09/02/2025. No new fall prevention interventions were identified, implemented, or documented in response to these falls.
Deficiencies (1)
F 0689: The facility failed to update Resident #5's Care Plan to reflect his falls on 08/31/2025 and 09/02/2025. No new fall prevention interventions were identified or implemented following these falls.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3ADON | Assistant Director of Nursing | Confirmed responsibility for Fall Prevention Program and acknowledged failure to update Resident #5's Care Plan |
| S2DON | Director of Nursing | Confirmed expectation to update Care Plan following falls and acknowledged failure to do so for Resident #5 |
Inspection Report — Aug 27, 2025
Routine CMS
Date: Aug 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, privacy, assessments, infection control, medication administration, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, lack of privacy during care and medication administration, inaccurate resident assessments, failure to implement care plans, improper medication administration techniques, inadequate personal hygiene care, improper respiratory care, unsafe waste disposal, incomplete documentation, and lapses in infection prevention and control practices.
Deficiencies (11)
F 0558: The facility failed to ensure call lights were within reach for 2 of 33 residents reviewed, resulting in residents being unable to summon assistance.
F 0583: The facility failed to protect residents' privacy during incontinence care and medication administration for 2 of 9 residents observed.
F 0641: The facility failed to ensure an accurate Minimum Data Set assessment for 1 of 2 residents reviewed for falls, incorrectly coding no falls when falls had occurred.
F 0644: The facility failed to refer a resident with a newly diagnosed serious mental disorder for a required PASRR Level II evaluation.
F 0656: The facility failed to implement care plan interventions for aphasia by not providing a communication board as required for 1 resident.
F 0658: The facility failed to ensure nursing staff followed manufacturer instructions for inhaler use, specifically not instructing a resident to rinse mouth after administration.
F 0677: The facility failed to provide necessary personal hygiene care by not trimming and cleaning fingernails for 1 resident unable to perform ADLs.
F 0695: The facility failed to ensure oxygen tubing was properly labeled with the date last changed for 1 resident receiving oxygen therapy.
F 0814: The facility failed to ensure outdoor trash dumpsters were properly contained, with lids left open and trash exposed.
F 0842: The facility failed to accurately document contact precautions on the Medication Administration Record for 1 resident with C. Diff infection.
F 0880: The facility failed to implement infection prevention and control practices, including failure to perform hand hygiene during medication administration and failure to wear gowns when administering medications via feeding tube.
Report Facts
Residents reviewed for accommodation of needs: 33
Residents affected by call light issue: 2
Residents observed for privacy: 9
Residents affected by privacy issue: 2
Residents reviewed for falls: 2
Residents affected by inaccurate assessment: 1
Residents reviewed for PASRR: 5
Residents affected by PASRR referral failure: 1
Residents reviewed for communication difficulty: 1
Residents reviewed for medication administration: 4
Residents affected by medication administration issue: 1
Residents reviewed for ADLs: 5
Residents affected by ADL care issue: 1
Residents reviewed for oxygen therapy: 1
Residents affected by oxygen tubing labeling: 1
Residents reviewed for infection control: 31
Residents affected by infection control documentation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S11CNA | Confirmed call light for Resident #82 was not in reach | |
| S10CNA | Confirmed call light for Resident #109 was not in reach | |
| S2DON | Director of Nursing | Provided multiple interviews confirming expectations for call light placement, privacy, PASRR referrals, care plan implementation, medication administration, infection control, and PPE use |
| S8CNA | Observed leaving Resident #6's door open during incontinence care | |
| S9CNA | Confirmed privacy breach during incontinence care for Resident #6 | |
| S5LPN | Licensed Practical Nurse | Observed administering medication without proper privacy and hand hygiene; failed to have Resident #88 rinse mouth after inhaler; failed to wear gown during feeding tube medication administration |
| S15LPN | Licensed Practical Nurse | Responsible for completing MDS assessments; confirmed inaccurate fall coding for Resident #19 |
| S14SW | Social Worker | Responsible for submitting PASRR Level II evaluations; confirmed failure to submit for Resident #71 |
| S3CA | Confirmed PASRR Level II evaluation not submitted for Resident #71 | |
| S13CNA | Familiar with Resident #84's communication needs; confirmed communication board not used or present | |
| S15MDS | Responsible for implementing care plan interventions; confirmed communication board missing for Resident #84 | |
| S16MDS | Assisted in inspecting Resident #84's room for communication board | |
| S12CNA | Confirmed Resident #107's fingernails were long and dirty | |
| S19LPN | Licensed Practical Nurse | Confirmed responsibility for nail care and keeping fingernails clean and trimmed |
| S7LPN | Licensed Practical Nurse | Confirmed oxygen tubing was not labeled and should have been |
| S4DM | Confirmed dumpster lid was open and should be closed | |
| S6HSK | Responsible for dumpster area; confirmed dumpster lid should be closed | |
| S5LPN | Licensed Practical Nurse | Observed failing to perform hand hygiene during medication administration |
| S17ADON | Assistant Director of Nursing | Confirmed missing documentation of contact precautions for Resident #21 |
| S15ADON | Assistant Director of Nursing | Confirmed expectation for PPE use during feeding tube medication administration |
Inspection Report — Jun 18, 2025
Routine CMS
Date: Jun 18, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality and safety in the nursing facility, including oxygen therapy, respiratory care, bed rail safety, medical record documentation, and call system functionality.
Findings
The facility failed to ensure physician orders for oxygen therapy were obtained before administration, proper cleaning protocols for respiratory equipment were followed, bed rails were safely installed with required assessments and consents, baths were documented as provided, and call lights in resident bathrooms were functioning properly.
Deficiencies (5)
F 0658: The facility failed to ensure Physician Orders for oxygen therapy were obtained for Resident #R2 prior to administration.
F 0695: The facility failed to implement a protocol for cleaning and/or replacing Resident #1's non-invasive ventilation tubing and mask and failed to timely change oxygen tubing and humidification bottles for Residents #2 and #R2.
F 0700: The facility failed to ensure risks and benefits were reviewed, informed consent obtained, and entrapment risk assessments completed prior to bed rail installation for 4 residents (#1, #3, #R1, and #R3).
F 0842: The facility failed to ensure baths were documented as provided for Resident #1 on scheduled dates in May 2025.
F 0919: The facility failed to ensure a functioning call system was available in Resident #R1's bathroom, as the call light did not function or illuminate outside the room.
Report Facts
Residents reviewed for respiratory care: 3
Residents reviewed for bed rails: 4
Residents reviewed for bathing documentation: 4
Residents reviewed for environment: 7
Residents affected by call light deficiency: 1
Residents affected by oxygen therapy order deficiency: 1
Residents affected by respiratory care cleaning deficiency: 3
Residents affected by bed rail deficiency: 4
Residents affected by bathing documentation deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Licensed Practical Nurse | Interviewed regarding oxygen therapy orders and equipment for Resident #R2 |
| S2DON | Director of Nursing | Reviewed clinical records and confirmed lack of physician orders and cleaning protocols |
| S9LPN | Licensed Practical Nurse | Interviewed about cleaning protocols for Resident #1's ventilation equipment |
| S10LPN | Licensed Practical Nurse | Interviewed about cleaning protocols for Resident #1's ventilation equipment |
| S11LPN | Licensed Practical Nurse | Interviewed about cleaning protocols for Resident #1's ventilation equipment |
| S1CNO | Chief Nursing Officer | Interviewed regarding expectations for cleaning protocols and documentation |
| S8NP | Nurse Practitioner | Confirmed need for cleaning protocols for Resident #1's ventilation equipment |
| S12CNA | Certified Nursing Assistant | Confirmed presence of bed rails on Resident #1's bed |
| S14CNA | Certified Nursing Assistant | Confirmed presence of bed rails on Residents #3 and #R3's beds |
| S15CNA | Certified Nursing Assistant | Confirmed presence of bed rail on Resident #R1's bed |
| S13CNA | Certified Nursing Assistant | Interviewed about bath provision and documentation for Resident #1 |
| S7CNA | Certified Nursing Assistant | Tested call light functionality for Resident #R1 |
| S3MS | Medical Staff | Tested call light functionality for Resident #R1 |
Inspection Report — Jan 29, 2025
Complaint Investigation CMS
Date: Jan 29, 2025
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse of Resident #2 by a Certified Nursing Assistant.
Complaint Details
The complaint was substantiated. Resident #2's representative reported on 01/01/2025 that a CNA verbally abused Resident #2 by telling him he was 'sh***y' and refusing to get him up for breakfast. The facility acknowledged the allegation and confirmed the failure to report within the required timeframe.
Findings
The facility failed to report an allegation of verbal abuse involving Resident #2 to the state agency within the required 2-hour timeframe. The allegation involved a CNA telling the resident he was 'sh***y' and refusing to assist him.
Deficiencies (1)
F 0609: The facility failed to timely report suspected verbal abuse of Resident #2 to the state agency within 2 hours as required by regulations.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator who confirmed the verbal abuse allegation and failure to report | |
| S2DON | Director of Nursing who confirmed the verbal abuse allegation and reporting requirements |
Inspection Report — Aug 14, 2024
Annual Inspection CMS
Date: Aug 14, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, safety, care quality, and regulatory reporting.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to ensure call lights were within reach, failure to promote resident self-determination, inadequate housekeeping and maintenance, failure to timely transmit MDS assessments, inaccurate and incomplete PASARR assessments and care planning, failure to provide necessary nail care, and failure to maintain a safe environment due to improperly secured padded wall.
Deficiencies (9)
F 0550: The facility failed to ensure Resident #61 was treated with respect and dignity, including staff telling the resident not to press the call light again.
F 0558: The facility failed to ensure call lights were within reach for Residents #1 and #16, limiting their ability to request assistance.
F 0561: The facility failed to promote and facilitate Resident #61's self-determination by not allowing him to choose when to go to bed.
F 0584: The facility failed to maintain a safe, clean, and comfortable environment by not repairing a window unit cover and a bathroom door, and by allowing a tile to be lifted in two resident rooms.
F 0640: The facility failed to transmit MDS assessments within the required timeframe for 8 residents, resulting in assessments remaining in progress past due dates.
F 0641: The facility failed to ensure MDS assessments accurately reflected residents' Level II PASARR status for Residents #22 and #108.
F 0644: The facility failed to coordinate assessments with PASARR Level II determinations and failed to implement or offer recommended services for Residents #13, #22, #24, and #108.
F 0677: The facility failed to provide necessary nail care for Resident #61, whose fingernails were long, jagged, and unclean, with no orders or documentation for nail care.
F 0689: The facility failed to ensure Resident #26's padded wall was properly secured, with screws extending out and posing a risk of injury.
Report Facts
Residents reviewed for dignity: 33
Residents affected by dignity deficiency: 1
Residents reviewed for call light accommodation: 2
Residents affected by call light deficiency: 2
Residents reviewed for self-determination: 33
Residents affected by self-determination deficiency: 1
Rooms reviewed for environment: 6
Rooms affected by environment deficiency: 2
Residents with late MDS transmissions: 8
Residents with inaccurate PASARR MDS: 2
Residents with PASARR coordination deficiencies: 4
Residents reviewed for ADL nail care: 2
Residents affected by nail care deficiency: 1
Residents reviewed for accident hazards: 3
Residents affected by accident hazard deficiency: 1
Inspection Report — Jun 24, 2024
Complaint Investigation CMS
Date: Jun 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians of significant changes in resident conditions, failure to develop and implement care plans for residents receiving IV fluids, failure to monitor and document intake and output for residents on IV therapy, and failure to post nurse staffing data.
Complaint Details
The complaint investigation focused on failure to notify physicians of significant changes in resident conditions, failure to develop care plans for hydration, failure to monitor and document intake/output for residents on IV therapy, and failure to post nurse staffing data. The Immediate Jeopardy related to Resident #3's no urine output and lack of notification was removed after corrective actions.
Findings
The facility failed to notify the physician of a resident's significant change in condition related to no urine output, failed to develop dehydration care plans for residents receiving IV fluids, failed to monitor and document intake and output accurately for residents on IV therapy, and failed to post daily nurse staffing data. These deficiencies resulted in an Immediate Jeopardy situation that was removed after corrective actions.
Deficiencies (6)
F580: The facility failed to notify the physician of Resident #3's no urine output while receiving IV therapy, resulting in Immediate Jeopardy.
F656: The facility failed to develop and implement dehydration care plans for 5 residents receiving IV fluids.
F684: The facility failed to monitor and document accurate intake and output for Resident #3 receiving IV therapy, resulting in Immediate Jeopardy.
F732: The facility failed to post daily nurse staffing data in a prominent location accessible to residents and visitors.
F835: The facility failed to administer care effectively by not ensuring communication of significant changes and proper monitoring of intake/output for residents on IV therapy, resulting in Immediate Jeopardy.
F842: The facility failed to ensure complete and accurate documentation of care, including toileting hygiene, for 3 residents.
Report Facts
Residents reviewed for notification of change: 8
Residents reviewed for IV therapy: 5
Residents affected by dehydration care plan deficiency: 5
Residents affected by intake/output documentation deficiency: 1
Residents affected by nurse staffing posting deficiency: 118
Residents affected by incomplete care documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Licensed Practical Nurse | Failed to notify physician of Resident #3's no urine output on 05/31/2024 at 4:00 a.m. |
| S6NP | Nurse Practitioner | Ordered IV fluids for Resident #3 and was not notified of no urine output; confirmed expectations for notification and intake/output monitoring. |
| S2DON | Director of Nursing | Notified of Immediate Jeopardy; confirmed policies and training; confirmed nurse staffing posting requirements. |
| S1ADM | Administrator | Notified of Immediate Jeopardy; confirmed nurse staffing posting requirements. |
| S3LPN | Licensed Practical Nurse | Assessed Resident #3 on 05/31/2024 and reported condition to Nurse Practitioner. |
| S7LPN | Licensed Practical Nurse | Failed to notify Nurse Practitioner of inability to start IV for Resident #R4. |
| S12MDS | MDS Coordinator | Confirmed dehydration care plan requirements and missing care plans. |
| S11ADON | Assistant Director of Nursing | Confirmed missing documentation of toileting hygiene. |
Inspection Report — Nov 29, 2023
Complaint Investigation CMS
Date: Nov 29, 2023
Visit Reason
The inspection was conducted due to a complaint regarding failure to notify a resident's physician and responsible party after a fall.
Complaint Details
The complaint investigation found that the facility did not notify Resident #1's physician or responsible party after a fall on 11/12/2023. Multiple staff interviews confirmed the lack of notification. The issue affected a few residents and was substantiated.
Findings
The facility failed to ensure that Resident #1's physician and responsible party were notified following a fall on 11/12/2023. Interviews and record reviews confirmed that notification did not occur as required by facility policy.
Deficiencies (1)
F 0580: The facility failed to notify the resident's physician and responsible party after Resident #1's fall on 11/12/2023, contrary to the Incident and Accident Policy. Staff interviews confirmed the notification was not made as required.
Report Facts
Residents reviewed for falls: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3RN | Registered Nurse | Named in failure to notify physician and responsible party after Resident #1's fall. |
Inspection Report — Aug 15, 2023
Complaint Investigation CMS
Date: Aug 15, 2023
Visit Reason
The inspection was conducted to investigate an allegation of sexual abuse reported by Resident #3 at Legacy Nursing and Rehabilitation of Port Allen.
Complaint Details
The complaint investigation involved Resident #3 who alleged he was sexually abused multiple times in the facility. Staff interviews revealed the allegations were not reported to the administrator or State Agency as required. The resident had severe cognitive impairment and exhibited delusional behavior. The facility staff and administration acknowledged the failure to report the allegations timely.
Findings
The facility failed to ensure that an allegation of sexual abuse by Resident #3 was reported to the administrator and the State Agency within two hours as required. Staff did not report the allegations despite multiple statements by the resident, and administrative staff confirmed no reports were received during the relevant period.
Deficiencies (1)
F 0609: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The facility failed to ensure an allegation of sexual abuse was reported to the administrator and State Agency within two hours for Resident #3.
Report Facts
Residents affected: 5
Times resident alleged rape: 27
Resident #3 BIMS score: 5
Resident #3 admission date: 12/16/2020 (date, not numeric value)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Licensed Practical Nurse | Reported Resident #3's allegations to S3ADON but did not report to administrator |
| S3ADON | Assistant Director of Nursing | Received reports of Resident #3's allegations from staff |
| S7CNA | Certified Nursing Assistant | Reported Resident #3's allegations to S3ADON |
| S6CNA | Certified Nursing Assistant | Reported Resident #3's allegations to S5LPN |
| S8RN | Former Director of Nursing | Confirmed no reports of Resident #3's allegations received during tenure |
| S4ADON | Assistant Director of Nursing | Confirmed no reports of Resident #3's allegations received since starting |
| S2DON | Director of Nursing | Started position recently and had not received reports of Resident #3's allegations |
| S1ADM | Administrator | Confirmed staff had not reported Resident #3's allegations and expected immediate reporting |
Inspection Report — Jun 2, 2023
Routine CMS
Date: Jun 2, 2023
Visit Reason
Routine state inspection of Legacy Nursing and Rehabilitation of Port Allen to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, notification of changes in condition, environmental safety and sanitation, abuse reporting, care planning, personal hygiene, range of motion assistance, accident hazard prevention, and food safety and sanitation.
Deficiencies (9)
F 0550: The facility failed to ensure Resident #32 was treated with dignity and respect, leaving him unclothed with no bed linens and privacy exposed.
F 0580: The facility failed to notify nursing and practitioners of a significant decline in condition for Resident #114.
F 0584: The facility failed to maintain a safe, functional, and sanitary environment for 13 residents, including loose toilets, stained mattresses, soiled privacy curtains, and missing bathroom fixtures.
F 0609: The facility failed to timely report an allegation of physical abuse involving Resident #113 to the administrator and State Agency within two hours.
F 0656: The facility failed to develop and implement a care plan to ensure Resident #56 wore a prescribed hand splint to prevent contractures.
F 0677: The facility failed to provide necessary nail care for Residents #20, #27, and #35, resulting in long and dirty nails.
F 0688: The facility failed to provide range of motion services to Resident #51 to maintain or improve mobility, leaving the resident's left hand contracted in a closed fist.
F 0689: The facility failed to ensure water temperatures in resident bathroom sinks remained under 120 degrees Fahrenheit, with temperatures measured up to 123.3F.
F 0812: The facility failed to store and prepare food under sanitary conditions, including expired tea, sticky ice cream cups, undated cake mix, and dirty kitchen vents and pipes.
Report Facts
Residents reviewed for accident hazards: 27
Residents affected by accident hazards: 11
Residents reviewed for personal hygiene nail care: 3
Residents affected by personal hygiene nail care deficiency: 3
Residents reviewed for range of motion: 3
Residents affected by range of motion deficiency: 1
Residents reviewed for abuse: 32
Residents affected by abuse reporting deficiency: 1
Residents served meals from kitchen: 115
Water temperature in bathroom sinks: 123.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S25CNA | Certified Nursing Assistant | Named in dignity and respect deficiency for leaving Resident #32 unclothed and exposed |
| S1ADMIN | Administrator | Interviewed regarding abuse allegation and environmental findings |
| S2DON | Director of Nursing | Interviewed regarding abuse allegation, notification failures, and range of motion care |
| S9LPN | Licensed Practical Nurse | Interviewed regarding nail care and range of motion deficiencies |
| S3ADON | Assistant Director of Nursing | Confirmed active orders and care plan deficiencies for Resident #56 and #51 |
| S22MAINTENANCE | Maintenance Staff | Interviewed regarding water temperature and environmental repairs |
| S7DIETARY | Dietary Staff | Interviewed regarding food storage and sanitation deficiencies |
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