Inspection Reports for
Pointe Coupee Healthcare

1820 FALSE RIVER ROAD, NEW ROADS, LA, 70760

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8 Reports

All CMS 2022–2025

Inspection Report — Sep 5, 2025

Enforcement CMS
Date: Sep 5, 2025

Visit Reason
The inspection was conducted due to an immediate jeopardy situation involving a medication error where a resident received an incorrect insulin dose, resulting in hypoglycemia and hospitalization.

Findings
The facility failed to accurately transcribe a resident's insulin order, resulting in the resident receiving 30 units of Lantus insulin daily instead of the prescribed 5 units. The resident experienced a hypoglycemic episode with a blood glucose level of 23 mg/dL and required emergency treatment. The facility implemented corrective actions and staff training prior to the investigation.

Deficiencies (2)
F 0658: The facility failed to ensure nursing staff accurately transcribed Resident #1's Lantus insulin order, clarify blood glucose monitoring orders, and obtain blood glucose levels when the resident experienced a change in condition, resulting in immediate jeopardy.
F 0760: The facility failed to ensure a resident was free from significant medication errors by transcribing an incorrect insulin dose, leading to hypoglycemia and hospitalization.
Report Facts
Insulin dose administered: 30 Blood glucose level: 23 Intravenous Dextrose administered: 25 Compliance date: Aug 18, 2025

Employees mentioned
NameTitleContext
S4LPNLicensed Practical NurseTranscribed incorrect insulin order into electronic medical record
S7LPNLicensed Practical NurseFailed to obtain blood glucose level when resident showed symptoms
S1DONDirector of NursingInvestigated medication error, provided staff education, and performed audits
S2NPNurse PractitionerReviewed insulin orders and confirmed medication error

Inspection Report — Dec 6, 2024

Complaint Investigation CMS
Date: Dec 6, 2024

Visit Reason
The inspection was conducted to investigate complaints regarding resident care, including failure to promote resident self-determination, failure to notify physicians of significant changes, failure to maintain a sanitary environment, inaccurate assessments, failure to implement care plans, medication administration errors, inadequate assistance with activities of daily living, pressure ulcer care, pain management, staffing shortages, hospice care coordination, and equipment safety.

Complaint Details
The complaint investigation revealed multiple deficiencies including failure to promote resident choice, failure to notify physicians of significant changes, unsanitary conditions, inaccurate assessments, failure to implement care plans, medication errors, inadequate ADL assistance, pressure ulcer care deficiencies, pain management failures, staffing shortages, hospice care coordination issues, and unsafe equipment.
Findings
The facility was found deficient in multiple areas including failure to timely assist residents with activities, failure to notify physicians of changes in condition, failure to maintain sanitary mattresses, inaccurate MDS assessments, failure to implement care plans especially related to orthopedic devices and follow-up appointments, unsafe medication administration practices, inadequate personal hygiene assistance, failure to prevent pressure ulcers, inadequate pain management for a resident with a fractured elbow, insufficient nursing staff to meet resident needs, failure to maintain accurate medication records, failure to coordinate hospice care properly, and failure to maintain safe bed equipment.

Deficiencies (13)
F0561: The facility failed to promote and facilitate resident self-determination through support of a resident's choice to participate in activities, affecting 1 of 2 residents reviewed.
F0580: The facility failed to notify a resident's physician of significant changes related to orthopedic braces for 1 of 3 residents, resulting in an Immediate Jeopardy situation that was removed prior to survey exit.
F0584: The facility failed to maintain a resident's mattress in a sanitary manner for 1 of 2 residents reviewed for environment.
F0641: The facility failed to ensure a resident's MDS assessment accurately reflected the PASARR status for 1 of 2 residents reviewed.
F0656: The facility failed to implement a resident's comprehensive care plan by not applying an immobilizing splint as ordered and failing to ensure follow-up appointments for 2 residents.
F0658: The facility failed to ensure medications were administered safely by leaving medications at bedside for 1 resident.
F0677: The facility failed to provide hair hygiene for 1 of 2 residents reviewed for ADL assistance, resulting in poor scalp hygiene.
F0686: The facility failed to ensure residents received care to prevent and heal pressure ulcers for 1 resident reviewed for pressure ulcers.
F0697: The facility failed to provide appropriate pain management for 1 resident with a fractured elbow, including failure to apply an immobilizing splint and failure to administer pain medication.
F0725: The facility failed to provide sufficient nursing staff to meet resident needs and failed to respond timely to a resident's requests for assistance with ADLs for 1 resident.
F0842: The facility failed to ensure a resident's Medication Administration Record was accurately documented for 1 resident regarding use of orthopedic devices.
F0849: The facility failed to designate a member of the interdisciplinary team to coordinate hospice care and failed to maintain current hospice documentation for 1 resident receiving hospice care.
F0908: The facility failed to maintain resident's bed equipment in safe operating condition for 1 resident, resulting in inability to adjust bed and delayed care.
Report Facts
Residents affected: 92 Residents affected: 5 Residents affected: 22 Residents affected: 3 Residents affected: 2 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1

Employees mentioned
NameTitleContext
S7NPNurse PractitionerNamed in pain management and orthopedic splint findings
S2DONDirector of NursingNamed in multiple findings including pain management, orthopedic splint, staffing, and hospice coordination
S13LPNLicensed Practical NurseNamed in orthopedic splint and pain management findings
S12LPNLicensed Practical NurseNamed in orthopedic splint and medication administration findings
S14CNACertified Nursing AssistantNamed in orthopedic splint and pain management findings
S15CNACertified Nursing AssistantNamed in orthopedic splint and pain management findings
S16CNACertified Nursing AssistantNamed in orthopedic splint and pain management findings
S4CNACertified Nursing AssistantNamed in staffing and ADL assistance findings
S5CNACertified Nursing AssistantNamed in staffing and ADL assistance findings
S3CSUPCNA SupervisorNamed in staffing findings
S1ADMAdministratorNamed in multiple findings including staffing, hospice coordination, and equipment safety
S22SWSocial WorkerNamed in hospice care findings
S8TRPTransportation CoordinatorNamed in care plan follow-up findings
S6MSMaintenance StaffNamed in bed equipment findings
S10CNACertified Nursing AssistantNamed in personal hygiene findings
S11CNACertified Nursing AssistantNamed in bed equipment findings

Inspection Report — Oct 1, 2024

Complaint Investigation CMS
Date: Oct 1, 2024

Visit Reason
The inspection was conducted following a complaint regarding undignified and unprofessional treatment of Resident #1 by a certified nursing assistant (S3CNA), including agitation, cursing, and rough handling during care.

Complaint Details
The complaint was substantiated based on video footage and interviews. Resident #1's family reported the incident, and staff confirmed the undignified treatment by S3CNA.
Findings
The facility failed to ensure Resident #1 was treated with dignity and respect. Video evidence and staff interviews confirmed that S3CNA acted with a poor attitude, used inappropriate language, and handled the resident roughly during care and transfer.

Deficiencies (1)
F 0550: The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. S3CNA was observed and confirmed to have treated Resident #1 with undignified and unprofessional behavior including yelling, cursing, and rough handling.

Employees mentioned
NameTitleContext
S3CNACertified Nursing AssistantNamed in undignified treatment and rough handling of Resident #1.
S2DONDirector of NursingInterviewed and confirmed the undignified behavior of S3CNA.
S1ADMAdministratorInterviewed and confirmed the undignified and unprofessional conduct of S3CNA.

Inspection Report — Dec 6, 2023

CMS
Date: Dec 6, 2023

Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of Pointe Coupee Healthcare.

Findings
No health deficiencies were found during the inspection.

Inspection Report — Aug 9, 2023

Complaint Investigation CMS
Date: Aug 9, 2023

Visit Reason
The inspection was conducted due to complaints regarding inadequate supervision and failure to implement fall prevention interventions for residents at risk of falls.

Complaint Details
The complaint investigation found substantiated issues with supervision and transfer procedures. Resident #1 was not properly monitored with his wheelchair alarm, and Resident #2 was transferred without the required two staff members, resulting in a fall and injuries.
Findings
The facility failed to ensure adequate supervision and proper use of assistive devices to prevent accidents for two sampled residents. Resident #1 did not have his wheelchair alarm in place as required, and Resident #2 was transferred without the required two staff members, resulting in a fall.

Deficiencies (2)
F 0689: The facility failed to ensure Resident #1's fall interventions were implemented as described in the plan of care, including proper use of wheelchair alarms and signage to call for assistance.
F 0689: The facility failed to ensure Resident #2 was transferred by two staff members as required, leading to a fall with injuries including hematomas and a laceration.
Report Facts
Residents sampled: 5 Residents affected: 2 BIMS score for Resident #1: 4 BIMS score for Resident #2: 8

Employees mentioned
NameTitleContext
S11 CNACertified Nursing AssistantNamed in the finding for transferring Resident #2 without assistance
S2 DONDirector of NursingConfirmed Resident #1's wheelchair alarm order and responsibility for supervision
S1 ADMAdministratorDiscussed incident involving S11 CNA transferring Resident #2 without assistance

Inspection Report — Jul 14, 2023

CMS
Date: Jul 14, 2023

Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Pointe Coupee Healthcare.

Findings
No health deficiencies were found during the survey.

Inspection Report — Jun 12, 2023

Complaint Investigation CMS
Date: Jun 12, 2023

Visit Reason
The investigation was conducted based on complaints regarding failure to treat residents with dignity and respect, and allegations of mental abuse by staff towards residents.

Complaint Details
The complaint investigation involved allegations of staff cursing in front of residents and mocking a resident's physical disability. The abuse was substantiated based on video evidence and staff interviews. The facility implemented corrective actions including staff suspension, in-service training, and monitoring.
Findings
The facility failed to ensure residents were treated with dignity and respect, including staff cursing in front of residents and improper feeding practices. Additionally, the facility failed to protect a resident from mental abuse by staff mocking his physical condition. Corrective actions were implemented prior to the State Agency's investigation.

Deficiencies (2)
F 0550: The facility failed to ensure residents were treated with dignity and respect, including staff cursing in the presence of a resident and standing over residents while feeding instead of sitting at their level.
F 0600: The facility failed to protect a resident from mental abuse by staff who mocked the resident's contracted arms through gestures, constituting verbal abuse.
Report Facts
Residents reviewed for dignity and respect: 5 Residents affected by dignity and respect deficiency: 3 Residents reviewed for abuse: 5 Residents affected by abuse deficiency: 1

Employees mentioned
NameTitleContext
S6CNANamed in findings for cursing in presence of Resident #1 and mocking Resident #3's arm contractures
S8CNAObserved standing over Resident #1 and Resident #2 while feeding
S10CNAObserved standing over Resident #4 while feeding
S1ADMAdministratorInterviewed regarding staff behavior and abuse incident
S2DONDirector of NursingInterviewed regarding feeding practices and abuse incident
S3RDRInterviewed regarding awareness of abuse incident
S4QINReported observations of staff mocking Resident #3
S5ADONAssistant Director of NursingInterviewed regarding abuse incident and video review

Inspection Report — Nov 3, 2022

Complaint Investigation CMS
Date: Nov 3, 2022

Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide paid services, protect residents from abuse, implement comprehensive care plans, and maintain sanitary food storage conditions.

Complaint Details
The complaint investigation involved failure to provide paid services, physical abuse between residents, inadequate care plan implementation, and improper food storage. The abuse incident was substantiated but determined to be past noncompliance due to corrective actions. Other issues were confirmed by interviews, observations, and record reviews.
Findings
The facility failed to provide a paid haircut service to Resident #91, protect Resident #75 from physical abuse by Resident #32, ensure Resident #91 wore her neck collar as ordered, and store food properly in the kitchen. Corrective actions and staff training were implemented for abuse prevention and care plan compliance.

Deficiencies (5)
F 0558: The facility failed to provide Resident #91 a haircut service paid for with her personal funds due to lack of communication and scheduling.
F 0600: The facility failed to protect Resident #75 from physical abuse by Resident #32, who struck Resident #75 in the head during an altercation.
F 0600: The facility failed to implement adequate monitoring and care for Resident #32 after the abuse incident, including medication adjustments and observation.
F 0656: The facility failed to ensure Resident #91 wore her neck collar at all times except during showering and sleeping, and staff did not consistently assist or encourage compliance.
F 0812: The facility failed to store food properly by keeping opened items in the walk-in freezer unlabeled and unsealed, and dry storage items that required refrigeration were not refrigerated.
Report Facts
Residents affected: 91 Deposit amount: 20 Medication dosage: 50

Employees mentioned
NameTitleContext
S7BOSResponsible for depositing funds into Resident #91's account and communication about haircut services
S8HDProvided hair services to residents; unaware of haircut request for Resident #91
S1ADMINAdministratorConfirmed haircut service payment and lack of scheduling process; confirmed abuse incident and corrective actions
S9LPNLicensed Practical NurseWitnessed altercation between Resident #32 and Resident #75
S10RNRegistered NurseWitnessed altercation and assisted in removing Resident #32
S12RNRegistered NurseEscorted Resident #32 and witnessed altercation
S17NPNurse PractitionerProvided psychiatric history of Resident #32
S2DONDirector of NursingConfirmed abuse incident and care plan compliance issues for Resident #91
S5CNACertified Nursing AssistantAssisted Resident #91 and noted lack of neck collar use
S4CNACertified Nursing AssistantNoted Resident #91's neck collar noncompliance
S3LPNLicensed Practical NurseAssisted Resident #91 with neck collar application
S6DSUPConfirmed improper food storage observations

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