Inspection Reports for
Senior Village Nursing & Rehabilitation Center
315 HARRY GUILBEAU ROAD, OPELOUSAS, LA, 70570
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Inspection Report — Dec 3, 2025
Routine CMS
Date: Dec 3, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to document gradual dose reduction attempts for psychotropic medications, failure to notify the State's Long-Term Care Ombudsman of emergency transfers, inaccurate resident assessments, incomplete care plans, and medication administration errors.
Deficiencies (6)
F 0605: The facility failed to ensure the physician documented a Gradual Dose Reduction (GDR) or clinical rationale for not reducing psychotropic medication for Resident #2.
F 0628: The facility failed to notify the State's Long-Term Care Ombudsman in writing of emergency transfers for Resident #7.
F 0641: The facility failed to ensure accurate assessments for Residents #1 and #43, including incorrect PASARR coding and medication use documentation.
F 0656: The facility failed to develop and implement comprehensive care plans for Residents #4 and #62, including missing wound care documentation and lack of care plan for bed rails.
F 0657: The facility failed to develop a person-centered comprehensive care plan within 7 days of the comprehensive assessment for Resident #16.
F 0755: The facility failed to ensure accurate administration of Zinc medication for Resident #79, administering 50 mg instead of the ordered 220 mg dose.
Report Facts
Residents sampled: 41
Residents reviewed for unnecessary medication: 5
Residents reviewed for emergency transfers: 4
Residents observed for medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to multiple findings including medication documentation and care plan deficiencies (referred to as S2DON) | |
| Assistant Administrator | Responsible for accuracy of State's Long-Term Care Ombudsman list of emergency transfers (referred to as S1AADM) | |
| Minimum Data Set Nurse | Involved in assessment and care plan reviews (referred to as S3MDS) | |
| Licensed Practical Nurse | Observed administering incorrect Zinc dose to Resident #79 (referred to as S5LPN) | |
| Certified Nursing Assistant | Interviewed regarding care of Resident #62 and bed rails (referred to as S6CNA and S7CNA) | |
| Social Service Director | Interviewed regarding assessment inaccuracies (referred to as S4SSD) |
Inspection Report — Dec 3, 2025
CMS
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical services regulations, specifically ensuring accurate administration of medications to residents.
Findings
The facility failed to administer the correct dose of Zinc to one resident (Resident #79) due to an incomplete medication order on the Medication Administration Record (MAR). The licensed practical nurse administered 50 mg instead of the prescribed 220 mg dose.
Deficiencies (1)
F 0755: The facility failed to ensure accurate administration of medications by administering an incorrect dose of Zinc to Resident #79. The MAR lacked the correct dosage, leading to administration of 50 mg instead of the ordered 220 mg.
Report Facts
Residents observed for medication administration: 4
Zinc dosage ordered: 220
Zinc dosage administered: 50
Inspection Report — Jun 18, 2025
CMS
Date: Jun 18, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to timely reporting of injuries, following physician's orders, and care plan implementation at Senior Village Nursing & Rehabilitation Center.
Findings
The facility failed to timely report an injury of unknown origin for one resident and failed to follow physician's orders for oxygen saturation checks for another resident. The facility also failed to develop and implement a complete care plan meeting all resident needs for a third resident. These deficiencies had the potential to affect a census of 126 residents.
Deficiencies (2)
F 0609: The facility failed to timely report an injury of unknown origin to the State Survey Agency within two hours for Resident #1. The injury was a dislocated right shoulder discovered on 05/31/2025 but was not reported because the facility believed only fractures required reporting.
F 0656: The facility failed to follow physician's orders for Resident #3 by not documenting oxygen saturation checks every shift as ordered starting 05/19/2025. No evidence of oxygen saturation monitoring was found in the medication administration record or nurse's notes.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Interviewed regarding injury reporting and oxygen saturation documentation |
| S1ADM | Administrator | Interviewed regarding injury reporting requirements |
| S3LPN | Licensed Practical Nurse | Interviewed regarding oxygen saturation monitoring for Resident #3 |
Inspection Report — Sep 10, 2024
Annual Inspection CMS
Date: Sep 10, 2024
Visit Reason
Annual inspection of Senior Village Nursing & Rehabilitation Center to assess compliance with regulatory requirements including resident care, food service, staffing, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean environment, timely transmission and accuracy of resident assessments, incomplete care plans, inadequate nutritional support, improper food preparation and storage, inaccurate staffing data submission, and unsafe equipment maintenance.
Deficiencies (9)
F 0584: The facility failed to maintain a clean and sanitary environment by allowing dust and lint to accumulate on Resident #231's personal equipment and room.
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessments within 14 days after completion for 8 out of 9 residents reviewed.
F 0641: The facility failed to ensure Resident #9's MDS assessment was accurately coded for anticoagulant use when no such medication was ordered.
F 0656: The facility failed to develop and implement a care plan addressing catheter care for Resident #63, and catheter care was not documented or performed as required.
F 0692: The facility failed to maintain acceptable nutritional status for Resident #127 by not addressing the Registered Dietician's recommendation for house supplements and lacking physician orders for supplementation.
F 0804: The dietary staff failed to prepare food according to standardized recipes, resulting in unpalatable and inconsistent food preparation affecting 111 residents.
F 0812: The facility failed to ensure all foods on the steam table were held at safe temperatures, with observed food temperatures below required minimums.
F 0851: The facility failed to electronically submit accurate payroll-based journal staffing data, resulting in underreporting of weekend staffing levels.
F 0908: The facility failed to maintain an air conditioner in safe operating condition as it was leaking liquid in Resident #48's room.
Report Facts
Residents affected: 1
Residents affected: 8
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 111
Weight loss percentage: 24.26
Weight loss percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Licensed Practical Nurse | Confirmed unclean personal equipment for Resident #231 |
| S8HK | House Keeper | Confirmed unclean personal equipment for Resident #231 |
| S3DON | Director of Nursing | Confirmed housekeeping responsibility and staffing issues |
| S7MDS | MDS Coordinator | Verified late transmission of MDS assessments |
| S1MDS | MDS Coordinator | Confirmed inaccurate MDS coding for Resident #9 and catheter care issues for Resident #63 |
| S2MDS | MDS Coordinator | Confirmed catheter care expectations for Resident #63 |
| S4LPN | Licensed Practical Nurse | Confirmed unawareness of nutritional supplement orders for Resident #127 |
| S5RD | Registered Dietician | Made nutritional supplement recommendations for Resident #127 |
| S11DM | Dietary Manager | Confirmed recipe use and food temperature monitoring deficiencies |
| S12DM/Cook | Dietary Manager/Cook | Observed preparing food without recipes and improper thickener use |
| S13Cook | Cook | Observed improper food temperature monitoring |
| S9AA | Administrative Assistant | Responsible for manual input of contract/agency staffing hours into PBJ system |
| S6MAINT | Maintenance | Confirmed leaking air conditioner in Resident #48's room |
Inspection Report — Oct 10, 2023
Complaint Investigation CMS
Date: Oct 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to follow grievance procedures, delayed reporting of alleged physical abuse, and inaccurate resident assessments.
Complaint Details
The investigation was complaint-driven, focusing on grievances not initiated for Resident #3, delayed abuse reporting for Resident #4, and inaccurate assessments for Residents #2 and #4. The abuse allegation was substantiated as the report was late.
Findings
The facility failed to initiate grievances as required for a resident's missing hearing aid, delayed reporting an alleged physical abuse incident beyond the required 2-hour timeframe, and did not complete accurate Minimum Data Set assessments for two residents.
Deficiencies (3)
F 0585: The facility failed to ensure their grievance policy was followed by not initiating a grievance for Resident #3's missing hearing aid reported on 09/29/2023.
F 0609: The facility failed to report an alleged physical abuse involving a staff member and Resident #4 within the required 2-hour timeframe, reporting it 3 hours after awareness.
F 0641: The facility failed to complete accurate Minimum Data Set assessments for Residents #2 and #4, misrepresenting hearing aid use and hospice care status.
Report Facts
Residents investigated for grievances: 6
Residents investigated for abuse: 6
Residents with inaccurate assessments: 2
Hours delayed in abuse report: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Named in delayed abuse reporting and grievance process oversight |
| S4SSD | Social Service Designee | Named in failure to initiate grievance for Resident #3's missing hearing aid |
| S2MDS | Minimum Data Set Nurse | Named in confirming inaccurate MDS assessments for Residents #2 and #4 |
| S3CNA | Certified Nursing Assistant | Named in confirming Resident #2's hearing aid use |
Inspection Report — Aug 9, 2023
Routine CMS
Date: Aug 9, 2023
Visit Reason
Routine inspection of Senior Village Nursing & Rehabilitation Center to assess compliance with regulatory standards including resident care, infection control, staffing, and facility conditions.
Findings
The facility was found deficient in multiple areas including cleanliness of resident equipment, timely transmission of resident assessments, care planning, pressure ulcer prevention, staffing adequacy, food safety and storage, medical record accuracy, and infection control practices.
Deficiencies (9)
F 0584: The facility failed to ensure residents' equipment was kept clean and in good repair, including stained hand rolls and bathroom sink buildup affecting multiple residents.
F 0640: The facility failed to transmit each resident's Minimum Data Set assessment within 7 days of completion for one resident.
F 0656: The facility failed to accurately document intake and output for two residents, resulting in incomplete care documentation.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for one resident with stage 2 pressure ulcers.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed ADLs and failure to pass ice to residents on multiple days.
F 0800: The facility failed to ensure cold foods and beverages were held at or below 41 degrees Fahrenheit, serving drinks at 50 degrees.
F 0812: The facility failed to ensure dishware was thoroughly cleaned, with black residue found inside multiple beverage bins used for resident drinks.
F 0842: The facility failed to accurately reflect residents' advanced directives in medical records, showing conflicting DNR and Full Code statuses for three residents.
F 0880: The facility failed to maintain infection control by not performing hand hygiene between distributing each resident's meal tray for three residents.
Report Facts
Residents affected: 114
Residents affected: 49
Residents affected: 107
Residents affected: 3
Residents affected: 3
Days: 31
Days: 8
Days: 31
Days: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S16NCP | Licensed Practical Nurse | Confirmed inaccurate advanced directives in resident care plans |
| S9CNA | Certified Nursing Assistant | Observed failing to perform hand hygiene between meal tray deliveries |
| S10DM | Dietary Manager | Confirmed cold beverages served above safe temperature and dirty beverage bins |
| S4CNA Supervisor | Certified Nursing Assistant Supervisor | Reported staffing shortages and inadequate CNA assignments |
| S1DON | Director of Nursing | Confirmed infection control responsibilities and staffing issues |
Inspection Report — Jun 21, 2023
Complaint Investigation CMS
Date: Jun 21, 2023
Visit Reason
The investigation was conducted due to a complaint regarding the facility's failure to provide appropriate treatment and care to Resident #2, specifically related to monitoring and managing his blood glucose levels after admission with Type 2 Diabetes Mellitus with Hyperglycemia.
Complaint Details
The complaint investigation substantiated that the facility did not monitor Resident #2's blood glucose as ordered and failed to follow up with the physician after notifying them of the resident's increased sleepiness and altered condition, resulting in harm.
Findings
The facility failed to assess Resident #2's glucose levels when symptoms of hyperglycemia were present and failed to follow up with the physician after notifying them of the resident's condition change. This resulted in actual harm, including delayed treatment and hospitalization for severe dehydration, uncontrolled diabetes, and acute kidney injury.
Deficiencies (1)
F 0684: The facility failed to identify and provide needed care to Resident #2 by not assessing glucose levels during symptoms of hyperglycemia and not following up with the physician after notifying them of the resident's condition change.
Report Facts
Blood glucose reading: 599
Blood pressure: 89
Blood pressure: 45
Hospitalization duration: 19
Insulin units administered: 10
IV fluids administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Failed to assess Resident #2's glucose and follow up with physician after notifying of condition change. |
| S4LPN | Licensed Practical Nurse | Assessed Resident #2 at 9:00 p.m. and identified elevated glucose and low blood pressure. |
| S5MD | Physician | Was notified of Resident #2's condition but did not return call before shift ended. |
| S1DON | Director of Nursing | Interviewed regarding the incident and agreed follow-up with physician was required. |
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