Inspection Reports for
St Agnes Healthcare and Rehab Center
606 LATIOLAIS ROAD, BREAUX BRIDGE, LA, 70517
Back to Facility Profile6 Reports
Inspection Report — Mar 26, 2025
Annual Inspection CMS
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at the facility.
Findings
The facility was found deficient in multiple areas including failure to assess resident self-administration of medication, failure to timely report suspected abuse, failure to follow care plans, improper medication handling, inadequate staffing data posting, unsecured medication storage, improper food storage, and deficiencies in infection prevention and control practices.
Deficiencies (8)
F 0561: The facility failed to assess 1 resident for self-administration of medication and left medication at the resident's bedside without assessment.
F 0609: The facility failed to timely report a resident's report of sexual abuse to the administrator and appropriate authorities.
F 0656: The facility failed to follow the care plan for 1 resident by not offering a visit with the in-house dental consultant.
F 0658: The facility failed to ensure services met professional standards as a nurse left medication at the bedside for a resident not assessed for self-administration.
F 0732: The facility failed to post nurse staffing information daily including resident census and total hours worked.
F 0761: The facility failed to ensure all drugs and biologicals were stored in locked compartments as a medication cart compartment was left unlocked and unattended.
F 0812: The facility failed to prepare, distribute, and serve food in accordance with professional standards by not dating opened food and not properly sealing and storing food.
F 0880: The facility failed to maintain an effective infection prevention and control program by improperly handling soiled laundry, failing to perform hand hygiene, incorrectly removing PPE, and failing to sanitize dirty scissors before reuse.
Report Facts
Residents in facility: 95
Sampled residents: 35
Staffing hours: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S11DON | Director of Nursing | Confirmed medication self-administration assessment was not conducted and medication cup should not have been left in resident's room |
| S13TN | Treatment Nurse | Responsible for applying medication and confirmed leaving medication cup in resident's room |
| S14SSD | Social Service Director | Involved in resident abuse report and dental service process |
| S15RDH | Registered Dental Hygienist | Confirmed delay in dental evaluation of resident |
| S2WC | Ward Clerk | Responsible for posting staffing sheets, confirmed missing census and hours |
| S3WC | Ward Clerk | Responsible for posting staffing sheets, confirmed missing census and hours |
| S4PR | Payroll Clerk | Confirmed ward clerks did not include census and hours on staffing sheets |
| S10LPN | Licensed Practical Nurse | Observed leaving medication cart compartment unlocked |
| S5CNA | Certified Nursing Assistant | Observed improperly handling soiled laundry and failing hand hygiene |
| S8ADONIP | Assistant Director of Nursing, Infection Preventionist | Provided infection control policy clarifications and confirmed deficiencies |
| S9RNTX | Treatment Nurse | Observed removing PPE incorrectly and failing to sanitize scissors |
Inspection Report — Jul 16, 2024
Complaint Investigation CMS
Date: Jul 16, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the competency of certified nursing aides (CNAs) in properly securing residents in the facility's transportation van according to the manufacturer's instructions.
Complaint Details
The complaint investigation found that one of two transportation CNAs did not follow the manufacturer's instructions for securing a resident's wheelchair in the van. The CNA secured the J-hooks to the wheels instead of the frame. Training records showed the CNA attended in-service trainings but no documentation confirmed training on proper wheelchair securement.
Findings
The facility failed to ensure that CNAs transporting residents in the van were trained and competent in properly securing wheelchairs. One CNA was observed securing a resident's wheelchair incorrectly by attaching straps to the wheels instead of the frame as required by the manufacturer's instructions.
Deficiencies (1)
F 0726: The facility failed to ensure that certified nursing aides transporting residents in the van were trained and competent on the proper and safe procedure for securing wheelchairs according to the manufacturer's instructions. One CNA was observed improperly securing a resident's wheelchair by attaching straps to the wheels instead of the frame.
Report Facts
Transportation CNAs observed: 2
Transportation CNAs improperly securing wheelchair: 1
In-service training dates attended: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2TransportationCNA | Certified Nursing Aide | Observed improperly securing resident's wheelchair in the transportation van |
| S1ADM | Administrator | Provided manufacturer's instruction manual and participated in observation |
Inspection Report — May 2, 2024
Complaint Investigation CMS
Date: May 2, 2024
Visit Reason
The inspection was conducted due to complaints alleging rough handling and potential abuse by Certified Nursing Assistants (CNAs) towards residents at the facility.
Complaint Details
The complaint investigation involved allegations from residents' family members about rough handling by CNAs during transfers. The facility's investigation found that staff did not immediately report the incidents to administrative staff, with delays of up to three days. The allegations were substantiated for two residents.
Findings
The facility failed to ensure that all alleged violations of abuse were reported immediately to administrative staff for 2 of 3 sampled residents. Investigations revealed incidents of rough handling by CNAs and delayed reporting of alleged abuse.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Two residents were affected by delayed reporting and rough handling incidents.
Report Facts
Residents affected: 2
Days delay in reporting: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4CNA | Certified Nursing Assistant | Witnessed rough handling by another CNA and reported incident |
| S5CNA | Certified Nursing Assistant | Alleged to have handled residents roughly during transfers |
| S3LPN | Licensed Practical Nurse | Informed about rough handling incident but did not report it |
| S2AsstAdm | Assistant Administrator | Initiated facility incident reports and investigations |
| S1DON | Director of Nursing | Oversaw facility incident reporting and investigations |
| S7CNA | Certified Nursing Assistant | Alleged to have clasped resident's hands too tightly causing injury |
| S8LPN | Licensed Practical Nurse | Received delayed report of alleged abuse from S7CNA |
| S4Adm | Administrator | Participated in investigation and incident report completion |
Inspection Report — Mar 6, 2024
Routine CMS
Date: Mar 6, 2024
Visit Reason
Routine inspection conducted to assess compliance with regulatory requirements related to resident safety, care, and facility operations at St. Agnes Healthcare and Rehab Center.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to unresolved maintenance issues including broken furniture and plumbing, failure to report alleged abuse timely, inadequate PASARR referrals, failure to accommodate a resident's smoking preference while on isolation, improper storage of respiratory equipment, and insufficient RN coverage hours.
Deficiencies (6)
F 0584: The facility failed to repair broken resident furniture and bathroom fixtures including a toilet paper dispenser, toilet bowl, headboard, and hot water faucets, resulting in a non-homelike environment.
F 0609: The facility failed to timely report an alleged abuse incident involving Resident #21 to the State Survey Agency within 2 hours as required.
F 0645: The facility failed to refer Resident #70 for a required Level II PASARR evaluation despite a qualifying mental disorder diagnosis.
F 0684: The facility failed to accommodate Resident #200's smoking preference while on contact isolation precautions, providing no alternatives to satisfy his needs.
F 0695: The facility failed to properly store Resident #57's respiratory equipment by not placing the oxygen mask in a dated plastic bag as required.
F 0727: The facility failed to ensure a Registered Nurse worked 8 consecutive hours per day on 4 of 14 days reviewed, falling short of staffing requirements.
Report Facts
Days RN hours insufficient: 4
Resident sample size: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2ADMAsst | Assistant Administrator | Conducted investigation of alleged abuse for Resident #21 |
| S1ADM | Administrator | Confirmed failure to report alleged abuse to state agency |
| S3MaintSup | Maintenance Supervisor | Confirmed multiple maintenance issues including broken furniture and plumbing |
| S4SSD | Social Services Director | Confirmed failure to resubmit PASARR for Resident #70 |
| S5ADON | Assistant Director of Nursing | Confirmed improper storage of respiratory equipment and failure to accommodate smoking preference |
| S7RN | Registered Nurse | Confirmed RN did not work 8 consecutive hours on certain dates |
| S8LPN | Licensed Practical Nurse | Confirmed Resident #200 was unable to smoke due to isolation |
| S9CNA | Certified Nursing Assistant | Confirmed Resident #200 was on contact precautions and unable to smoke outside |
| S11MDS | Minimum Data Set Coordinator | Completed Safe Smoking assessment for Resident #200 |
| S12RAD | Resident Activity Director | Completed activity assessments and interviews for Resident #200 |
Inspection Report — Oct 25, 2023
Complaint Investigation CMS
Date: Oct 25, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to notify residents' representatives of changes in residents' conditions, including hospital admissions and returns, and to assess nursing staff competencies in resident care.
Complaint Details
The complaint investigation found substantiated failures in notifying residents' representatives about hospital admissions and returns for Resident #1 and Resident #3. Interviews confirmed the nursing staff's responsibility for notification and assessment was not met.
Findings
The facility failed to notify representatives of residents' hospital admissions and returns for 2 out of 4 sampled residents. Additionally, the facility failed to complete accurate weekly skin assessments and readmit assessments for residents returning from the hospital.
Deficiencies (2)
F 0580: The facility failed to immediately notify residents' representatives of hospital admissions and returns for 2 of 4 sampled residents, affecting all residents.
F 0726: The facility failed to ensure nursing staff completed accurate weekly skin assessments and readmit assessments for residents returning from the hospital.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S8LPN | Licensed Practical Nurse | Conducted inaccurate skin assessment for Resident #1 |
| S1DON | Director of Nursing | Confirmed nursing responsibility for notification and assessments |
| S6LPN | Licensed Practical Nurse | Worked with Resident #1 during hospital transfer and failed to notify representative |
| S5SSD | Social Services Director | Interviewed regarding hospital follow-up procedures |
| S3QA | Quality Assurance Nurse | Interviewed regarding hospital follow-up procedures |
| S4QA | Quality Assurance Nurse | Interviewed regarding hospital follow-up procedures |
| S2ADON | Assistant Director of Nursing | Unable to provide documentation of readmit assessment for Resident #3 |
Inspection Report — Feb 1, 2023
Annual Inspection CMS
Date: Feb 1, 2023
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare facility standards and regulations.
Findings
The facility was found deficient in implementing resident care plans, pharmaceutical services, food storage safety, and hospice service communication. Specific issues included inaccurate meal intake documentation, failure to monitor medication side effects, improper narcotic medication handling, inadequate cleaning of food storage units, and lack of hospice documentation and communication.
Deficiencies (4)
F 0656: The facility failed to implement residents' care plans for two residents by inaccurately documenting meal intake and not monitoring side effects of antipsychotic medications.
F 0755: The facility failed to destroy narcotic medications removed from original blister packages for three residents, risking medication safety.
F 0812: The facility failed to maintain cleanliness and integrity of walk-in cooler and freezer units, with dust, grime, ice buildup, and condensation observed, potentially affecting food safety for 96 residents.
F 0849: The facility failed to ensure hospice agencies communicated with staff and maintained updated medical records for hospice residents, affecting documentation and coordination of care.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 96
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Confirmed staff should record meal percentages after residents complete meals and confirmed hospice documentation deficiencies |
| S13LPN | Licensed Practical Nurse | Confirmed hospice services and communication issues for Resident #9 |
| S3QA | Quality Assurance Licensed Practical Nurse | Confirmed hospice documentation deficiencies for Resident #74 |
| S7Maint | Maintenance | Reported cleaning status of walk-in cooler and freezer |
Viewing
Loading inspection reports...
