Inspection Reports for St Francisville Nursing and Rehab, L.L.C.
15243 Hwy. 10 East, Saint Francisville, LA 70775, LA, 70775
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 10
Date: Apr 16, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, abuse prevention, assessment accuracy, treatment and care, trauma-informed care, medication management, dental services, food safety, staffing data submission, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, prevent abuse, accurately assess residents, provide ordered treatments and referrals, implement trauma-informed care, properly label and store medications, ensure food safety and sanitation, submit accurate staffing data, and maintain infection prevention protocols.
Deficiencies (10)
Failed to ensure Resident #68's urinary drainage bag remained covered to maintain dignity.
Failed to protect Resident #75 from physical abuse and psychosocial harm by Resident #46.
Failed to ensure accurate resident assessments for PTSD diagnoses for Residents #40 and #87.
Failed to ensure Resident #34 received an appointment with an ENT specialist as ordered.
Failed to provide trauma-informed care for Residents #40 and #87 with PTSD diagnoses.
Failed to label and date multi-dose insulin vial and keep medication cart locked when unattended.
Failed to ensure referral was made to oral surgeon for Resident #92 as ordered.
Failed to store, distribute, and serve food in sanitary conditions including unlabeled opened food, improper thermometer sanitation, serving ground beef at unsafe temperature, and unsanitary kitchen air conditioner.
Failed to submit accurate payroll based journal staffing data for direct care staff.
Failed to maintain infection prevention and control program by not performing hand hygiene and proper glove use during perineal care for Residents #77 and #86.
Report Facts
Residents reviewed for dignity deficiency: 23
Residents affected by dignity deficiency: 1
Residents reviewed for abuse: 2
Residents affected by abuse deficiency: 1
Residents reviewed for PTSD assessment: 2
Residents affected by PTSD assessment deficiency: 2
Residents reviewed for trauma-informed care: 2
Residents affected by trauma-informed care deficiency: 2
Residents reviewed for medication labeling: 105
Residents reviewed for dental services: 105
Residents affected by dental referral deficiency: 1
Residents affected by infection control deficiency: 2
Residents affected by food safety deficiency: 104
PBJ staffing report infraction dates: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S13CNA | Certified Nursing Assistant | Named in dignity and infection control deficiencies related to Resident #68 and Resident #86 |
| S2DON | Director of Nursing | Interviewed regarding dignity, abuse, assessment, treatment, medication, dental, infection control findings |
| S1ADM | Administrator | Interviewed regarding food safety, medication, dental, and staffing data findings |
| S17MDS | MDS Nurse | Interviewed regarding inaccurate PTSD assessments for Residents #40 and #87 |
| S10WC | Scheduler/Coordinator | Interviewed regarding failure to schedule ENT and dental appointments |
| S5CK | Kitchen Staff | Observed and interviewed regarding food temperature and thermometer sanitation |
| S12CNA | Certified Nursing Assistant | Observed and interviewed regarding infection control during perineal care for Resident #77 |
| S7NP | Nurse Practitioner | Interviewed regarding orders for ENT and dental referrals |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident-to-resident physical abuse incidents involving Resident #2 assaulting Residents #1 and #3.
Complaint Details
The complaint investigation substantiated that Resident #2 physically abused Resident #1 on 11/22/2024 by punching him multiple times, causing physical pain, facial swelling, and a bloody nose. Resident #2 also pushed Resident #3 on 11/06/2024 causing her to fall and sustain injuries. The facility failed to maintain required line of sight supervision of Resident #2, which contributed to these incidents. The CNA responsible for supervision was terminated. The facility implemented a plan of correction including staff education, revised care plans, and ongoing monitoring.
Findings
The facility failed to protect residents from physical abuse by another resident and failed to maintain line of sight supervision as required by Resident #2's care plan. Resident #2 physically assaulted Resident #1 and pushed Resident #3 causing injury. The facility implemented corrective actions prior to the State Agency's investigation, resolving the issues.
Deficiencies (2)
Failed to protect residents from physical abuse by another resident, resulting in actual harm to Residents #1 and #3.
Failed to implement and maintain line of sight supervision per Resident #2's care plan, leading to physical abuse incidents.
Report Facts
Residents affected: 3
Incident date: Nov 22, 2024
Termination date: Nov 26, 2024
Plan of Correction completion date: Dec 1, 2024
QAPI target completion date: Feb 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Nurse on duty who witnessed the incident and reported failure of supervision |
| S5CNA | Certified Nursing Assistant | CNA assigned to Resident #2 who failed to maintain line of sight supervision and was terminated |
| S1DON | Director of Nursing | Confirmed abuse incidents and supervised staff education and corrective actions |
| S7LPN | Licensed Practical Nurse | Confirmed abuse incident and staff training |
| S2ADM | Administrator | Confirmed abuse incidents and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide appropriate treatment and care to a cognitively impaired resident, specifically related to communication failures and delayed treatment following a fall.
Complaint Details
The complaint investigation focused on Resident #2's fall on 04/01/2024, failure of S5LPN to transcribe and communicate new telephone orders for Tylenol and an X-Ray, and failure to notify oncoming staff and the X-Ray company, resulting in delayed diagnosis of a displaced femoral neck fracture and actual harm. The investigation included interviews with involved staff and review of clinical records.
Findings
The facility failed to ensure Resident #2 received timely and appropriate treatment after a fall on 04/01/2024, including failure to transcribe and communicate telephone orders for Tylenol and an X-Ray, resulting in delayed diagnosis of a displaced left femoral neck fracture. Additionally, the facility failed to accurately document medication administration on the MAR.
Deficiencies (2)
Failure to transcribe and communicate telephone orders for Tylenol and an X-Ray for Resident #2 after a fall, resulting in delayed treatment and actual harm.
Failure to maintain accurate medical records by not transcribing and documenting administration of Tylenol on the MAR for Resident #2.
Report Facts
Residents sampled: 3
Residents affected: 1
Tylenol dosage: 650
BIMS summary score: 99
Date of fall: Apr 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Licensed Practical Nurse | Failed to transcribe and communicate telephone orders for Tylenol and X-Ray; left shift without notifying oncoming staff. |
| S4LPN | Licensed Practical Nurse | Received delayed notification of Resident #2's fall and new orders; notified imaging company and administered Tylenol later in the day. |
| S3OCNP | On-Call Nurse Practitioner | Gave telephone orders for Tylenol and X-Ray after Resident #2's fall. |
| S2NP | Nurse Practitioner | Assessed Resident #2 after delayed notification and ordered X-Ray. |
| S6CNA | Certified Nursing Assistant | Notified S4LPN of Resident #2's complaints of pain and need for increased assistance. |
| S1DON | Director of Nursing | Provided expectations for communication and documentation; confirmed orders were not transcribed or documented. |
Inspection Report
Deficiencies: 2
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with environmental safety standards, specifically to ensure residents had a clean and safe environment.
Findings
The facility failed to ensure that Resident #36's air condition/heater unit front cover was properly secured and that the nightstand was not missing the third drawer. Observations and interviews confirmed these issues were not reported to maintenance as required.
Deficiencies (2)
The front face covering for Resident #36's air condition/heater unit was not properly secured.
Resident #36's nightstand was missing the third drawer.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3DON | Confirmed the air conditioner cover was detached and the third drawer missing from Resident #36's nightstand. | |
| S10MD | Interviewed regarding maintenance log procedures and awareness of the issues. |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident environment safety, accurate resident assessments, comprehensive care planning, and nurse staffing postings.
Findings
The facility was found deficient in maintaining a safe and clean environment for residents, ensuring accurate coding of residents' PASRR assessments, developing comprehensive care plans reflecting resident needs, and posting nurse staffing information daily as required.
Deficiencies (4)
The facility failed to ensure Resident #36's air condition/heater unit front cover was properly secured and the nightstand was missing the third drawer.
The facility failed to ensure residents' Minimum Data Set assessments were accurately coded for PASRR for Residents #27 and #52.
The facility failed to develop a comprehensive person-centered care plan reflecting hydration interventions for Resident #59.
The facility failed to post required nurse staffing information daily, missing facility name, resident census, and actual hours worked.
Report Facts
Residents reviewed for environment: 2
Residents reviewed for PASRR: 4
Residents affected by PASRR coding deficiency: 2
Residents reviewed for care plan: 25
Residents affected by care plan deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3DON | Confirmed environmental deficiencies and care plan issues | |
| S10MD | Interviewed regarding maintenance log and environmental issues | |
| S2CCO | Verified PASRR coding deficiencies for Residents #27 and #52 | |
| S6CNA | Interviewed about hydration intervention for Resident #59 | |
| S5LPN | Interviewed about hydration intervention for Resident #59 | |
| S4MDS | Responsible for updating care plans, confirmed care plan deficiency for Resident #59 | |
| S7ADON | Responsible for posting nurse staffing, confirmed staffing posting deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 9, 2023
Visit Reason
The inspection was conducted to assess the accuracy of resident assessments, specifically focusing on weight loss documentation for residents.
Findings
The facility failed to ensure that Resident #1's Minimum Data Set (MDS) accurately reflected the resident's nutritional status, incorrectly coding the weight loss as physician prescribed when it was unplanned. Interviews with staff confirmed the incorrect coding and the need for accurate MDS submissions.
Deficiencies (1)
Failed to ensure resident assessments accurately reflected the resident's status for weight loss, specifically Resident #1's MDS incorrectly coded weight loss as physician prescribed instead of unplanned.
Report Facts
Weight measurements: 129.8
Weight measurements: 132.6
Weight measurements: 135.8
Weight measurements: 136.1
Weight measurements: 143.9
Weight measurements: 142.8
Weight measurements: 142.6
Weight measurements: 144.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3NP | Confirmed Resident #1 had unplanned weight loss and was monitoring it | |
| S2MDS | Reviewed Resident #1's MDS and confirmed incorrect coding of weight loss | |
| S1DON | Confirmed Resident #1 was never on prescribed weight loss regimen and MDS was coded incorrectly |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 30, 2023
Visit Reason
The inspection was conducted due to allegations of physical abuse involving residents #98 and #63, specifically incidents of resident-to-resident physical altercations on 03/02/2023 and 03/03/2023.
Complaint Details
The complaint involved substantiated physical abuse by resident #63 against resident #98 on 03/02/2023 and 03/03/2023, including pushing and throwing coffee resulting in injury. The facility staff confirmed the incidents as abuse. The facility failed to report these incidents to the state agency within the required timeframe.
Findings
The facility failed to protect resident #98 from physical abuse by resident #63, resulting in a dime-sized skin tear to resident #98's left wrist. Additionally, the facility failed to report the abuse incidents to the state agency within the required two-hour timeframe.
Deficiencies (2)
Failed to protect residents from physical abuse by another resident.
Failed to timely report suspected abuse to the state agency within 2 hours.
Report Facts
Residents reviewed for abuse: 3
Incidents of resident-to-resident physical altercation: 2
BIMS score: 9
BIMS score: 15
Skin tear size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Prepared incident reports and assessed Resident #98 after abuse incidents | |
| S4LPN | Witnessed and reported Resident #63 pushing Resident #98 | |
| S9CNA | Witnessed abuse incidents and confirmed them as abuse | |
| S7CNA | Observed Resident #98 after coffee throwing incident and confirmed abuse | |
| S2DON | Confirmed abuse incidents and injury to Resident #98 | |
| S1ADM | Administrator responsible for reporting abuse incidents; confirmed failure to report to state agency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 30, 2023
Visit Reason
The inspection was conducted due to allegations of physical abuse between residents and failure to timely report suspected abuse.
Complaint Details
The complaint involved physical abuse incidents between Resident #63 and Resident #98 on 03/02/2023 and 03/03/2023. Resident #98 sustained a dime-sized skin tear to the left wrist. Staff interviews confirmed the abuse and failure to report the incidents to the state agency within 2 hours.
Findings
The facility failed to protect a resident from physical abuse by another resident, resulting in a skin tear. Additionally, the facility failed to report the abuse incidents to the state agency within the required 2-hour timeframe. Multiple staff interviews and record reviews confirmed the abuse incidents and the failure to report.
Deficiencies (2)
Failed to protect residents from physical abuse by another resident.
Failed to timely report suspected physical abuse to the state agency within 2 hours.
Report Facts
Residents reviewed for abuse: 3
Incidents of resident to resident physical altercation: 2
Assessment Reference Date (ARD): Feb 27, 2023
Assessment Reference Date (ARD): Jan 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Prepared incident reports describing abuse incidents | |
| S4LPN | Witnessed and reported abuse incident on 03/02/2023 | |
| S9CNA | Witnessed abuse incident and confirmed abuse | |
| S7CNA | Observed Resident #98 after abuse incident and confirmed abuse | |
| S2DON | Confirmed abuse incidents and failure to report to state agency | |
| S1ADM | Administrator responsible for reporting abuse incidents; confirmed failure to report |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's physician of a change in condition and failure to obtain physician orders for wound care for a resident with surgical wounds.
Complaint Details
The complaint investigation revealed that nursing staff did not notify the physician or nurse practitioner when Resident #1 experienced bleeding from a surgical incision. Additionally, physician orders for wound care were not obtained for several days after admission despite the presence of surgical wounds.
Findings
The facility failed to notify Resident #1's physician or nurse practitioner about bleeding from a surgical wound and failed to obtain physician orders for wound care from 01/31/2023 through 02/02/2023. Documentation and communication deficiencies were identified, and the resident was later diagnosed with left lower extremity cellulitis.
Deficiencies (2)
Failure to notify the resident's physician of a change in condition related to bleeding from a surgical wound.
Failure to obtain physician orders for wound care for Resident #1 from 01/31/2023 through 02/02/2023.
Report Facts
Residents reviewed with surgical wounds: 2
Residents affected: 1
Dates without physician wound care orders: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Responsible for wound care on 02/04/2023 and 02/05/2023; did not notify physician or document bleeding. | |
| S2NP | Nurse Practitioner who expected notification of bleeding or changes to surgical site. | |
| S6LPN | Reported assessment of Resident #1's surgical wounds and communicated with wound care nurse. | |
| S1DON | Director of Nursing who confirmed lack of wound care orders and expected admitting nurse to obtain orders. | |
| S3LPN | Facility wound care nurse responsible for skin assessments and obtaining wound care orders. |
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