Inspection Reports for
The Encore Healthcare and Rehabilitation Center
19110 CROWLEY-EUNICE HWY, CROWLEY, LA, 70526
Back to Facility Profile5 Reports
Inspection Report — Jul 23, 2025
Routine CMS
Date: Jul 23, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity during feeding, improper medication administration and documentation, incomplete care plans, inadequate grooming assistance, and improper storage of medications.
Deficiencies (7)
F550: The facility failed to promote resident dignity during dining by having staff stand over a resident while feeding instead of sitting at eye level.
F554: The facility failed to ensure a resident was safe to self-administer medication, lacking proper assessment and physician order.
F656: The facility failed to develop complete person-centered care plans for three residents, including failure to address hospice status and overdue updates.
F677: The facility failed to provide necessary grooming assistance to a resident with impaired cognition, resulting in overgrown facial hair.
F755: The facility failed to provide pharmaceutical services including improper crushing of extended-release medication and inaccurate controlled medication reconciliation.
F759: The facility failed to maintain medication error rates below 5%, with a 6.06% error rate observed during medication administration.
F761: The facility failed to ensure expired medications were discarded, with an expired aspirin bottle found in a medication cart.
Report Facts
Residents observed for medication administration: 4
Medication error opportunities: 33
Medication errors: 2
Medication error rate: 6.06
Residents sampled: 37
Residents affected by dignity deficiency: 1
Residents affected by self-administration deficiency: 1
Residents affected by care plan deficiency: 3
Residents affected by grooming deficiency: 1
Residents affected by pharmaceutical services deficiency: 1
Residents affected by controlled medication reconciliation deficiency: 1
Residents affected by medication error rate deficiency: 2
Expired medication found: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S9LPN | Licensed Practical Nurse | Named in findings related to feeding dignity and medication administration errors |
| S8LPN | Licensed Practical Nurse | Named in findings related to medication administration and self-administration observation |
| S10LPN | Licensed Practical Nurse | Named in findings related to controlled medication reconciliation and expired medication observation |
| S3ADON | Assistant Director of Nursing | Interviewed regarding feeding dignity, medication documentation, and expired medication |
| S2DON | Director of Nursing | Interviewed regarding medication administration and self-administration policies |
| S1CN | Corporate Nurse | Interviewed regarding medication administration and self-administration policies |
| S4CNASupervisor | Certified Nursing Assistant Supervisor | Interviewed regarding grooming assistance deficiency |
| S7HairDresser | Hairdresser | Observed grooming deficiency related to resident's facial hair |
| S6MDS | MDS Coordinator | Interviewed regarding care plan deficiencies |
Inspection Report — Sep 17, 2024
Complaint Investigation CMS
Date: Sep 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged staff-to-resident physical abuse at the facility.
Complaint Details
The complaint involved an allegation of physical abuse by a Certified Nursing Assistant (S5CNA) against Resident #3 on 08/26/2024. The abuse was witnessed by another CNA (S4CNA) who delayed reporting the incident until the next day. The facility also delayed notifying the resident's responsible party and failed to report the incident to the State Survey Agency within the required 2-hour window. The allegation was substantiated with interviews and record reviews.
Findings
The facility failed to immediately report an alleged physical abuse incident involving a staff member and Resident #3 to administrative staff and failed to notify the resident's responsible party in a timely manner. Additionally, the facility did not report the incident to the State Survey Agency within the required 2-hour timeframe.
Deficiencies (2)
F 0607: The facility failed to implement policies and procedures to prevent abuse, neglect, and theft by not immediately reporting alleged staff-to-resident physical abuse and failing to notify the resident's responsible party for one resident.
F 0609: The facility failed to timely report suspected abuse to the State Survey Agency within 2 hours after the allegation was made, reporting it 10 days late.
Report Facts
Days late reporting to State Survey Agency: 10
Residents sampled: 7
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 CNA | Certified Nursing Assistant | Witnessed abuse and delayed reporting |
| S5 CNA | Certified Nursing Assistant | Accused staff member in physical abuse incident |
| S3 LPN | Licensed Practical Nurse | Received abuse report from S4 CNA and reported to supervisor |
| S2 CNA Supervisor | CNA Supervisor | Received report from S3 LPN and informed Administrator |
| S1 ADM | Administrator | Facility Administrator who was informed of abuse and reported to State Survey Agency |
Inspection Report — Jun 20, 2024
Routine CMS
Date: Jun 20, 2024
Visit Reason
Routine inspection of The Encore Healthcare and Rehabilitation Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to inform residents of their rights to choose hospice providers, untimely discharge MDS assessment, inaccurate coding of diagnoses on MDS assessments, failure to refer for PASARR evaluation, incomplete care planning for edema, improper respiratory care, medication labeling errors, and inaccurate medication administration documentation.
Deficiencies (9)
F 0552: The facility failed to ensure residents were fully informed and understood their right to choose hospice providers, as Resident #28's representative was not informed of alternative hospice options.
F 0640: The facility failed to complete and transmit a Discharge Minimum Data Set (MDS) assessment timely for Resident #38.
F 0641: The facility failed to accurately code all applicable diagnoses on two consecutive MDS assessments for Resident #41.
F 0644: The facility failed to refer Resident #41 for Level II PASARR evaluation after a newly identified serious mental disorder diagnosis.
F 0656: The facility failed to develop a comprehensive care plan with nursing interventions to address edema in Resident #324, including failure to elevate legs as needed.
F 0695: The facility failed to provide oxygen at the ordered rate for Resident #42 due to a kinked oxygen tubing obstructing flow.
F 0755: The facility failed to ensure medication labeling reflected physician orders for Resident #55, resulting in incorrect dosage labeling of Tramadol.
F 0761: The facility failed to ensure medications were labeled correctly and stored securely as per professional standards for Resident #20.
F 0842: The facility failed to maintain accurate medication administration records for Residents #35 and #71, including incorrect documentation of PEG tube presence and failure to document medication administration or reasons for omission.
Report Facts
Residents sampled: 35
Medication doses missed: 1
Edema severity grades: 4
Medication dosage discrepancy: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3SSD | Social Services Director | Interviewed regarding hospice education and PASARR referral. |
| S2DON | Director of Nursing | Interviewed regarding hospice rights, care planning, and medication administration documentation. |
| S7RCE | Regional Clinical Educator | Interviewed regarding MDS assessments, PASARR referral, and medication administration. |
| S15LPN | Licensed Practical Nurse | Interviewed regarding Resident #324's edema and care plan. |
| S6NP | Nurse Practitioner | Interviewed regarding Resident #324's edema and treatment. |
| S8LPN | Licensed Practical Nurse | Interviewed regarding medication labeling and administration for Residents #55 and #71. |
| S12LPN | Licensed Practical Nurse | Interviewed regarding medication administration documentation for Resident #71. |
| S17RCS | Regional Clinical Specialist | Interviewed regarding medication dosage for Resident #55. |
| S4LPN | Licensed Practical Nurse | Interviewed regarding Resident #35's PEG tube documentation. |
Inspection Report — Jun 20, 2024
Complaint Investigation CMS
Date: Jun 20, 2024
Visit Reason
The inspection was conducted following a complaint filed by Resident #28's responsible party regarding the facility's failure to inform the resident and/or representative of their right to choose a hospice provider other than the facility's contracted hospice provider.
Complaint Details
Resident #28's responsible party filed a complaint on 05/23/2024 stating she did not want the facility's contracted hospice provider services. The complaint was substantiated by interviews and record reviews showing the facility did not inform the resident's representative of the right to choose other hospice providers.
Findings
The facility failed to ensure that Resident #28 and/or her representative were fully informed of their right to choose a hospice provider. The resident's representative reported being presented only with the facility's contracted hospice provider and not informed of other options, leading to dissatisfaction and a grievance.
Deficiencies (1)
F 0552: The facility failed to ensure residents are fully informed and understand their health status, care, and treatments. Resident #28's representative was not informed of the right to choose a hospice provider other than the facility's contracted provider.
Report Facts
Residents investigated for hospice services: 35
Residents with hospice services complaint: 1
Date of hospice service admission: Feb 12, 2024
Date of hospice service discharge: May 10, 2024
Date of hospice service consult with non-contracted provider: May 29, 2024
Date of complaint filed: May 23, 2024
Date of phone interview with RP: Jun 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director (S3SSD) | Conducted hospice education and consults; interviewed regarding hospice provider choice information | |
| Director of Nursing (S2DON) | Informed about grievance and confirmed resident rights to choose hospice providers | |
| Administrator (S1ADM) | Interviewed regarding informing family/resident of hospice provider choice rights |
Inspection Report — May 24, 2023
Routine CMS
Date: May 24, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements and resident care standards at The Encore Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' advance directives were accurately reflected in care plans, failure to notify physicians of changes in residents' conditions, failure to follow care plans, medication administration errors, late medication passes, improper food preparation, failure to protect resident confidentiality, and lapses in infection control practices.
Deficiencies (10)
F 0578: The facility failed to ensure residents' advance directives were accurately reflected in their care plans for 2 residents, resulting in mismatched code status documentation.
F 0580: The facility failed to notify a resident's physician of a change in condition and failed to notify nursing staff of multiple scratches on a resident, affecting resident care.
F 0656: The facility failed to follow the plan of care for a resident by not placing the oxygen concentrator against the wall and securing the cord, contributing to a fall and injury.
F 0697: The facility failed to provide appropriate pain management for a resident with recurrent oral ulcers, including failure to obtain timely physician orders and follow-up assessments.
F 0726: The facility failed to ensure nursing staff competency, resulting in medication errors including administering medication despite contraindications, late medication passes, and incorrect medication dosing.
F 0759: The facility's medication error rate was 41.68%, with multiple residents receiving medications late and improper medication administration practices observed.
F 0808: The facility failed to serve the therapeutic diet prescribed by the physician for a resident requiring mechanically soft with chopped meat diet.
F 0812: The facility failed to properly store food, including use of compromised canned goods and unlabeled seasoning containers, risking food safety.
F 0842: The facility failed to protect resident confidentiality by not initiating computer privacy screens during medication administration.
F 0880: The facility failed to maintain an effective infection prevention program, including lack of Legionella water system assessment and failure to maintain sterile technique during tracheostomy care.
Report Facts
Residents Affected: 2
Residents Affected: 1
Residents Affected: 1
Residents Investigated: 18
Medication Error Rate: 41.68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S8LPN | Licensed Practical Nurse | Named in findings related to failure to document and assess PRN pain medication administration |
| S14LPN | Licensed Practical Nurse | Named in findings related to failure to follow physician's parameters for medication administration |
| S15LPN | Licensed Practical Nurse | Named in findings related to late medication administration and improper medication dosing |
| S2DON | Director of Nursing | Interviewed regarding care plan and medication administration deficiencies |
| S7LPN | Licensed Practical Nurse | Named in findings related to failure to protect resident confidentiality during medication pass |
| S13TX | Treatment Nurse | Named in findings related to failure to maintain sterile technique during tracheostomy care |
| S12DS | Dietary Staff | Named in findings related to failure to serve prescribed therapeutic diet |
| S3DM | Dietary Manager | Named in findings related to improper food storage and labeling |
Viewing
Loading inspection reports...
