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23515 HIGHWAY 190 MANDEVILLE, LA 70448 | Voluntary non-profit - Private

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Health deficiencies are assigned during inspections that assess compliance with rules related to patient health and safety. Examples include violations of patients' rights and safety standards, as well as the administration of drugs and other treatments.

Life Safety deficiencies are assigned during inspections that assess a facility's compliance with National Fire Protection Association codes related to life safety in health care facilities. They are often conducted in tandem with health inspections. Examples include faulty or improperly maintained fire suppression and electrical systems.

Emergency Preparedness deficiencies can be cited during either a health or life safety inspection and relate to violations of CMS' Emergency Preparedness Rule. Examples include a lack of emergency plans, inadequate staff training and insufficient emergency supplies.

Complete reports and deficiency counts

Report date	Health Deficiencies	Life Safety	Emergency Preparedness	Total
Jun 11, 2024	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: PERSONAL PRIVACY
Jan 22, 2024	10	0	0	10	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT QUALITY IMPROVEMENT ACTIVITIES RN SUPERVISION OF NURSING CARE PATIENT CARE ASSIGNMENTS SUPERVISION OF CONTRACT STAFF Treatment Plan
Dec 5, 2023	5	0	0	5	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT USE OF RESTRAINT OR SECLUSION
Oct 18, 2023	5	0	0	5	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT SAFETY
Jul 12, 2023	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
Jun 20, 2023	9	0	0	9	Read full report
Deficiencies cited in this report: LICENSURE OF PERSONNEL PATIENT RIGHTS: INFORMED CONSENT QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY RN SUPERVISION OF NURSING CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS Recording Progress Notes Personnel - Discharge Planning
Mar 30, 2023	20	0	0	20	Read full report
Deficiencies cited in this report: PATIENT RIGHTS INFECTION PREVENTION CONTROL ABX STEWARDSHIP PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION QUALITY IMPROVEMENT ACTIVITIES FORM AND RETENTION OF RECORDS CONTROLLED DRUGS KEPT LOCKED SCOPE AND FREQUENCY OF REVIEW MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM INFECTION CONTROL SURVEILLANCE, PREVENTION Neurological Examination Psych Eval - Medical History Treatment Plan Treatment Plan - Substantiated Diagnosis Personnel - Active Treatment
Mar 30, 2023	0	6	0	6	Read full report
Deficiencies cited in this report: Fire Alarm System - Testing and Maintenance Sprinkler System - Maintenance and Testing Corridors - Construction of Walls Corridor - Openings HVAC Fire Drills
Mar 1, 2023	2	0	0	2	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING
Oct 19, 2022	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
Jul 1, 2020	4	0	0	4	Read full report
Deficiencies cited in this report: CHIEF EXECUTIVE OFFICER QUALITY IMPROVEMENT ACTIVITIES PATIENT CARE ASSIGNMENTS INFECTION CONTROL PROGRAM
Jun 26, 2019	4	0	0	4	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT RN SUPERVISION OF NURSING CARE
Apr 9, 2019	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: INFORMED CONSENT
Feb 14, 2019	6	0	0	6	Read full report
Deficiencies cited in this report: PATIENT RIGHTS LICENSURE OF PERSONNEL PATIENT RIGHTS: CARE IN SAFE SETTING RN SUPERVISION OF NURSING CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS
Dec 28, 2018	3	0	0	3	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING MEDICAL RECORD SERVICES INDIVIDUAL COMPREHENSIVE TREATMENT PLAN
Aug 3, 2018	0	5	0	5	Read full report
Deficiencies cited in this report: Alcohol Based Hand Rub Dispenser (ABHR) Corridors - Construction of Walls Corridor - Openings HVAC Electrical Systems - Essential Electric Syste
Aug 1, 2018	11	0	0	11	Read full report
Deficiencies cited in this report: EMERGENCY SERVICES PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT PATIENT RIGHTS: RESTRAINT OR SECLUSION RN SUPERVISION OF NURSING CARE MEDICAL RECORD SERVICES MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION CONTROL PROGRAM EVALUATION ESTIMATES INTELLECTUAL/MEMORY FUNCTIONING INDIVIDUAL COMPREHENSIVE TREATMENT PLAN
Apr 17, 2018	8	0	0	8	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: GRIEVANCES PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION RN SUPERVISION OF NURSING CARE NURSING CARE PLAN SUPERVISION OF CONTRACT STAFF ADMINISTRATION OF DRUGS INFECTION CONTROL PROGRAM IMPLEMENTATION OF A DISCHARGE PLAN
Jul 21, 2017	4	0	0	4	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT PATIENT RIGHTS: RESTRAINT OR SECLUSION FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
May 11, 2016	11	0	0	11	Read full report
Deficiencies cited in this report: RADIOLOGIC SERVICES PATIENT RIGHTS: CARE IN SAFE SETTING QAPI GOVERNING BODY, STANDARD TAG FORM AND RETENTION OF RECORDS CONTENT OF RECORD: ORDERS DATED & SIGNED PHARMACY: REPORTING ADVERSE EVENTS SAFETY POLICY AND PROCEDURES RADIOLOGIST RESPONSIBILITIES INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM DIRECTOR OF RESPIRATORY SERVICES
Apr 19, 2016	12	0	0	12	Read full report
Deficiencies cited in this report: NURSING SERVICES SPECIAL PROVISIONS APPLYING TO PSYCHIATRIC HOSPITALS SPECIAL MEDICAL RECORD REQUIREMENTS SPECIAL STAFF REQUIREMENTS FOR PSYCHIATRIC HOSPITALS PATIENT RIGHTS: REVIEW OF GRIEVANCES PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT RN SUPERVISION OF NURSING CARE NURSING CARE PLAN PATIENT CARE ASSIGNMENTS MEET COPS IN 482.1 - 482.23 AND 482.25 - 482.57 INDIVIDUAL COMPREHENSIVE TREATMENT PLAN ADEQUATE PERSONNEL TO EVALUATE PATIENTS
Nov 17, 2014	10	0	0	10	Read full report
Deficiencies cited in this report: QAPI PATIENT RIGHTS: GRIEVANCES PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY QAPI PERFORMANCE IMPROVEMENT PROJECTS QAPI GOVERNING BODY, STANDARD TAG QAPI EXECUTIVE RESPONSIBILITIES INDIVIDUAL COMPREHENSIVE TREATMENT PLAN
Mar 25, 2014	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 RECIPIENT HOSPITAL RESPONSIBILITIES
Mar 21, 2014	20	0	0	20	Read full report
Deficiencies cited in this report: PATIENT RIGHTS NURSING SERVICES SPECIAL PROVISIONS APPLYING TO PSYCHIATRIC HOSPITALS SPECIAL MEDICAL RECORD REQUIREMENTS SPECIAL STAFF REQUIREMENTS FOR PSYCHIATRIC HOSPITALS MEDICAL STAFF - ACCOUNTABILITY PATIENT RIGHTS: CARE IN SAFE SETTING DATA COLLECTION & ANALYSIS STAFFING AND DELIVERY OF CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS MEET COPS IN 482.1 - 482.23 AND 482.25 - 482.57 IDENTIFICATION DATA INCLUDES PATIENT'S LEGAL STATUS PROVISIONAL DIAGNOSIS MADE AT TIME OF ADMISSION PSYCHIATRIC EVALUATION INDIVIDUAL COMPREHENSIVE TREATMENT PLAN PLAN INCLUDES SHORT TERM/LONG RANGE GOALS PLAN INCLUDES SPECIFIC TREATMENT MODALITIES UTILIZED ADEQUATE STAFF TO PROVIDE NECESSARY NURSING CARE ADEQUATE STAFF TO PROVIDE THERAPEUTIC ACTIVITIES
May 23, 2013	6	0	0	6	Read full report
Deficiencies cited in this report: NURSING SERVICES PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT STAFFING AND DELIVERY OF CARE RN SUPERVISION OF NURSING CARE PATIENT CARE ASSIGNMENTS ADEQUATE STAFF TO PROVIDE NECESSARY NURSING CARE
Mar 14, 2013	4	0	0	4	Read full report
Deficiencies cited in this report: NURSING CARE PLAN ADMINISTRATION OF DRUGS DELIVERY OF DRUGS PLAN INCLUDES SUBSTANTIATED DIAGNOSIS
Mar 12, 2013	0	3	0	3	Read full report
Deficiencies cited in this report: No Description Available No Description Available No Description Available
Dec 10, 2012	6	0	0	6	Read full report
Deficiencies cited in this report: PATIENT RIGHTS SPECIAL STAFF REQUIREMENTS FOR PSYCHIATRIC HOSPITALS PATIENT RIGHTS: CARE IN SAFE SETTING QUALITY IMPROVEMENT ACTIVITIES ADEQUATE PERSONNEL TO EVALUATE PATIENTS AVAILABILITY OF REGISTERED NURSE 24 HRS EACH DAY

Some state health departments and regional offices of the Centers for Medicare and Medicaid Services sometimes did not upload their inspection reports into a central computer system that could then be shared by us. In such cases, CMS identified the dates of the missing inspections and the number of deficiencies identified. You can request the actual reports from CMS or your state health department.

* Deficiencies cited in follow-up inspections are not counted toward a facility's total deficiency count.

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Complete reports and deficiency counts