St. Margaret's Daughters Home: Fall Care Failures - LA
The first fall happened on August 17, 2025. Resident #72, who had a history of falling before ever arriving at the facility on Bienville Street, fell with no injury while staff watched. The charge nurse or nursing supervisor on duty was supposed to update the resident's care plan before the end of that shift. Nobody did.
The care plan sitting in the electronic medical record still carried a last revision date of May 19, 2025. The next scheduled review wasn't until November. After the August 17 fall, it went untouched.
Two days later, on August 19, staff finally updated the care plan for activities of daily living. It was clear: Resident #72 required maximal assistance and two people to complete any transfer.
The next morning, a CNA attempted the transfer alone.
Resident #72 fell again.
In an interview on August 19 at 1:30 p.m., the Director of Nursing confirmed the care plan had not been updated after the August 17 fall and said it should have been. An hour later, the facility's MDS Nurse said the same thing, placing the responsibility on whoever was the charge nurse or supervisor on duty that evening. That person, the MDS Nurse said, did not update the care plan before leaving for the night.
Neither the Director of Nursing nor the MDS Nurse disputed what had happened. The documentation was straightforward. The facility's own accidents and incidents policy, last revised in June 2002, states that the charge nurse or nursing supervisor will initiate a care plan change before the end of the shift following any incident that warrants one. A witnessed fall on a resident with a documented fall history warrants one.
The August 20 fall, the one caused by the solo transfer attempt, was also witnessed and logged. The Director of Nursing confirmed in an interview that afternoon that Resident #72's care plan required two staff for transfers, and that the CNA had not followed it.
Federal inspectors identified the failures during a complaint inspection completed August 20, 2025. They reviewed four residents' records for accident-related concerns. Only Resident #72's file produced findings.
The deficiency was rated at the minimal harm level, meaning inspectors determined the violations caused minimal harm or had the potential for actual harm rather than documented serious injury. Resident #72's August 17 fall was recorded as resulting in no injury. The inspection report does not describe the outcome of the August 20 fall.
What the record does show is a resident who came to St. Margaret's Daughters Home already carrying a fall history, fell once under staff observation, waited two days for a care plan that should have been updated within hours, and then fell again when a staff member ignored the instructions that update contained.
The care plan revision that should have happened the night of August 17 was not a complicated intervention. It was a written record telling staff what the resident needed to stay safe. It took until August 19 to exist. It took until August 20 to be ignored.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Margaret's Daughters Home from 2025-08-20 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
St. Margaret's Daughters Home in New Orleans, LA was cited for violations during a health inspection on August 20, 2025.
The first fall happened on August 17, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.