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Legrand Healthcare And Rehabilitation Center

650 Holt Street, Bastrop, LA 71220 · For profit - Corporation · 125 certified beds · (318) 281-0322 Medicare & Medicaid certified

Call the home — (318) 281-0322 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
206 S Vine St · (318) 281-3521 · Call to confirm hours
Pharmacy
1930 E Madison Ave · (318) 281-7410 · Call to confirm hours
Grocery
Sav U Mor0.8 mi
1003 E Madison Ave · (318) 556-2693 · Call to confirm hours
Park
8015 Park Loop Dr · Typically dawn to dusk
Place of worship
1908 Cooper Lake Rd · (318) 791-2762

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.3%17.8%15.4%better
Long-stay residents who lose too much weight7.6%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder2.4%1.2%0.9%worse
Long-stay residents with a urinary tract infection0.8%2.1%2.0%better
Long-stay residents with depressive symptoms1.7%2.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.4%0.2%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury10.5%3.5%3.3%worse
Long-stay residents whose ability to walk worsened16.9%17.9%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.6%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine95.4%94.9%95.3%typical
Long-stay residents with pressure ulcers4.8%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control10.7%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table28.6%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%3.1%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine45.2%76.3%79.4%worse
Short-stay residents rehospitalized after admission38.3%28.0%22.6%worse
Short-stay residents with an outpatient ER visit33.5%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.862.561.67worse
Long-stay outpatient ER visits per 1,000 resident days4.452.741.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.6%U.S. median 51.5%
Got home and stayed home
13.0%U.S. median 10.7%
Went back to hospital
54.5%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 54.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 61% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.6%CMS range 37.8–65.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.0%CMS range 9.4–18.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge54.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay10.9%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.8%CMS range 4.5–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.12
RN hours/ resident / day
1.01
LPN hours/ resident / day
2.87
Aide hours/ resident / day
4.00
Total nurse hours/ resident / day
0.12
RN hoursweekends
38.4%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 125 beds and averages 65.7 residents a day — about 53% occupied, or roughly 59 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.00 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.12 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 4.25 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.12 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2026-05-13)
8
at the previous standard inspection (2025-03-26)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Ecited before2026-05-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections to the extent possible by failing to document urine output for 1 (#59) of 1 residents reviewed with a urinary catheter.Findings:On 05/11/2026 at 9:20 a.m., observation of resident #59 revealed he had a urinary catheter.Review of the medical record revealed Resident #59 had an admission date of 09/04/2024 with diagnoses which included epilepsy and retention of urine. Review of the May 2026 physician orders revealed an order to monitor urine output. Review of the May 2026 urine output log revealed the following:On 05/07/2026 there was no documentation of urine output on the night shift. On 05/08/2026 there was no documentation of urine output on the night shift. On 05/09/2026 there was no documentation of urine output on the day, evening and night shifts.On 05/10/2026 there was no documentation of urine output on the day, evening and night shifts.On 05/11/2026 there was no documentation of urine output on the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-13 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, record review and interview, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident needs for 1 (#59) of 1 residents reviewed for urinary catheters by failing to report lack of urine output to the nursing staff.Findings:On 05/11/2026 at 9:20 a.m., observation of resident #59 revealed he had a urinary catheter.Review of the medical record revealed Resident #59 had an admission date of 09/04/2024 with diagnoses which included epilepsy and retention of urine. Review of the March 2026 physician orders revealed an order to monitor urine output. Review of the March 2026 urine output log revealed on March 28, 29 and 30 on all three shifts the recorded output was zero.Review of the progress notes revealed there was no documentation CNAs notified nursing staff that Resident #59 had zero urine output. On 05/12/2026 at 11:10 a.m., interview with S2DON confirmed there was no documentation that the CNAs notified the nursing staff that Resident #59 had zero urine output.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interviews the facility failed to maintain, store, prepare, distribute and serve food under sanitary conditions. The facility failed to monitor and document the refrigerators and freezer temperature.Findings:During a brief tour of the kitchen on 05/11/2026 at 8:00 a.m. the following was observed: the reach in refrigerator had a temperature of 35 degrees Fahrenheit, the walk in refrigerator had a temperature of 35 degrees Fahrenheit, and the walk in freezer had a temperature of 5 degrees Fahrenheit.Further observation of the kitchen revealed there was no log documenting the temperature readings of the reach in refrigerator, walk in refrigerator, or walk in freezer.On 5/11/2026 at 8:12 a.m. an interview with S3Dietary Manager reported she did not keep a log documenting the temperatures of the reach in refrigerator, walk in refrigerator, or walk in freezer.On 05/11/2026 at 10:30 a.m. an interview with S1Administrator confirmed S3Dietary Manager should have be monitoring and documenting the temperatures of the refrigerators and freezer daily.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to ensure drugs and biologicals used in the facility were stored properly in a locked compartment by having medications in resident's room for 1 (#14) of 1 residents reviewed for accident hazards. Findings:Review of the facility's undated Storage of Medication policy revealed the following in part:Policy StatementThe facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Review of the medical record for Resident #14 revealed an initial admission date of 05/03/2025 with a readmit date of 07/04/2025. Resident #14 had diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, schizophrenia, and seizures.Review of the current care plan revealed Resident #14 had impaired cognitive function/dementia or impaired thought processes. Interventions included to administer medications as ordered and to assist resident with all decision making. Review of the annual MDS assessment dated [DATE] revealed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-10-01 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. The nurse failed to: 1) review Resident #1 discharge orders when writing his admission orders to the facility and 2) clarify with the Physician if Resident #1 need to continue his home medications.Findings:Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses included encounter for surgical aftercare following surgery on the nervous system, type 2 diabetes mellitus with diabetic neuropathy, low back pain, hyperlipidemia, post-traumatic osteoarthritis, insomnia, constipation, depression, intervertebral disc disorders with myelopathy, thoracolumbar region, edema, and hypokalemia.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact for daily…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 3 (#2, #13, and #27) of 4 (#2, #13, #33, and #27) sampled residents reviewed for environmental issues. The facility failed to ensure: 1. Resident #2, #13, and #27's air conditioning/heating units were free from trash and debris; 2. Resident #2's air conditioning/heating unit had control knobs attached; 3. Resident #2's television frame remained in good repair; and 4. Resident #13's dresser and bed footboard remained in good repair. Findings: Resident #2 On 03/24/2025 at 10:04 a.m. observation of resident #2's room revealed the air conditioning/heating unit contained debris and the unit control knobs were missing. The television frame was also observed separated from the top left corner of the television. On 03/25/2025 at 9:06 a.m. observation of resident #2's room revealed debris remained in air conditioning/heating vent and control knobs remain missing. On 03/26/2025 at 10:35 a.m. the surveyors and S1Administrator observed the air conditioning/heating unit…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-26 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM or prevent further decrease in ROM for 2 (#3 and #23) of 3 (#3, #23, and #35) residents reviewed for limited range of motion. Findings: Resident #3 Review of the record for resident #3 revealed an admission date of 09/27/2016 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, contracture right wrist, abnormal posture, dysphagia following cerebral infarction, muscle wasting and atrophy of left thigh, right lower leg, right thigh, and aphasia following other cerebrovascular disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. Further review of the MDS revealed resident requires maximal assistance with activities of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident with a urinary catheter received appropriate care and services to prevent urinary tract infections by having the urinary catheter tubing on the floor and not having justification for the use of an indwelling Foley catheter for 1 (#8) of 2 (#8, #63) residents reviewed for urinary catheters. Findings: Review of the record for resident # 8 revealed an admit date of 05/31/2024 with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Record review revealed a physician's order dated 12/12/2024 for resident # 8 to have a Foley catheter changed on the 12th of every month related to frequency of micturition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #8 had a brief interview for mental status (BIMS) score of 4 which indicated severe cognitive impairment. Further…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-26 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure that the licensed nurses have the specific competencies and skill sets necessary to care for a resident's needs for 1 (# 8) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications. The licensed nurses were duplicating documentation of administration of 2 different short-acting insulins. Findings: Review of the record for resident # 8 revealed an admit date of 05/31/2024 with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Record review revealed a physician's order dated 09/23/2024 for Humulin R (short-acting insulin) injected subcutaneously twice daily per sliding scale. Further review revealed an order dated 10/18/2024 for Novolin R (short-acting insulin) injected subcutaneously before meals and at bedtime per sliding scale. Review of the March 2025 Medication Administration Record (MAR) revealed the order for Humulin R (short-acting insulin) dated 09/23/2024 was documented…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living received the necessary services to maintain good grooming and personal hygiene for 1 (#35) of 3 (#3, #23, #35) residents reviewed for Activities of Daily Living (ADL) care. Findings: Resident #35 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction with hemiparesis affecting right dominant side. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed in section C- Cognitive Patterns that resident #35 had a brief interview of mental status (BIMS) score of 6 which indicated severe cognitive impairment. Further review of the MDS revealed in section GG-Functional Abilities that resident #35 was dependent on staff for personal hygiene care that included nail care. Review of March 2025 physician orders revealed an order dated 03/12/2025 for fingernail care every shift for resident #35. Review of the Electronic Medication Administration…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2025-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure residents with a history of falls, received appropriate interventions to prevent future falls for 1 (#22) of 4 (#22, #30, #41, #63) residents reviewed for falls. Findings: Record review revealed resident #22 was admitted to the facility on [DATE] with diagnoses including profound intellectual disabilities, generalized anxiety disorder, epilepsy, right femur fracture, and autistic disorder. Review of accident/incident reports revealed resident #22 had a fall from his bed witnessed by S3Certified Nursing Assistant (CNA) Supervisor as she was assisting him to get dressed on 02/07/2025. Review of the S3CNA Supervisor`s hand written witness statement included in the complaint investigation revealed resident #22 was on the floor tangled up in his bedding. On 03/26/2025 at 2:31 p.m., an interview with S3CNA Supervisor confirmed she was assisting resident #22 getting dressed on 02/07/2025. S3CNA Supervisor reported resident #22 was fully dressed laying…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director, and director of nursing for 1 (#8) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications Findings: Review of the record for resident # 8 revealed an admit date of 05/31/2024 with diagnoses in part of urinary tract infection, frequency of micturition, overactive bladder, type 2 diabetes mellitus with diabetic chronic kidney disease, and cystitis. Review of the Medication Record Review (MRR) for February 2025 revealed no documented evidence that the pharmacist identified duplicate short-acting insulin therapy for resident #8. Record review revealed a physician's order dated 09/23/2024 for Humulin R (short-acting insulin) injected subcutaneously twice daily per sliding scale. Further review revealed an order dated 10/18/2024 for Novolin R (short-acting insulin) injected subcutaneously before meals and at bedtime per sliding scale. Review of the March 2025 Medication Administration Record (MAR) revealed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident was free from unnecessary medications by failing to implement a gradual dose reduction for a psychotropic medication for 1 (#14) of 5 (#8, #14, #37, #41, #57) residents reviewed for unnecessary medications. A psychotropic drug is any drug that affects brain activities associated with mental processes and behaviors. These drugs include, but are not limited to, drugs in the categories of antipsychotics, antidepressants, anti-anxiety, and hypnotics. Findings: Record review revealed resident #14 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, delirium due to known physiological condition, essential hypertension, lower back pain, neuralgia, and neuritis. Review of the March 2025 physician orders revealed the following orders dated 08/05/2024: Quetiapine Fumarate (Seroquel, an antipsychotic medication) 50 milligrams (mg) tablet give one tablet orally one time a day, Bupropion Hydrochloride…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-08 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the resident's representative after an accident for 2 (#1, #2) of 2 (#1, #2) residents reviewed for falls. Findings: Resident #1 Review of the record for resident #1 revealed an admit date of 12/04/2024 with diagnoses in part of alcohol dependence with withdrawal, other seizures, pain, anxiety disorder, shortness of breath, malignant neoplasm of palate, pulmonary embolism without acute cor pulmonale, malignant neoplasm of overlapping sites of oropharynx, cerebral ischemia, dysphagia, and severe protein calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the current plan of care for resident #1 revealed at risk for falls related to impaired balance, and unsteady gait. Review of the Incident and Accident report dated 12/10/2024 at 2:20 a.m. revealed resident #1 was found by…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-28 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure that the plan of care had been revised for 1 (#4) of 1 (#4) residents' care plans reviewed for limited range of motion. Findings: Record review revealed resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses include essential hypertension, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, other sequelae of cerebral infarction, abnormal posture, lack of coordination, history of falling, contracture right wrist, contracture of muscle unspecified, aphasia following cerebrovascular disease, dysphagia following cerebral infarction, unspecified abnormalities of gait and mobility, and chronic pain. Review of the yearly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A further review of the MDS revealed resident was documented as having range of motion impairment on one…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-28 · tag F0688 — failed to keep residents mobile / prevent decline — pattern
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion by failing to apply a splint daily for 1 (#4) of 1 (#4) residents reviewed for limited range of motion out of 31 sampled residents. Findings: Record Review revealed resident #4 was admitted to the facility on [DATE]. Resident #4's diagnoses included essential hypertension, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, other sequelae of cerebral infarction, abnormal posture, lack of coordination, history of falling, contracture right wrist, contracture of muscle unspecified, aphasia following cerebrovascular disease, dysphagia following cerebral infarction, unspecified abnormalities of gait and mobility, and chronic pain. Review of yearly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-28 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice by failing to assess the dialysis access site every shift, according to the facility's policy for hemodialysis access care, for 1 (#53) of 1 (#53) residents reviewed for dialysis. Findings: Review of the facility's policy and procedure on Hemodialysis Access Care revealed the following, in part: 3. Post-care of access site: b.) Nurse will inspect access port for bleeding, redness, or inflammation documenting any changes in the medical chart. Nurse is to notify medical doctor (MD) of any pertinent findings; c.) Nurse is to assess access site to ensure intactness and patency every shift (listening for bruit and feeling for a thrill); d.) Nurse is to document all findings such as condition of dressing (interventions if needed); report from dialysis facility, and observations post-dialysis. Review of the record for resident…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-28 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#60) of 6 (#15, #24, #34, #55, #60, and #122) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for pain every shift for resident #60 while receiving pain medication. Findings: Review of the facility's current policy and procedure on Pain-Clinical Protocol revealed, in part: 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review of the facility's current policy and procedure on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-28 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 4 (#15, #34, #60, and #122) of 6 (#15, #24, #34, #55, #60, and #122) residents reviewed for unnecessary medications. The facility failed to: 1) Monitor residents #15 and #122 for bleeding when administered an anticoagulant, 2) Monitor resident #15's blood pressure when administered an antiarrhythmic medication, 3) Document insulin injection sites for resident #34, 4) Check resident #60 for edema when administered a diuretic, failed to monitor resident #60's blood glucose level, and, failed to 5.) Monitor resident #60 for pain while administered pain medication as needed. Findings: Review of the facility's current policy on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-28 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that each resident was free from unnecessary medication use for 3 (#15, #60 and #122) of 6 (#15, #24, #34, #55, #60 and #122) residents reviewed for unnecessary medications. The facility failed to monitor for side effects and behaviors for residents #15 and #122 when administerd a psychotropic medication, and the physician failed to give a rationale for continuing a PRN psychotropic medication greater than 14 days for resident #60. Findings: Review of the facility's current policy on Pharmacy Services: Medication Regimen Reviews revealed in part: 5. The Medication Regimen Review (MRR) involves a thorough review of the resident's medical record to prevent , identify, report, and resolve medication related problems, medication errors and other irregularities, for example: d. inadequate monitoring for adverse consequences; 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services, standards of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident assessment was transmitted in a timely manner by failing to transmit the resident assessment within 7 days of completion for 1 (Resident #5) of 1 (Resident #5) residents reviewed for resident assessments. Findings: Review of resident #5's record revealed resident expired at the facility on [DATE]. Review of the resident #5's Minimum Data Set (MDS) assessments revealed the last assessment was a significant change assessment dated [DATE]. Further review of the MDS revealed there was no discharge assessment completed and transmitted for resident #5. An interview on [DATE] at 2:35 p.m. with S2Assistant Director of Nursing (ADON) confirmed that resident #5 expired at the facility on [DATE]. S3ADON confirmed that a discharge assessment was not completed on resident #5. S3ADON confirmed that a discharge assessment should have been completed on resident #5 on [DATE] and transmitted by [DATE].

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PARAMOUNT HEALTHCARE CONSULTANTS — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.9+0.1 vs chain
Staffing 3 of 52.3+0.7 vs chain
Quality measures 2 of 52.0≈ chain avg
The other 13 homes this chain runs (chain average 2.4★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
DUPREE, DORISIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF16%since 01/01/2018
REDD, SHARONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF15%since 01/01/2018
REYNOLDS, DONNICEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF8%since 01/01/2018
REYNOLDS, GABRIELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 01/01/2018
SISTRUNK, ADAMIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 01/01/2018
SISTRUNK, JOSEPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 01/01/2018
SISTRUNK, TAMMIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF8%since 01/01/2018
SMITH, DAWNEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF15%since 01/01/2018
VIDRINE, TERESAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF16%since 01/01/2018
VYVIAL, LAURENIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 01/01/2018
HILLVIEW NURSING HOME INCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 01/01/2018
STOKES, VINSONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/16/2022
PARAMOUNT HEALTHCARE CONSULTANTS, LLCOrganizationADP OF THE SNFsince 01/01/2018
STEPHEN DUCK, CPA PCOrganizationADP OF THE SNFsince 06/27/2025
POST, LISAIndividualADP OF THE SNFsince 07/01/2022

CMS files one row per role, so the 27 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.4M
Net patient revenuemost recent cost report
+18.8%
Operating marginrevenue minus expenses
$308K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 11%Other / private 16%

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $308K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$220per resident / day
operating cost
$6,700per month
≈ monthly operating cost
$271per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in LA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.

Typical monthly cost in Louisiana
$7,604/mo
Nursing home (semi-private)
$8,076/mo
Nursing home (private)
$5,163/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195554. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-13, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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