Central Guest House Healthcare & Rehabilitation Ce
10748 Joor Road, Baton Rouge, LA 70818 · For profit - Limited Liability company · 170 certified beds · (225) 416-6006 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $26,790 in federal fines (most recent 2024-03-21)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 22% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 3 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 improved from 1 to 3 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 21.6% | 17.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.2% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 2.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.4% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 27.1% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.2% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 75.5% | 94.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.9% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.3% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.0% | 22.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.2% | 3.1% | 1.4% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 76.1% | 76.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 35.6% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.1% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.94 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.82 | 2.74 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
54.6% 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 50 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% 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 24 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.6%CMS range 39.3–69.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 6.9–14.4 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 54.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 95.6% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 90.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 4.5–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 170 beds and averages 164.1 residents a day — about 97% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 is below 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 2.85 hrs/resident/day on weekends vs 3.47 on weekdays — 18% thinner on weekends. RN hours go from 0.25 to 0.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% 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
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.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · J2024-03-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 interviews and record reviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure physicians orders were obtained and clarified upon readmission from the hospital for 2 (#64, and #500) of 4 (#49, #64, #149, and #500) residents reviewed for hospitalizations. This deficient practice resulted in an Immediate Jeopardy situation on 03/16/2024 at 9:00 p.m., when Resident #500 returned to the facility without hospital discharge orders. Resident #500 was admitted to the hospital on [DATE] with symptoms including facial edema, tongue swelling, disoriented, and difficulty breathing. The hospital diagnoses was anaphylactic allergic reaction to Amiodarone. The facility failed to obtain records and orders from the hospital upon readmission on [DATE] and Amiodarone 200 mg BID remained on the eMAR. On 03/18/2024 at 8:00 a.m., S20LPN administered Amiodarone to Resident #500. S1ADM was notified of the Immediate Jeopardy situation on 03/19/2024 at…
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.
- Potential for harm · D2026-04-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 residents received their dietary supplements with each meal for 1 (Resident #1) of 3 residents reviewed for nutrition. Resident #1Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, Unspecified Level of Spinal Cord Injury, and Unspecified Protein-Calorie Malnutrition. Review of Resident #1's most recent MDS with an ARD of 03/22/2026, revealed a BIMS of 5, which indicated severe cognitive impairment. Review of Resident #1's current Physician Orders revealed the following, in part:Start date 03/16/2026- Magic cup with meals. Review of Resident #1's most recent Registered Dietician Assessment Summary revealed, in part, the following:Current Diet Order: NAS (No Added Salt) diet. Regular texture, Regular/Thin consistency, double portion meats. Magic cup with meals three times a day. Liquid protein three times a day. House supplement four times a day.…
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.
- Potential for harm · Ecited before2026-03-25 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. There were 166 residents in the facility who ate food from the kitchen.Findings:On 03/23/2026 at 8:50 a.m., an initial tour of the kitchen was conducted with S2DM, who confirmed the following observations:Freezer:The following items were observed in unsealed bags in open cardboard boxes:-1 10 pound bag of fully cooked sausage patties-1.2 ounce plastic bag of cheese and garlic biscuit dough-1.5 pound plastic bag of diced ham-10.35 pound plastic bag of fully cooked chicken breast patties-10 pound plastic bag of fish fingers-1 pound bag of egg rollsOn 03/23/26 at 8:55 a.m., an interview was conducted with S2DM. S2DM confirmed the aforementioned items were open, and not sealed. S2DM stated all foods stored in the freezer should have been sealed and not left open to air.On 03/24/2026 at 4:18 p.m., an interview was conducted with S1ADM. S1ADM was notified of the aforementioned findings. S1ADM stated opened food items should have been sealed and not…
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.
- Potential for harm · Dcited before2026-03-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 implement a resident's person centered plan of care for 1 (#114) of 7 sampled residents reviewed. The facility failed to ensure Resident #114's shrinker sock was applied to his right below the knee amputation (BKA) as identified in his plan of care.Review of Resident #114's Clinical Record revealed he admitted to the facility on [DATE] with diagnoses, which included Acquired Absence of Right Leg Below Knee. Review of Resident #114's Annual MDS with ARD of 02/04/2026 revealed a BIMS of 06, which indicated severe cognitive impairment. Review of Resident #114's current Physician's Orders revealed the following, in part:Shrinker sock to be applied to right BKA anytime prosthetic leg and silicone liner with screw is removed. On 03/23/2026 at 9:45 a.m., an observation and interview was conducted with Resident #114. He was lying in bed with no shrinker sock in place to right BKA with a sign above his bed, stating gray shrinker sock to be worn…
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.
- Potential for harm · Dcited before2026-03-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#59) of 3 residents reviewed for ADL's. The facility failed to shampoo Resident #59's hair.Findings:Review of Resident #59's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Abnormalities of Gait and Mobility, Generalized Muscle Weakness, Anxiety Disorder, Idiopathic Progressive Neuropathy, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, and Acute on Chronic Respiratory Failure with Hypoxemia. Review of Resident #59's Quarterly MDS with an ARD of 02/19/2026 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed she required partial/moderate assistance with personal hygiene. Review of Resident #59's Care Plan revealed the following, in part:Problem: The resident requires staff assistance with…
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.
- Potential for harm · Dcited before2026-03-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure medications were administered as ordered for 1 (#162) of 7 residents reviewed for medication administration.Findings: Review of the facility's policy titled, Medication Administration with an effective date of 10/04/2024, revealed the following, in part:Policy: Nursing personnel shall ensure the safe and effective administration of medications.Procedure:1. Medication Administration:g. Administer the medication as ordered .4. Missing Medication:a. Notify the Pharmacy immediately to fill the order during regular pharmacy hours. After hours, retrieve the medication from the emergency medication kit. Review of Resident #162's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which…
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.
- Potential for harm · Dcited before2026-03-25 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#135) of 4 residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing care to a resident who was on Enhanced Barrier Precautions (EBP).Review of the facility's policy titled Enhanced Barrier Precautions Policy & Procedure dated 04/2024, revealed the following, in part: Procedure:1. EBP are indicated for residents with any of the following: b. Indwelling medical devices even if the resident is not known to be infected or colonized with and MDRO. ii. Indwelling medical device examples include urinary catheters4. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: b. Providing hygiene g. Device care or use (urinary…
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.
- Potential for harm · Ecited before2025-02-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure staff with facial hair wore a beard restraint while preparing to serve food. This deficient practice had the potential to affect any of the 155 residents who received food from the facility's kitchen. Findings: Review of the facility's policy titled, Medical Nutrition Therapy and Food Systems Management with a revision date of 10/2018 revealed the following, in part: 3. Proper Work Attire b. The food service employee observes the following dress standards: i. Employees with facial hair wear a beard restraint. An observation was made in the facility's kitchen on 02/10/2025 at 11:26 a.m. The dietary staff were preparing to serve lunch. There were three male dietary aides with beards preparing drinks and placing lids on the cups. None of the three male dietary aides had on a facial hair restraint. An interview was conducted with S5DM on 02/11/2025 at 11:33 a.m. She confirmed the male…
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.
- Potential for harm · D2025-02-12 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 Significant Change in Status Minimum Data Set (MDS) Assessment was completed within 14 days of a resident admitted to hospice for 1 (#136) of 3 (#76, #136, and #159) sampled residents who received hospice services. Findings: Review of Resident #136's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #136's Physicians Orders revealed Resident #136 was admitted to Hospice on 04/30/2024. Review of Resident #136's MDS assessments from 04/30/2024 to present revealed no Significant Change MDS was submitted to reflect Hospice services were provided. On 02/12/2025 at 10:54 a.m., an interview was conducted with S3MDS. She stated an admission to Hospice services required a Significant Change MDS assessment. She reviewed Resident #136's MDS assessments and confirmed a Significant Change MDS was not completed after being admitted to Hospice on 04/30/2024 and should have. On 02/12/2025 at 2:04 p.m., an interview was…
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.
- Potential for harm · D2025-02-12 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure MDS assessments accurately reflected the residents' status by failing to ensure: 1.Discharge dispositions were accurately coded for 1 (#161) of 4 (#159, #161, #312, and #412) discharged resident records reviewed; and 2. Hospice services were accurately coded for 1 (#136) of 3 (#76, #136 and #159) residents reviewed who received hospice services. Findings: Review of the facility's policy titled, MDS Policy and Procedure dated 06/25/2015 revealed the following, in part: Policy: All Minimum Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. 1. Resident #161 Review of Resident #161's Clinical Record revealed an admission date of 10/16/2024 and a discharge date of 11/12/2024. Further review of the Clinical Record revealed she was a planned discharge home with Home Health Services. Review of Resident #161's Discharge MDS assessment with an ARD of 11/12/2024 revealed her discharge from the facility was unplanned. An interview was conducted with…
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.
- Potential for harm · Dcited before2025-02-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, interviews, and policy review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 (Cart A, Cart B, and Cart C) medication carts observed. The facility failed to ensure: 1. Insulin vials were labeled with the date opened and discarded 28 days after the date opened; and 2. Medications were discarded by their expiration date. Findings: Review of the facility's policy titled, Medication Administration dated [DATE] revealed the following, in part: Purpose: To define responsibility and delineate processes for safe administration of medications by nursing personnel. Procedure: 7. Multi-dose vials: b. All multi-dose vials shall be labeled with the initials of the person opening the vial and an expiration date that is 28 days after opening. c. Opened multi-dose vials that lack dates or initials shall be discarded. Cart A An observation was made of Cart A on [DATE] at 2:24…
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.
Show the remaining 16 citations
- Potential for harm · Dcited before2025-02-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
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 reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of infection by failing to ensure staff donned proper Personal Protective Equipment (PPE) when performing high-contact resident care for 1 (#18) of 8 (#18, #28, #33, #55, #67, #136, #154 and #362) residents reviewed on Enhanced Barrier Precautions (EBP). This deficient practice had the potential to affect any of the 33 residents residing in the facility who had Enhanced Barrier Precautions implemented. Findings: Review of the facility's policy which had an effective date of 04/01/2024, and titled Enhanced Barrier Precautions Policy and Procedure revealed the following, in part: Purpose: To prevent the spread of potential infection by implementing Enhanced Barrier Precautions when contact precautions do not apply. This approach recommends the use of EBP during high-contact care activities for residents with chronic wounds . Procedure:…
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.
- Potential for harm · Dcited before2024-10-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 alleged violations involving verbal abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to the state survey agency for 1 (#8) of 4 (#4, #6, #7, and #8) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse Prevention and Prohibition Policy, dated 03/25/2023, revealed, in part: Policy: If you suspect verbal abuse of a resident or mistreatment of a resident contact the Administrator immediately. Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/14/2024 revealed a Brief Interview for Mental Status (BIMS) of 15, indicating he was cognitively intact. Review of the facility's Investigative Reports submitted to the state survey agency dated May 2024 to October 2024 revealed there were no reports filed 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.
- Potential for harm · D2024-10-18 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 Minimum Data Set (MDS) assessments were completed and transmitted timely for 1 (#1) of a total of 16 sampled residents reviewed for Resident Assessment. Findings: Review of the facility policy titled, MDS Policy and Procedure, with an effective date of 06/25/2015, revealed the following, in part: All Minimum Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument manual. Resident #1 Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. On 10/14/2024, review of Resident #1's admission MDS with an ARD of 08/30/2024 revealed the MDS was incomplete and had a status of in progress. On 10/14/2024, review of Resident #1's Quarterly MDS with an ARD of 09/11/2024 revealed the MDS assessment was incomplete and had a status of in progress. On 10/15/2024 at 1:10 p.m., an interview was conducted with S4MDS. She reviewed the above MDS assessments and confirmed they…
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.
- Potential for harm · E2024-03-21 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to initiate and resolve grievances voiced for 1 (#114) of 34 sampled residents reviewed for grievances. Findings: Review of the facility's policy titled, Grievance Policy and Procedure, reviewed on 03/19/2024, and dated 10/10/2022 revealed the following, in part: Policy: The resident, family member, visitor, volunteer individual or employee has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Documentation: 1. Document grievances made by a resident, resident's family member . the grievance shall include: a. Date the grievance was received. b. A summary statement of the grievance. c. Steps taken to investigate the grievance. d. A summary of the pertinent findings or conclusions regarding the concerns. i. Record the grievance on the facility's Grievance log. Follow Up/Resolution: 1. The grievance official/compliance liaison or designee will follow up with the complainant with a resolution within 5 business days of the date that the grievance was…
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.
- Potential for harm · Ecited before2024-03-21 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#64, #113) of 4 (#64, #80, #113 and #116) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #64 and #113. Findings: Review of the facility's policy, Bath, Bed Policy and Procedure, dated 08/01/2017, revealed the following, in part: Procedure: 16. Care of fingernails and toenails are part of the bath. Be certain nails are clean. Inform the charge nurse if a resident needs his/her toenails cut if they are diabetic or have poor circulation. 17. Fingernails and toenails of diabetic residents are cut by the licensed nurse or podiatrist. Resident #64 Review of the Medical Record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness and Need for Assistance with Personal Care. Review of the most recent MDS…
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.
- Potential for harm · Ecited before2024-03-21 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#64, #113) of 4 (#64, #80, #113 and #116) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #64 and #113. Findings: Review of the facility's policy, Bath, Bed Policy and Procedure, dated 08/01/2017, revealed the following, in part: Procedure: 16. Care of fingernails and toenails are part of the bath. Be certain nails are clean. Inform the charge nurse if a resident needs his/her toenails cut if they are diabetic or have poor circulation. 17. Fingernails and toenails of diabetic residents are cut by the licensed nurse or podiatrist. Resident #64 Review of the Medical Record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness and Need for Assistance with Personal Care. Review of the most recent MDS…
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.
- Potential for harm · Ecited before2024-03-21 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
Based on record review, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 (Cart A, Cart B, and Cart C) medication carts observed. The facility failed to ensure: 1. Insulin pens were labeled with the date opened; 2. Insulin pens were discarded 28 days after the date opened; and 3. Insulin pens were labeled with resident identification. Findings: Review of the updated 04/2023 facility's policy titled PCSA - Medications with Shortened Expiration Dates, on 03/18/2024, revealed, in part: Review of the Lantus (Insulin Glargine) revealed the following, in part: Expiration time after puncturing or placing at room temperature - 28 days. Review of Novolog Flexpen revealed the following, in part: Expiration time after puncturing or placing at room temperature - 28 days. Review of Levimir Flexpen revealed the following, in part: Expiration time after puncturing or placing at room temperature - 42 days. Cart A: An observation was made 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.
- Potential for harm · Ecited before2024-03-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 158 residents who were served from the kitchen. Findings: Review of the 10/2018 revised facility's policy titled Storage of Refrigerated Food on 03/20/2024 revealed the following, in part: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 3. Food taken out of original containers is put in a clean sanitized container with a tight fitting lid. No food is left uncovered. 4. All non-hazardous, opened foods are labeled with name of food and date stored. 5. All hazardous foods are labeled with name of food and date to be discarded or the date stored. Cooked foods are held no longer than 48 hours. Review of the 10/2018 revised facility's policy titled Storage of Frozen Food on 03/20/2024 revealed the following, in part Policy: The facility ensures the quality and safety of frozen foods through accepted storage practices. Procedure: 5.…
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.
- Potential for harm · D2024-03-21 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to complete quarterly assessments for 1 (#130) of 42 residents reviewed for resident assessment. Findings: Review of the facility's policy titled MDS Policy and Procedure, reviewed on 03/20/2024, dated 06/15/2015, revealed, in part: All Minimal Data Set (MDS) are to be completed according to the most current Resident Assessment Instrument (RAI) manual. Review of Resident #130's most recent Quarterly Minimum Data Set (MDS) revealed an Assessment Reference Date (ARD) of 03/12/2024. On 03/20/2024 at 11:00 a.m., an interview was conducted with S25MDS. He stated he was responsible for completing MDS assessments. He reviewed the quarterly assessment for Resident #130 and confirmed the MDS assessment had not been submitted to CMS within the required timeframe. He said Resident #130's MDS assessment was completed greater than 120 days. An interview was conducted on 03/20/2024 at 11:25 a.m. with S2ADON. She reviewed the quarterly MDS for Resident #130 dated 03/12/2024. She confirmed Resident #130's quarterly MDS assessment was not…
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.
- Potential for harm · D2024-03-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure the oxygen tubing and humidification bottles were properly labeled for 2 (#500 and #601) of 3 (#54, #500, and #601) residents reviewed for oxygen therapy. Findings: Review of the facility policy and procedure, named Oxygen Concentrator Cleaning revealed, in part: 3. Oxygen tubing, cannula, and mask must be changed out weekly and as needed. Resident # 500 Review of the Clinical Record for Resident #500 revealed she was admitted to the facility on [DATE] and had diagnoses which included Chronic Obstructive Pulmonary Disease and Shortness of Breath. Review of the current Physician Orders for Resident #500 revealed the following, in part: Start date: 12/29/2023 - Oxygen at 3 liters via nasal cannula continuously, may remove for ADL's. Start date: 12/29/2023 - Change oxygen…
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.
- Potential for harm · Ecited before2023-12-20 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 reviews, the facility failed to ensure medications were available for administration as ordered by the physician for 1 (#3) of 3 (#1, #2, and #3) sampled residents. Findings: Review of the facility's policy titled, Medication Administration revealed, in part, the following: Nursing personnel shall ensure the safe and effective administration of medication. 1. Medication administration: prior to administration, the nursing staff member administering the medication shall ensure that the following steps are accomplished. E. Resolve any concerns about the medication with the provider, prescriber, and/or staff involved with the patent's care. G. Administer the medication as ordered and document the administration, along with any special requirements needed, in the electronic medication administration record as appropriate. Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, Insomnia Due to Other…
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.
- Potential for harm · E2023-12-20 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 reviews, the facility failed to maintain accurate medical records in accordance with acceptable standards of practice. The facility failed to ensure S1LPN and S2LPN accurately documented administration of a controlled substance medication for 1 (#3) of 3 (#1, #2, and #3) residents reviewed with controlled substances. Findings: Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Insomnia Due to Other Mental Disorder. Review of Resident #3's Quarterly MDS with an ARD of 11/29/2023 revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of Resident #3's current physician orders revealed, in part, the following: Start Date: 12/15/2023 - Ambien 5 mg tablet 1 tablet by mouth at bedtime. Review of Resident #3's MAR dated December 2023 included, in part, Ambien 5 mg tablet by mouth at bedtime with a check mark and initials, which indicated the medication was administered 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.
- Potential for harm · D2023-12-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 interviews and record review, the facility failed to ensure a resident's right to be free from physical and/or verbal abuse from Resident #3 for 1 (#R2) of 6 (#1, #2, #3, #R1, #R2,#R3) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse - Prevention and Prohibition Policy and Procedure revealed, in part, the following: Purpose: Each resident has the right to be free from abuse . No one shall abuse a resident. This policy applies to . other residents . Policy: To provide a safe, abuse-free environment for all residents. I. Types of Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 1. Verbal Abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance or sight, regardless of the resident's age, ability to comprehend, or disability. Examples: -Name…
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.
- Potential for harm · Dcited before2023-12-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 interviews and record review, the facility failed to ensure alleged incidents of abuse were reported to the state survey agency immediately, but no later than 2 hours after the incident, for 1 (#R2) of 6 (#1, #2, #3, #R1, #R2, #R3) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse - Prevention and Prohibition Policy and Procedure revealed, in part, the following: Policy: To provide a safe, abuse-free environment for all residents. If you suspect verbal . physical or mental abuse of a resident . contact the Administrator immediately. 7. Reporting/Response The facility employee or covered individual who becomes aware of abuse . shall immediately report the matter to the facility administrator . The Administrator shall immediately initiate a State Agency Report and the facility's local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical abuse . verbal abuse, mental abuse) Resident #3…
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.
- Potential for harm · D2023-11-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interviews and record review, the facility failed to ensure a resident received adequate supervision to prevent an accident for 1 (#3) of 4 (#1, #2, #3, and #R1) residents reviewed for supervision. The facility failed to ensure S7CNA did not leave Resident #3 in the whirlpool tub unsupervised. Findings: Review of the facility's policy titled, Bath, Tub Policy and Procedure revealed the following, in part: Procedure: Note: Never leave a resident in the tub alone. If you need assistance, put on the emergency call light. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Muscle Weakness and Other Abnormalities of Gait and Mobility. Review of Resident #3's Quarterly MDS with an ARD of 10/25/2023 revealed, in part, she had a BIMS of 15, which indicated she was cognitively intact. Further review of the MDS revealed she required supervision or touching assistance with showers and/or baths. Review of Resident #3's Care Plan 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.
- No harm found · C2025-02-12 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interviews, the facility failed to ensure nurse staffing data was posted in a prominent place readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 157 residents residing in the facility. Findings: A tour was conducted of all facility common areas on 02/10/2025 at 9:50 a.m. Observations revealed there was no nurse staffing data posted. An interview was conducted with S8UC on 02/10/2025 at 10:03 a.m. She stated she was responsible for writing the nurse staffing data on the facility's form. She stated she kept the form in a binder behind the nurses' station. She confirmed a resident or family member would have to ask to view the nurse staffing data. She confirmed the nurse staffing data was not posted in a prominent area readily accessible to residents and visitors. An interview was conducted with S1ADM on 02/10/2025 at 10:07 a.m. He confirmed the facility's nurse staffing data was not posted in a prominent area readily accessible to residents and visitors.
“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.
- 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.
Fines & penalties
$26,790 in federal fines across 1 penalty.
- $26,790 — penalty dated 2024-03-21
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PLANTATION MANAGEMENT COMPANY — 16 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 1.8 | +1.2 vs chain |
| Health inspection | 3 of 5 | 2.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 1.3 | +0.7 vs chain |
| Quality measures | 2 of 5 | 1.9 | +0.1 vs chain |
The other 15 homes this chain runs (chain average 1.8★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| QSST TRUST FOR GENE OLIVER QUIRK III | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 15% | since 12/31/2012 |
| QSST TRUST FOR MARSHALL TODD QUIRK | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 15% | since 12/31/2012 |
| QSST TRUST FOR SCOTT HOLDEN QUIRK | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 15% | since 12/31/2012 |
| QUIRK, CYNTHIA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 28% | since 12/31/2012 |
| QUIRK, GENE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 28% | since 12/31/2012 |
| DELATTE, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/31/2012 |
| QUIRK, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2005 |
CMS files one row per role, so the 8 rows in the source record cover these 7 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.
About 75% 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 $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
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.
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 195382. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-25, 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 →
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