Mid City Community Nursing and Rehab
4005 North Blvd., Baton Rouge, LA 70806 · For profit - Corporation · 184 certified beds · (225) 923-7280 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $44,090 in federal fines (most recent 2024-04-18)
- its payroll-based staffing rating is low (2/5)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 4 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 | 7.9% | 17.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.1% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.3% | 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 | 0.5% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.5% | 17.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.7% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.2% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.7% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.3% | 22.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.1% | 3.1% | 1.4% | typical for the state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 94.4% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 31.0% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.1% | 14.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.63 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.28 | 2.74 | 1.80 | worse |
* 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.
Met the expected recovery: 27.0% 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 37 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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
| 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.2–18.0 | 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 | 27.0% | 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 | 29.7% | 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 | 24.3% | 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 | 89.1% | 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 | not 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 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.90 | 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 184 beds and averages 113.0 residents a day — about 61% occupied, or roughly 71 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.19 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 2.74 hrs/resident/day on weekends vs 3.30 on weekdays — 17% thinner on weekends. RN hours go from 0.23 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2024-04-18 · 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 observation, record review, and interviews the facility failed to protect the resident's right to be free from verbal and mental abuse by a staff member for 1 (#116) of 22 residents reviewed in the final sample. This deficient practice resulted in psychosocial harm on 04/18/2024 at 11:24 a.m. when surveyor observed S10CNA provide care to Resident #116, a [AGE] year old moderately cognitively impaired resident with a diagnosis of Guillain Barre Syndrome. Upon S10CNA entering the room, Resident #116 became visibly tense throughout her body, hands clenched into tight fist around the side rail, and her eyes filled with tears. S10CNA rushed through care then became argumentative with a rude, aggressive tone and tense body language after the resident requested to have her teeth brushed. This interaction left Resident #116 tearful and her body language tense. Resident #116 stated S10CNA made her feel worthless. Resident #116 reported S10CNA and other CNA staff spoke to her with harsh tones, exhibited negative…
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 before2026-04-08 · 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 record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure: Food was properly stored, labeled and dated with an open date, or discarded for safety; and Staff documented food temperatures on food served to residents. There were 114 residents who received food served from the kitchen. Review of facility's policy titled, Food Safety Requirements, last revised August 2022, revealed the following, in part:Policy: It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.Policy Explanation and Compliance Guidelines: 1. B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. 3.c. Practices to maintain safe refrigerated storage include: iv. Labeling,…
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 before2026-04-08 · 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 interviews and record review, the facility failed to develop a trauma-informed, comprehensive person-centered care plan, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 (#14) of 30 Residents reviewed in the final sample. The facility failed to develop a care plan for Resident #14's diagnosis of Post-Traumatic Stress Disorder (PTSD).Review of Resident #14's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of Resident #14's most current care plan revealed no documented evidence of a care plan for diagnosis of PTSD. On 04/08/2026 at 1:25 p.m., an interview was conducted with S4LPN. S4LPN stated he was unaware Resident #14 had a diagnosis of PTSD and confirmed he was not familiar with Resident #14's triggers that may result in a mental health crisis. S4LPN reviewed and confirmed Resident #14's care plan did not include a history of PTSD. On 04/08/2026 at 2:45 p.m., an 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.
- Potential for harm · D2026-04-08 · 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
Based on observation, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure a medication cart was free of unlabeled capsules for 1 (Cart A) of 2 medication carts reviewed.Review of facility's policy titled, Labeling of Medications and Biologicals, last revised October 2020, revealed the following, in part: Policy: All medications and biologicals in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 1. All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices. On 04/06/2026 at 12:25 p.m., an observation was made of Cart A with an interview from S4LPN. Observation of Cart A revealed an unlabeled, clear, medication cup with 10 unidentified white capsules in 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 · Dcited before2025-08-20 · 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 review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#2) of 1 resident reviewed for Enhanced Barrier Precautions (EBP). 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). Findings:Review of the facility's policy titled, Enhanced Barrier Precautions with a revision date of 04/2024 revealed the following, in part:Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves…
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 · D2025-03-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#4) of 22 residents reviewed in the final sample. Findings: Review of Resident #4's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included morbid obesity. Review of Resident #4's Significant Change MDS with an ARD of 02/25/2025 revealed a BIMS of 14, which indicated she was cognitively intact. On 03/17/2025 at 11:05 a.m., an observation was made of Resident #4 in her room. She was lying in bed, with her call light resting on the floor behind the bed. On 03/17/2025 at 11:10 a.m., an interview was conducted with Resident #4. Resident #4 stated she was independent with eating but was dependent for all other ADL care. Resident #4 stated her call light was frequently out of reach and she had to yell out until someone responded. On 03/17/2025 at 1:45 p.m., an observation was made of Resident # 4 in her room. She was lying in bed, 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 before2025-03-19 · tag F0641 — isolatedEnsure each resident receives an accurate 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 interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#4 and #50) residents out of a total of 22 sampled residents. The facility failed to ensure: 1. Resident #4 was coded correctly for functional abilities and goals; and 2. Resident #50 was coded correctly for medications. Findings: Resident #4 Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #4's Significant Change MDS with an ARD of 02/25/2025 revealed a BIMS of 14, which indicated she was cognitively intact. Further review revealed she was coded as being independent for toileting hygiene, showering/bathing, and putting on/taking off footwear in Section GG: Functional Abilities and Goals. On 03/17/2025 at 11:10 a.m., an interview was conducted with Resident #4. Resident #4 stated she was independent with eating but was dependent for all other ADL care. On 03/19/2025 at 1:37 p.m., 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 · D2025-03-19 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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's laboratory tests were completed as ordered by the physician for 1(#52) of 22 residents investigated in the final sample. Findings: Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with a diagnosis which included Diabetes. Review of Resident #52's Physician's Orders revealed, in part: Order date 11/25/2024- laboratory blood draw for HGBA1C every three months in March, June, September, December once every 3 months starting on the 25th of each month. Review of Resident #52's clinical record revealed the last collected HGBA1C was performed on 10/26/2024. Review of the Medication Administration Record from November 2024 to present revealed no documented evidence Resident #52's HGBA1C labs were collected. Review of Resident #52's Care Plan Report revealed the following: Focus- I have a History of Diabetes Interventions- Obtain lab work as ordered An interview was conducted on 03/19/2025 at 3:08…
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 before2025-02-11 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 protect the residents' right to be free from physical abuse for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents reviewed for physical abuse. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025. Findings: Review of the facility's policy dated 02/2025 and titled, Abuse, Neglect, and Exploitation revealed in part, the following: Definitions: Physical Abuse-includes, but is not limited to hitting, slapping, punching. Prevention of Abuse-The facility will implement policies and procedures to prevent and prohibit all types of abuse. Resident #1 Review…
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 · E2025-02-11 · tag F0609 — failed to report abuse allegations — patternTimely 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 allegations of physical abuse were reported to the facility's administrator and the state agency in an appropriate time frame for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for physical abuse. The facility failed to ensure: 1. Staff immediately reported physical abuse to administration when Resident #1 and Resident #2 got into a physical altercation; and 2. The administrator reported 3 separate incidents of physical abuse involving Resident #1 and #2; Resident #2 and #3; and Resident # 1 and #4 to the state survey agency. This deficient practice resulted in an actual physical harm on 01/18/2025, when Resident #1, a cognitively intact Resident, punched Resident #2 in his face three times. Resident #1 was diagnosed with Unspecified Fracture of Fifth Metacarpal Bone of his Right Hand on 01/20/2025. Findings: Cross Reference F600 Review of the facility's policy dated 02/2025 and titled, Abuse, Neglect, and Exploitation…
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 before2025-02-11 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 record review and interviews, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASARR. Findings: Review of the facility's policy dated 02/2025 and titled, Resident Assessment-Coordination with PASARR Program revealed in part, the following: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State's Medicaid rules for screening. 1ai. Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. Resident #1 A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder. Further review revealed additional medical…
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 11 citations
- Potential for harm · Ecited before2025-02-11 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Residents with newly diagnosed mental illnesses were reevaluated for PASRR Level II determinations for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for PASRR; and 2. Allegations of physical abuse were reported to the state agency, immediately but not later than 2 hours after the allegation for 4 (#1, #2, #3, and #4) of 4 (#1, #2, #3, and #4) residents reviewed for abuse; and 3. Allegations of physical abuse were reported to the administrator immediately after the allegation for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for abuse. The deficient practice had the potential to affect a census of 110 residents. This deficient…
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 · D2025-02-11 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 interviews, the facility to ensure nursing staff communicated a significant change in status to the residents' nurse practitioner for 2 (#1 and #2) of 4 (#1, #2, #3, and #4) residents reviewed for notification of change. Findings: Review of the facility's policy dated 02/2025 and titled, Notification of a Change in a Patient's Condition or Status revealed the following, in part: Procedure: The Nurse will notify the patient's Attending Physician or On-Call Physician when there has been: An accident or incident involving a patient Resident #1 A review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizophreniform Disorder. A review of Resident #1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 13, which indicated Resident #1 was cognitively intact. Resident #2 A review of Resident #2's Clinical Record…
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 before2024-04-18 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into resident's assessment, care planning and transitions of care for 3 (#12, #24 and #63) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101 ) reviewed for PASRR. Findings: Resident #12 Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Schizoaffective Disorder and Bipolar Type (05/06/2022). Review of Resident #12's OBH-PASRR Level II Summary and Determination Notice, dated 09/11/2023, revealed, in part, the following: Recommended Lesser Services: Training in Activities of Daily Living; Training in Independent Living Skills; and Crisis Intervention Plan/Safety Plan. Recommended Specialized Services: Outpatient Therapy (Individual); and Outpatient Therapy (Group). Review of Resident #12's Clinical Record revealed no…
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 before2024-04-18 · 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, prepare, and distribute foods under sanitary conditions by failing to maintain a clean kitchen environment. There were 109 facility residents residing in the facility who received food from the facility's kitchen. Findings: An initial tour was conducted of the facility's kitchen with S11KC on 04/16/2024 beginning at 8:56 a.m. There was a slug moving on the floor under the mixer on the electrical cord of the mixer. There were three slugs actively moving on the floor behind the plate warmer between the tile and the wall. There was food debris on the floor throughout the kitchen. There was accumulated food debris under the oven, stove, plate warmer, steam table, and dishwasher. There were four french fries on the floor between the steam table and plate warmer. An interview was conducted with S11KC during the observations. S11KC confirmed the observation of the slugs. S11KC stated the french fries were from supper the night before. She stated the kitchen floor should have been cleaned nightly. A tour was conducted 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 before2024-04-18 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Recommendations from PASRR Level II Determinations and PASRR Evaluation Reports were incorporated into a resident's assessment, care plan and transitions of care for 3 (#12, #24, #63) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR; and 2. The coding accuracy for Minimum Data Set assessments regarding PASRR Level II for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, #101) residents reviewed for PASRR. The deficient practice had the potential to affect a census of 110 residents. Cross Reference F641. Cross Reference F644. Findings: 1. Resident #12 Review of Resident #12's Clinical Record revealed he was admitted to the facility…
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 before2024-04-18 · tag F0641 — isolatedEnsure each resident receives an accurate 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 interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the residents' status by failing to ensure a resident's Minimum Data Set was accurately coded for PASRR Level II (Pre-admission Screening and Resident Review) for 1 (#12) of 8 (#12, #24, #39, #50, #63, #71, #72, and #101) sampled residents reviewed for PASRR. Findings: Review of Resident #12's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Schizoaffective Disorder, Bipolar Type (05/06/2022). Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2023 revealed the following in Section A1500 PASRR: Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition with an entry of 0 (No). Section A1510A: Serious Mental Illness Level II PASRR conditions was blank. Review of Resident #12's OBH-PASRR Level II Summary 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.
- Potential for harm · Dcited before2024-04-18 · 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 comprehensive person-centered plan of care by failing to follow Physician's Orders for 1 (#45) of 4 (#4, #43, ##66, #114) residents reviewed for nutrition. The facility failed to ensure Resident #45 received a House Supplement with Meals three times daily. Findings: Review of Resident #45's medical records revealed he was admitted to the facility on [DATE]. Review of the Quarterly MDS with an ARD of 10/27/2023 revealed Resident #45 had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #45's current physician orders revealed: House Supplement with Meals; Three times daily. On 04/18/2024 at 09:29 a.m., an interview was conducted with Resident #45. He stated his physician ordered a house supplement to be given with meals, three times a day. He stated he was not receiving his house supplement. On 04/17/2024 at 12:36 p.m. an observation was made of Resident #45's lunch tray. His house supplement 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 · D2024-04-18 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 that appealing options of similar nutritive value were offered to residents who choose not to eat food that is initially served or who request a different meal choice for 1 (#45) of 32 sampled residents reviewed in the initial pool. Findings: Review of the Clinical Record revealed Resident #45 was admitted to the facility on [DATE]. Review of the Quarterly MDS with an ARD of 10/27/2023 revealed Resident #45 had a BIMS of 13, which indicated he was cognitively intact. Review of the current Care Plan revealed Resident # 45 was care planned for the following problems: Problems: My current diet is regular. Approaches: Offer food alternatives when appropriate On 04/17/2024 at 12:36 p.m., an interview was conducted with Resident #45. He stated his food was cold. He stated he asked kitchen staff for it to be heated or substituted. He stated the kitchen did not honor his request. On 04/18/2024 at 9:29 a.m., an interview was conducted with Resident #45.…
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 · D2024-04-18 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#39) of 32 residents reviewed for advanced directives in the initial screening process. Findings: Review of Resident #39's Clinical Record revealed he was admitted to the facility on [DATE]. Further review of the quarterly MDS assessment with an ARD date of 01/31/2024 revealed he had a BIM's of 14, which indicated he was cognitively intact. Review of Resident #39's Electronic Health Record Physician's Orders revealed the following: Order date: 11/20/2020 - Code Status: Full Code Review of Resident #39's Hard Chart revealed an Advanced Directive Form with DNR checked and signed by Resident #39, which indicated he did not want to be resuscitated if found with no pulse or respirations. A signed physician order dated, 04/30/2021, for Resident #39 confirmed a DNR code status. On 04/16/2024 at 1:58 p.m., 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 before2024-04-18 · 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 and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing catheter care for 1 (#12) of 3 (#12, #52 and #102) sampled residents reviewed for catheter care. Findings: Review of the facility's policy revised 03/2024, titled, Enhanced Barrier Precautions revealed, in part: Policy: It is the policy of this facility to implement enhanced barrier precautions (EBPs) for the prevention of transmission of multidrug-resistant organism. Definitions: -EBPs refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities. Policy Explanation and Compliance Guidelines: a. An order for enhanced barrier precautions will be…
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 · C2025-03-19 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview, the facility failed to ensure the results from the most recent complaint survey was readily available for resident review. This deficient practice had the potential to affect the 104 residents who currently resided in the facility. Findings: Review of the facility's Survey History revealed the most recent survey was a Complaint Survey on 02/11/2025. An observation was made on 03/17/2025 at 9:30 a.m. of the facility's Survey Results folder located near the entrance of the facility. Review of the Survey Results folder revealed the last survey posted in the binder was dated 04/18/2024. Further review revealed no documented evidence of the survey results from complaint survey dated 02/11/2025. An interview was conducted on 03/17/2025 at 9:35 a.m. with S1ADM. He reviewed the facility's Survey Results folder. He confirmed the survey results from complaint survey dated 02/11/2025 were not located in the folder.
“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
$44,090 in federal fines across 1 penalty. 2 Medicare payment denials on record.
- $44,090 — penalty dated 2024-04-18
- Medicare payment denial — starting 2025-03-07 for 6 days
- Medicare payment denial — starting 2024-05-16 for 8 days
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 THE CARPENTER HEALTH NETWORK — 4 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 | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 3.3 | +0.7 vs chain |
| Staffing | 2 of 5 | 1.5 | +0.5 vs chain |
| Quality measures | 2 of 5 | 2.0 | ≈ chain avg |
The other 3 homes this chain runs (chain average 2.5★, 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 |
|---|---|---|---|---|
| PCM HOLDINGS I, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/18/2025 |
| ST. GEORGE LLC | Organization | DIRECT OWNERSHIP INTEREST | — | since 07/18/2025 |
| PCM INTERMEDIATE HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 07/18/2025 |
| PCM REHAB ENTERPRISES LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 07/18/2025 |
| PHOENIX SNF HOLDINGS, LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 07/18/2025 |
| PTM 2018 FAMILY TRUST | Organization | INDIRECT OWNERSHIP INTEREST | — | since 07/18/2025 |
| MITCHELL, PATRICK | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | — | since 10/01/2020 |
| JOSEPH, ERNEST | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/06/2025 |
| NNADI, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2024 |
| HOLLEMAN, EMILY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/12/2026 |
| MITCHELL, KELLY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 02/12/2026 |
| ST. JOSEPH HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 02/12/2026 |
CMS files one row per role, so the 15 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
7 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 86% 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 $709K 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
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 195505. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, 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.