The Guest House Care Center
10145 Florida Blvd, Baton Rouge, LA 70815 · For profit - Limited Liability company · 104 certified beds · (225) 272-0111 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- 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 recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $33,001 in federal fines (most recent 2024-07-31)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 20% 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 held steady at 1 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 | 20.1% | 17.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.7% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 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 | 3.7% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.4% | 17.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.8% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 13.5% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.5% | 22.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 3.1% | 1.4% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 93.0% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 9.2% | 28.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 13.7% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.62 | 2.56 | 1.67 | typical |
| 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.
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 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | 0.92 | 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 104 beds and averages 93.6 residents a day — about 90% occupied, or roughly 10 beds typically open. It runs fairly full. 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 2.89 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 1.47 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 2.40 hrs/resident/day on weekends vs 3.09 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.22 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 55% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.
- Immediate jeopardy · J2024-07-31 · 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 interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in condition to the resident's physician for 1(#1) of 3 (#1, #2, #3) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on 07/13/2024 at 5:24 a.m., when Resident #1, a resident who at baseline was active and could independently ambulate, complained of pain to the lower extremities, exhibited swelling to the left knee, and was unable to bear weight or ambulate. S3LPN failed to report Resident #1's significant change in status to the medical provider on call immediately. Resident #1 continued to decline in activities of daily living until 07/15/2024 around 8:00 a.m. when an x-ray was ordered and revealed an acute Left proximal femur fracture and Chondral irregularity of the left femoral head, which could indicate AVN. Resident #1 was transferred to the hospital where he underwent Left Hip Hemiarthroplasty on 07/16/2024. 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.
- Immediate jeopardy · J2024-07-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to recognize, monitor, intervene, and document a resident's significant change in condition to avoid delayed treatment for 1(#1) of 3 (#1, #2, and #3) residents reviewed for injuries which required hospitalization. This deficient practice resulted in an Immediate Jeopardy situation on 07/13/2024 at 5:24 a.m., when Resident #1, a cognitively impaired resident who at baseline ambulated independently without pain, was observed by staff to have new onset pain to the lower extremities, swelling to the left knee, and was unable to bear weight or ambulate. Resident #1 continued to exhibit signs of pain, decreased mobility, decline in activities of daily living, limited range of motion as well a new onset incontinence between the dates of 07/13/2024 through 07/15/2024. On 07/15/2024 around 8:00 a.m., an x-ray was ordered 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 · Ecited before2026-06-04 · 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 observations, interviews and record review, the facility failed to protect the resident's right to be free from physical and mental abuse by Resident #86 for 4 (#19, #46, #61, and #63) of 5 residents reviewed for abuse. Findings: Review of the Policy, Abuse- Prevention and Prohibition Policy and Procedure, dated 03/25/2023 revealed the following: Policy: To provide a safe, abuse free environment for all residents. Types of abuse- Abuse is the willful infliction of injury, intimidation with resulting in physical harm, pain or mental anguish. Our policy presumes that abuse of any resident, even a resident in a coma, causes physical harm, pain, or mental anguish. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents regardless of their age, ability to comprehend or disability. Name calling, cursing or yelling at a resident in anger. Physical abuse may include hitting, slapping, pinching, biting, shoving, and kicking. Mental abuse…
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 · E2026-06-04 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 and interviews, the facility failed to ensure a resident received puree food prepared in a form designed to meet individual needs for 1 (#100) of 2 residents reviewed for nutrition. This deficient practice had the potential to affect 10 residents who consume puree food from the facility's kitchen.Findings:Review of Resident #100's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction and Dysphagia. Review of Resident #100's current, physician orders revealed the following, in part:Start Date: 04/03/2026; Pureed texture, Nectar/Mildly Thick ConsistencyReview of Resident #100's current Care Plan revealed the following, in part:Problem: The resident has nutritional problem or potential nutritional problem r/t puree.Interventions: Provide and serve diet as ordered.On 06/01/2026 at 12:08 p.m., an observation was made of Resident #100 eating lunch in the dining room. Observation of her lunch revealed the red beans were noted 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 · D2026-06-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review the facility failed to ensure residents had a clean, and homelike environment for 1 (#72) of 1 Resident's reviewed for Environment. Findings: On 05/31/2026 at 12:27p.m., an observation was conducted of Resident #72's bathroom which revealed the ceiling had splotchy gray colored substance covering approximately 2/3 the ceiling. On 06/01/2026 at 12:00 p.m., a second observation was conducted of Resident #72's bathroom which revealed the ceiling had a splotchy gray colored substance covering approximately 2/3 of the ceiling. On 06/02/2026 at 1:00 p.m., a review of the facility's maintenance log for the previous three months revealed no evidence of Resident #72's bathroom ceiling was reported for maintenance. On 06/02/2026 at1:58 p.m., an interview was conducted with S15MS. S15MS confirmed on 06/01/2026, and 06/02/2026 he was in Resident #72's bathroom fixing her toilet and never noticed the ceiling. He confirmed the staff had not put in a work order for the ceiling, and he did not complete proactive rounds of resident's rooms unless…
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 · D2026-06-04 · 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 report allegations of mental and physical abuse to the State Survey Agency immediately, but no later than 2 hours, for 3 (#19, #61, and #63) of 5 residents reviewed for abuse. The provider failed to ensure staff:Reported allegations of abuse when Resident #86 physically abused Resident #63 on 04/12/2026; and Reported allegations of abuse when Resident #86 physically abused Residents #19 and #61 on 05/07/2026. Findings:Cross Reference F600 Review of the Policy, Abuse- Prevention and Prohibition Policy and Procedure, dated 03/25/2023 revealed the following:Policy: to provide a safe, abuse free environment for all residents. It you suspect verbal, physical or mental abuse of a resident contact the administrator immediately. Types of abuseAbuse is the willful infliction of injury, intimidation with resulting in physical harm, pain or mental anguish. Our policy presumes that abuse of any resident, even a resident in a coma, causes physical harm, pain, or…
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 before2026-06-04 · 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 ensure interventions for dysphagia were implemented as identified on the care plan and in physician orders for 1 (#65) of 2 residents reviewed for tube feeding. Findings: Review of Resident #65's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Alzheimer's Disease, Cerebral Infarction, Dysphagia, and Gastronomy status. Review of Resident #65's Quarterly MDS with an ARD of 12/31/2025 revealed a BIMS of 8, which indicated her cognition was moderately impaired. Review of Resident #65's current, physician orders revealed the following, in part: Start date: 04/01/2025; NPO diet related to Dysphagia following Cerebral Infarction Review of Resident #65's current Care Plan revealed the following, in part:Date initiated: 12/16/2024Problem: The resident requires tube feeding via PEG. Resident is NPO.Interventions: The resident needs assistance with tube feeding. See MD orders for current…
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 before2026-06-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 residents received care, consistent with professional standards of practice to promote prevention and healing of pressure ulcers for 1 (#22) of 1 resident reviewed for pressure ulcers. This deficient practice had the ability to further affect any of the 3 resident's in the facility who were being treated for Pressure Ulcers. Findings: Review of the facility's Policy titled Skin Protocol with effective date 03/13/2026, revealed the following, in part: Purpose: To maintain healthy skin integrity, to prevent skin breakdown, to heal skin breakdown and prevent further skin breakdown. Procedure: 4. Residents will be turned/ repositioned every two hours or as appropriate. Review of Resident #22's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease and Pressure Induced Deep Tissue Damage of Right Heel. Resident #22 received a diagnosis of Pressure Ulcer of Sacral Region…
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 · F2025-04-30 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed hand hygiene and proper glove use for 11 (#3, #14, #20, #26, #30, #33, #39, #54, #61, #65, and #67) of 13 (#3, #4, #14, #20, #26, #30, #33, #39, #54, #61, #65, #67, and #80) resident's observed for incontinence care. Findings: Review of the facility's policy titled, Perineal Care Policy and Procedure with an effective date of 11/17/2015, revealed the following, in part: Purpose: 2. To prevent infection . Procedure: 5. Wash hands. 6. Put on disposable gloves. 13. Female perineal care. 14. Male perineal care. 20. Remove gloves. Wash hands. 21. Replace top bed linen as appropriate. 22. Make resident comfortable and or reposition resident as appropriate. Review of the facility's policy titled, Hand Hygiene Policy and 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 · Ecited before2025-04-30 · 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 implement a person-centered care plan by failing to perform blood sugar monitoring according to sliding scale and monitor the side effects/effectiveness of medications for 4 (#12, #24, #46, and #70) of 4 (#12, #24, #46, and #70) resident's reviewed. Findings: Resident #12 Review of admission Records for Resident #12 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Major Depressive Disorder, and Anxiety. Review of Quarterly MDS, revealed Resident #12 had BIMS 9, indicating cognitive impairment. Review of Plan of Care for Resident #12 dated 02/24/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the doctor. 2. Problem: Resident uses antidepressant medication Interventions: Administer Antidepressant medications as ordered by physician, monitor and document adverse reactions, side effects and effectiveness as…
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 · E2025-04-30 · 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 record reviews and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals to meet the needs of each resident. The facility failed to ensure medications were administered for 4 (#12, #24, #46, and #70) of 4 (#12, #24, #46, and #70) residents reviewed for medication administration. Findings: Resident #12 Review of admission Records for Resident #12 revealed he was admitted to the facility on [DATE] with diagnosis that included, in part: Type 2 Diabetes Mellitus, Hyperlipidemia, and Insomnia. Review of Quarterly MDS (Minimum Data Set), with ARD (Assessment Data Reference) of 01/29/2025 for Resident #12 revealed he had a BIMS of 9, indicating cognitive impairment. Review of Plan of Care for Resident #12 dated 02/24/2025 included, in part: 1. Problem: Resident has Diabetes Mellitus Interventions: Diabetes medications as ordered by the physician. 2. Problem: Resident is on sedative/hypnotic therapy…
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 · D2025-04-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 and interviews the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#54) of 13 (#3, #4, #14, #20, #26, #30, #33, #39, #54, #61, #65, #67, and #80) residents observed for dignity during incontinence care. The facility failed to ensure staff greeted the resident and explained the care to be provided. Findings: Review of the facility's General admission and Financial Agreement, packet dated 01/2023 revealed the following: IX Educational Material & Consents B. Residents Rights - Every resident in this facility has the right to: 12. Be treated courteously, fairly, and with the fullest measure of dignity. Review of Resident #54's Clinical Record revealed he was admitted on [DATE] with diagnoses which included the following in part; Unspecified Dementia without behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, and Cognitive…
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 19 citations
- Potential for harm · D2025-04-30 · 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 review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#93) of 3 (#93, #94, and #95) residents reviewed for closed records. Findings: Review of Resident #93's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 01/28/2025 revealed Resident #93 was discharged to a Short-Term General Hospital. Review of Resident #93's January 2025 Physician's Orders revealed the following, in part: 01/24/2025 Discharge home with Home Health. Review of Resident #93's Nurse's Notes revealed the following, in part: 01/28/2025 at 11:10 a.m. Resident exited the facility via manual wheel chair. En route to group home with medications. On 04/30/2025 at 11:40 a.m., an interview was conducted with S15MDS. She reviewed Resident #93's Nurse's Notes and confirmed he discharged to a group home. She reviewed Resident #93's Discharge MDS with an ARD of 01/28/2025 and confirmed it indicated he discharged to a…
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 before2025-04-30 · 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 activities of daily living (ADLs) received fingernail care to maintain good hygiene for 1 (#198) of 3 (#3, #26, and #198) residents reviewed for ADLs. Findings: Review of the facility's policy dated 08/01/2017 and titled, Bath, Bed Policy and Procedure revealed the following, in part: Procedure: 16. Care of fingernails and toenails are part of the bath. Be certain nails are clean. Review of Resident #198's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Malignant Neoplasm of Brain and Traumatic Hemorrhage of Right Cerebrum Without Loss of Consciousness. Further review of the Clinical Record revealed Resident #198 was dependent on staff for ADLs. Review of Resident #198's Bath Documentation dated April 2025 revealed she was scheduled to receive baths on Tuesdays, Thursdays, and Saturdays. Further review revealed she received a bath on…
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 before2025-04-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 at risk for pressure ulcer development received care consistent with professional standards of practice and based on the comprehensive assessment by failing to float heels while in bed for 1 (#197) of 2 (#8 and #197) residents reviewed with Pressure Ulcers. Findings: Review of the facility's policy dated 11/17/2014 and titled, Pressure Ulcer, Prevention of Policy and Procedure revealed the following, in part: Purpose: To prevent skin breakdown and development of pressure sores. Policy: Pressure Ulcer prevention will be used as ordered and/or as applicable. Procedure: 3. Develop care plan to eliminate or minimize risk factors. d. Pressure relief 7. Use pressure reducing or relieving devices as necessary. Review of Resident #197's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Pressure Ulcer of Sacral Region - Stage 4, Type 2 Diabetes Mellitus without Complications, 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 · D2025-04-30 · 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 observations, record review and interviews, 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: 1. An insulin pen was labeled with an opened date for Resident #82 during an observation of medication administration; 2. Eye Drops were labeled with an opened date on 1(Med Cart b) of 2 (Med Cart a and Med Cart b) medication carts reviewed; and 3. Insulin pens were labeled with an opened date on 1(Med Cart b) of 2 (Med Cart a and Med Cart b) medication carts reviewed. This deficient practice had the potential to affect all of the 98 residents residing in the facility. Findings: On 04/28/2025 at 11:39 a.m., during an observation of medication pass with S17LPN, Resident #82's Novolog FlexPen Subcutaneous Solution Pen was observed to not contain an opened date. On 04/28/2025 at 11:39 a.m., an interview was conducted with S17LPN. S17LPN confirmed Resident #82's Novolog FlexPen Subcutaneous Solution Pen did not have an opened dated and she did not know when…
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 before2025-04-30 · 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 interviews and record review, the facility failed to ensure S16LPN completed and accurately documented interventions on the Medication Administration Record (MAR) for 1 (#94) of 3 (#93, #94, and #95) residents reviewed as closed records. Findings: Review of Resident #94's clinical record revealed the resident was re-admitted to the facility on [DATE] and had diagnoses which included Acute Respiratory Failure with Hypercapnia, Anxiety Disorder, Hypertensive Heart Disease without Heart Failure, and Amyotrophic Lateral Sclerosis. Review of Resident # 94's MAR dated February 2025 revealed the following, in part: Catheter - document the amount of urine output every 8 hours total every shift - No documentation for the day shift on 02/22/2025; Catheter - urine clarity . every shift - No documentation for the day shift on 02/22/2025; Catheter - urine color . every shift - No documentation for the day shift on 02/22/2025; Catheter - urine odor . every shift - No documentation for the day shift on 02/22/2025;…
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 · D2025-04-30 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 there was a functioning call system to allow residents to call for staff assistance for 1 (#26) of 5 (#1, #14, #26, #79, and #197) residents reviewed for environment. This deficient practice had the potential to affect any of the 98 residents residing in the facility who utilized the call light system. Findings: Review of the facility's policy titled, Resident Call Light System Policy and Procedure with an effective date of 09/14/2022, revealed the following, in part: Purpose: 1. To provide a communication system with audible or visual signals to allow residents to call for staff assistance from their bedsides . The communication system should relay the call directly to a centralized staff work area. 3. To assure call system is in proper working order. Review of the facility's Daily Maintenance Log dated April 2025 revealed the following, in part: Date of Issue: 04/27/2025, Location: Resident #26's room, Maintenance Issue: Call…
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 before2025-01-07 · 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 record reviews, observation, and interviews the facility failed to develop and implement a comprehensive person-centered care plan which met the needs of 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed. The facility failed to: 1. Ensure S2ADON followed physician's orders for Resident #2 whom was ordered wheel chair brake extenders; and 2. Ensure Resident #3's care plan was comprehensive and individualized for activities of daily living (ADLs) dependency deficits. Findings: Review of the facility's policy titled, Care Plan Policy and Procedure, dated 05/22/2017 revealed the following, in part: Purpose: The comprehensive plan of care is an interdisciplinary tool used to communicate and address care issues that are relevant to the resident's individual needs. Policy: A comprehensive plan of care will be used to communicate and address care issues that are relevant to the resident's individual needs. 1. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE], 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 · D2025-01-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions after each fall for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for falls. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Fractured Right Femur, Dementia, Pain, and Insomnia. Review of Resident #3's Nurse's Note dated 12/31/2024 revealed, in part, the following: Nurse called to common lounge area by ward clerk stating resident fell as I entered the area. Resident noted sitting half on wheelchair foot rest with right leg hanging over right foot rest. Resident was seated on lift pad and slid out of wheelchair with some of the pad behind her. Review of the facility's Incident Report dated 12/31/2024 revealed, in part the following: Resident #3 had an unwitnessed fall in lounge. Review of Resident #3's Care Plan revealed it was not revised to include interventions for falls after…
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 · E2024-09-10 · tag F0658 — failed to meet professional standards of care — patternEnsure 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 record review and interviews, the facility failed to ensure services were provided to meet quality professional standards for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for pain medication administration. The facility failed to ensure Resident #1's Oxycodone was documented in the MAR (Medication Administration Record) at the time of administration. Findings: Review of the facility's policy titled, Medication Administration with an effective date of 08/27/2018, revealed the following, in part: Purpose: To define responsibility and delineate processes for safe administration of medications by nursing personnel. Procedure: g. Administer the medication as ordered and document the administration .in the electronic medication administration record as appropriate. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Other Chronic Pain, Opioid Use, Peripheral Vascular Disease, Acquired Absence of Right Leg, Above Knee, and Generalized Abdominal Pain.…
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 · F2024-04-18 · tag F0578 — failed to honor advance directives / code status — widespreadHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 advanced directive was honored for 1 (#1) of 3 ( #1, #2, and #3) residents reviewed for advanced directives. Findings: Review of the facility's policy and procedure titled, Cardiopulmonary Resuscitation (CPR) read in part: Procedure: 1) Assess the resident to determine if he/she is unconscious. While checking for responsiveness, check to see if the patient is apneic or only gasping, assume that he/she is in cardiac arrest. 2) Delegate a specific individual to check the resident's advance medical directive, orders and care plan for CPR or no CPR order; have individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. 3) If CPR is not elected on resident's advance medical directives, follow advance medical directives and stay with resident as appropriate until emergency medical personnel (EMT, Paramedics, etc.) arrive. Review of Resident #1's Clinical…
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 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 interviews and record review, the facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed. The facility failed to ensure nursing staff documented on Resident #1's Medication Administration Record accurately. Findings: Review of the Clinical Record revealed Resident #1 was admitted to the facility on [DATE] with the diagnosis which included Major Depressive Disorder. Review of the current Physician Orders for Resident #1 revealed the following, in part: Start date: 11/23/2023 Cymbalta 60mg capsule-one capsule by mouth once a day-targeted behavior: Depressed Mood. Review of the April 2024 MAR for Resident #1 revealed the following on 8:00 a.m. dose of Cymbalta 60mg: 04/01/2024- Sadness-Present- Signed: S2LPN 04/02/2024- Sadness-Present- Signed: S2LPN 04/03/2024- Sadness-Present- Signed: S2LPN 04/04/2024- Sadness-Present- Signed: S2LPN 04/06/2024- Sadness-Present- Signed:…
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 before2024-04-11 · 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 reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 2 (#75 and #88) of 5 (#28, #34, #67, #75, and #88) residents reviewed for ADLs. The facility failed to ensure Resident #75 and Resident #88 received incontinence care timely. Findings: Resident #75 Review of Resident #75's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Muscle Wasting and Atrophy and Unspecified Dementia. Review of Resident #75's current Care Plan revealed the following: Problem: I am incontinent of bowel. Staff provides perineal care every two hours and as needed. Problem: I am incontinent of urine. Staff provides perineal care every two hours as needed. Review of Resident #75's Yearly MDS with an ARD of 02/07/2024 revealed a BIMS of 3, which indicated severe cognitive impairment. Further review revealed she was always incontinent 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 · E2024-04-11 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 ensure residents were assessed for risk of entrapment from bedrails and obtain informed consent for bed rails prior to installation for 1 (#41) of 2 (#41 and #49) residents identified for having side rails in use. Findings: Review of the facility's policy titled Side Rail Policy and Procedure, effective 11/25/2014, revealed the following, in part: Policy: We use side rails as appropriate to resident need in creating better bed mobility and positioning, as ordered by physician. Procedure: 1. Obtain . consent for use of side rails. Resident #41 Review of Resident #41's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Other Specified Extrapyramidal and Movement Disorders, History of Falling, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbances, Generalized Muscle Weakness, and Unspecified Lack of Coordination. Review of Resident #41's MDS with an ARD of 03/20/2024…
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 · E2024-04-11 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure each nurse aide was able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 (#28 and #34) of 5 (#28, #34, #67, #75, and #88) residents reviewed for ADLs. Findings: Review of the Certified Nursing Assistant (CNA) Orientation Proficiency Form, dated effective 12/4/2017, revealed the following, in part: Print out each policy pertaining to each topic that is applicable in policy tech and ensure the employee reviews the policy. Further review revealed the following topics, in part: Scheduled Care Monitor: Documentation of ADLs, how to code ADLs, how to use Kiosk, scheduled care and unscheduled care, Keeping residents dry (changing gown, diaper and linens), Perineal Care, Transferring Residents (two person assist, Hoyer lift, stand up life safety with transfers) and AM/PM Care. Resident #28 Review of 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 · E2024-04-11 · 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 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 S5CNA was competent in skills and techniques for 2 (#28 and #34) of 5 (#28, #34, #67, #75, and #88) residents reviewed for ADLs. Findings: Resident #28 Review of Resident #28's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Hemiplegia Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #28's current Care Plan revealed the following, in part: Problem: I require staff assistance with ADLs. Interventions: I require assistance with transfers; and Transfer me on my strong side 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 · D2024-04-11 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 promote and facilitate resident self-determination through support of the resident's choice of when to get out bed for 1 (#28) of 4 (#1, #28, #53, and #89) residents reviewed for resident rights. Findings: Review of Resident #28's Clinical record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Hemiplegia Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #28's MDS with and ARD of 03/20/2024 revealed a BIMS of 10, which indicated moderate cognitive impairment. Further review revealed she required extensive assistance with transfers. Review of Resident #28's current Care Plan revealed the following, in part: Problem: I require staff assistance with ADLs. Interventions: I require assistance with transfers; and Transfer me on my strong side An interview was conducted with S5CNA on 04/11/2024 at 2:23 p.m.…
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 · D2024-04-11 · tag F0576 — isolatedEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review the facility failed to ensure residents received mail on Saturdays for 4 (#6, #51, #53 and #66) of 17 residents reviewed for mail during resident council. This deficient practice had the potential to affect 92 residents residing in the facility. Findings: Review of the facility's General admission & Financial Agreement, reviewed on 04/09/2024, dated 01/2023, revealed, in part: Mail: The resident has the right to privacy in written communications including the right to: a. Send and promptly receive mail that is unopened. During the resident council meeting on 04/08/2024 at 2:00 p.m. Resident #6, Resident #51, Resident #53 and Resident #66 all stated mail was not delivered on Saturdays and was held until the following Monday. An interview was conducted with S5AD on 04/08/2024 at 2:10 p.m. She stated she and S4FIN were responsible for distributing resident's mail. She verbalized she works Monday through Friday and there was no one present to deliver mail to residents on Saturdays. She confirmed all mail and packages delivered to the facility 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 · D2024-04-11 · tag F0585 — failed to handle grievances — isolatedHonor 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 for 1 (#11) of 2 (#11 and #67) residents reviewed for grievances. Findings: Review of grievance policy titled, Grievance Policy and Procedure; effective 10/10/2022, reviewed on 04/11/2024; revealed the following: Purpose: to support each resident, family member to voice grievances (e.g . lost clothing ) and to assure that after receiving a grievance the facility actively seeks resolution and keeps the individual filing the grievance appropriately apprised of its progress toward resolution. Policy: The resident has the right to and the facility must make prompt efforts to resolve grievances. 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…
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 before2023-08-30 · 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 interview and record review, the facility failed to ensure a resident's right to be free from sexual abuse for 1(#1) of 9 (#1, #2, #4, #5, R1, R2, R3, R4, and R5) sampled residents reviewed for abuse. The facility failed to protect Resident #1 from being inappropriately touched and kissed by Resident #2. 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. Findings: A review of the facility's policy titled, Abuse-Prevention and Prohibition Policy and Procedure revealed the following, in part: Purpose: Each Resident has the right to be free from abuse. No one shall abuse a resident. This policy applies to other residents . Policy: 2. Sexual Abuse is non-consensual sexual contact of any type with a resident A review of the facility's Self-Reported Incident Report, dated 08/02/2023, revealed the following, in part: Victim: Resident #1 Accused: Resident #2 Allegations: Sexual Abuse Resident #1…
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.
“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
$33,001 in federal fines across 3 penalties.
- $13,627 — penalty dated 2024-07-31
- $15,646 — penalty dated 2024-07-31
- $3,728 — penalty dated 2023-08-30
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 | 1 of 5 | 1.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 1 of 5 | 1.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 1.9 | +1.1 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 |
|---|---|---|---|---|
| QUIRK, CYNTHIA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 02/13/2002 |
| QUIRK, GENE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 02/13/2002 |
| BURTON, ROBERT | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2018 |
| QUIRK, SCOTT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/13/2002 |
| PLANTATION MANAGEMENT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/13/2002 |
| DELATTE, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/21/2010 |
CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 77% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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 195537. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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.