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The Woodleigh of Baton Rouge

14333 Old Hammond Hwy., Baton Rouge, LA 70816 · For profit - Limited Liability company · 120 certified beds · (225) 272-1401 Medicare & Medicaid certified

Call the home — (225) 272-1401 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Sep 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$10,748 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,748 in federal fines (most recent 2024-05-30)

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2001 Millerville Rd · (225) 272-3529 · Call to confirm hours
Pharmacy
Rite Aid0.2 mi
1029 Millerville Rd · (225) 275-6461 · Call to confirm hours
Grocery
13555 Old Hammond Hwy · (225) 272-4876 · Call to confirm hours
Park
399 Lafitte Dr · (225) 272-9200 · Typically dawn to dusk
Place of worship

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 1 of 5
Short-stay residentsrehab / post-hospital 4 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 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.7%17.8%15.4%worse
Long-stay residents who lose too much weight6.9%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%1.2%0.9%better
Long-stay residents with a urinary tract infection7.5%2.1%2.0%worse
Long-stay residents with depressive symptoms0.0%2.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened18.2%17.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication10.2%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine98.8%94.9%95.3%typical
Long-stay residents with pressure ulcers4.6%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control15.7%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table29.3%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.9%3.1%1.4%worse than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine84.7%76.3%79.4%typical
Short-stay residents rehospitalized after admission19.1%28.0%22.6%better
Short-stay residents with an outpatient ER visit14.9%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.442.561.67worse
Long-stay outpatient ER visits per 1,000 resident days1.362.741.80better

* 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.

63.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

63.9%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF63.9%CMS range 52.6–78.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.6–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge63.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge16.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay2.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.6–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.26
RN hours/ resident / day
1.07
LPN hours/ resident / day
2.53
Aide hours/ resident / day
3.86
Total nurse hours/ resident / day
0.13
RN hoursweekends
48.2%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 100.5 residents a day — about 84% occupied, or roughly 20 beds typically open. It usually has some room. 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.42 hrs/resident/day on weekends vs 4.03 on weekdays — 15% thinner on weekends. RN hours go from 0.31 to 0.13 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%.

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

7
deficiencies at the latest standard inspection (2025-06-05)
9
at the previous standard inspection (2024-05-30)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2024-05-30 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure each nurse aide was competent when transferring a resident with the slide board for 1 (#29) of 3 (#29, #61, and #69 ) residents reviewed for falls. This deficient practice resulted in an actual harm for Resident #29, beginning on 04/02/2024 at 4:30 p.m. when S16CNA inappropriately used the slide board during a transfer, which resulted in Resident #29 falling to the floor. On the morning of 04/03/2024, Resident #29 refused care due to severe pain when she moved. On 04/03/2024 at 12:12 p.m., Resident #29 had X-rays in the facility that revealed a Left Femur Fracture. Resident #29 was transferred to the emergency room and found to have a Left Distal Femur Fracture and a Right Displaced fracture that required surgical interventions. Review of the Facility's November 2023 Training Materials revealed the following, in part: Sliding Board Transfer 7. The caregiver should position themselves in front of the patient when performing the transfer, using…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency, within two hours for 1 (#R1) of 5 (#1, #2, #3, #4, and #R1) residents investigated for abuse.Findings: Review of the facility policy titled, Abuse Investigation and Reporting with a revision date of 06/2024 revealed the following, in part:All reports of resident abuse . shall be promptly reported to the local, state and federal agencies .Reporting: 1. All alleged violations involving abuse .will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility; A request was made to review reports submitted to the State Agency since 05/01/2025. On 09/25/2025 at 10:35 a.m., an interview was conducted with S2DON. S2DON confirmed there had been no reports submitted to the State Agency from 05/01/2025 to present. On 09/24/2025 at 10:05 a.m., an interview was conducted with S3LPN. S3LPN stated S4CNA was reported by a resident's anonymous,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 (#34) of 34 residents reviewed during the initial pool. Findings: Review of the facility's policy titled, Call System, Residents, with a revision date of September 2022, revealed the following, in part: Policy Statement: Residents are provided with a means to call staff for assistance through a communication system which notifies a staff member or a centralized work station. Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff to notify them for assistance from his/her bed, floor, and from toileting/bathing facilities. Review of Resident #34's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Need for Assistance with Personal Care, Left Hand Contracture, and Left Elbow Contracture. Review of Resident #34's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 2 (#67 and #78) of 34 residents reviewed in the initial screening for advance directives. This deficient practice had the potential to affect 103 that resided in the facility. Findings: Resident #67 Review of Resident #67's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #67's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, the resident had a Brief Interview for Mental Status (BIMS) of 12 indicating he was cognitively moderately impaired. Review of Resident #67's physical chart revealed the following documents, in part: LaPost dated [DATE] and signed by Resident's Power of Attorney and Physician which, indicated Resident #67 was a DNR (Do Not Resuscitate). Review of Resident #67's [DATE] Physician Orders revealed: [DATE] Full Code Status. Review of Resident #67's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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 observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were stored safely and were kept locked by leaving medication at the bedside for 1 (#341) of 33 residents observed during the initial screening of residents upon facility entrance. Findings: Review of the facility's policy Medication Labeling and Storage, with a revised date of 02/2024, revealed, in part, the following: Policy Heading The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity, and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes)…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing was properly labeled for 1 (#342) of 5 (#65, #77, #84, #341, and #342) residents reviewed for oxygen therapy. Findings: Review of Resident #342's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Chronic Diastolic Heart Failure, Ischemic Cardiomyopathy, and Asthma. Review of Resident #342's Physician's Orders revealed the following, in part: Start date: 05/29/2025: Oxygen at 2 Liters per nasal cannula, as needed for Chronic Obstructive Pulmonary Disease. On 06/02/2025 at 11:45 a.m., an observation was made of Resident #342's oxygen tubing, which was not labeled with the date. On 06/03/2025 at 9:47 a.m., an observation was made of Resident #342's oxygen tubing, which was not labeled with the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure: 1. An expired medication was not available for use for Resident #54 in 1 (Cart B) of 2 carts (Cart A and Cart B) reviewed; and 2. An opened medication was labeled with an open date and not available for use in 1 (Cart B) of 2 carts (Cart A and Cart B) reviewed. Findings: On 06/02/2025 at 11:15 a.m., an observation was made of Cart B with S6LPN. The following was observed: One medication card containing 21 tablets of Hyoscyamine Sulfate Sublingual 0.125 mg tablets with a discard after date of 02/28/2025 for Resident #54; and One bottle of Vitamin D 10 mcg tablets was opened and not labelled with the open date. On 06/02/2025 at 11:20 a.m., an interview was conducted with S6LPN. She observed the above findings and confirmed the Hyoscyamine Sulfate Sublingual 0.125 mg tablets for Resident #54 were expired and available for use. She also confirmed the bottle of Vitamin D…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster. Findings: On 06/02/2025 at 9:04 a.m., an observation was made of the facility's two outdoor trash dumpsters with S3DM. One of the dumpsters was observed with the door open and a clear plastic bag containing soiled briefs and gloves hanging out of the lid. Scattered trash was observed on the ground around the dumpster including the following: plastic bag, plastic cups, plastic utensils, gloves, one green cloth, empty juice containers, and other unidentifiable paper items. On 06/02/2025 at 9:10 a.m., an interview was conducted with S3DM. She observed and confirmed the above mentioned observations of the dumpster area. She stated the dumpster door should be kept closed and the surrounding area kept free of trash. She stated maintenance was responsible for keeping the dumpster area clean. On 06/02/2025 at 10:00 a.m., an interview was conducted with S4MA. He stated he and S5MS were responsible for keeping the dumpster area clean. He stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 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 S12LPN wore proper Personal Protective Equipment (PPE) while providing urinary catheter care for 1 (#67) of 2 (#13 and #67) residents with indwelling medical devices. Findings: Review of the facility's policy, dated 08/2024, titled Enhanced Barrier Precautions, revealed, in part: Policy Interpretation and Implementation: 2. Enhanced Barrier Precautions (EBP) employ targeted gown and glove use during high contact resident care activities . 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include: g) device care or use (urinary catheter .) Review of Resident #67's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Benign Prostatic Hyperplasia (BPH)…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-26 · tag F0641 — pattern
    Ensure 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 observations, interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the assistance required for eating for 1(#1) of 4 (#1, #2, #3, and #4) sampled residents. Findings: Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Quarterly MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of 03/02/2025, revealed the resident required setup or cleanup assistance for meals. On 03/26/2025 at 12:45 p.m., an observation was conducted of Resident #1 in the dining room. Resident #1 is noted with a bib on with S3CNA was feeding the resident. S9CNA held the cup for Resident #1 and placed the straw next to his lips. On 03/26/2025 at 11:19 a.m., an interview was conducted with S9CNA. She stated Resident #1 returned from the hospital on [DATE] with a sling for his left upper…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-03-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure that a resident that was frequently incontinent was provided services to restore as much normal bowel function as possible for 1 (#1) of 4 (#1, #2, #3 and #4) residents reviewed for Bladder and Bowel Incontinence. Findings: Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: Septic Arthritis Of Left Shoulder, History Of Falling, Need For Assistance With Personal Care, and Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Side. Review of Resident #1's Quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 03/02/2025 revealed the resident was always incontinent of bowel and bladder. Further review revealed Resident #1 was assessed by the facility to have a BIMS of 11, indicating he was moderately cognitively impaired. Review of Resident #1's Care Plan revealed the following, in part: Problem:…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · E2025-03-26 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard 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 Activities of Daily Living (ADL) care was accurately documented for 1 (#1) of 4 (#1, #2, #3 and #4) Residents reviewed for ADL care. Findings: Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Septic Arthritis of Left Shoulder, Need for Assistance with Personal Care, and Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Side. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/2025 revealed a Brief Interview for Mental Status (BIMS) of 11, indicating the resident had moderate cognitive impairment. Further review revealed the resident required limited set up/cleanup for meals. Review of Resident #1's Eating ADL log, dated 03/01/2025-03/24/2025, revealed the following: Eating: Self Performance- How resident eats and drinks Limited Assistance- Resident highly involved in…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-30 · tag F0940 — failed to train staff — widespread
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    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 all licensed nursing and certified nursing assistant staff had documented new hire and annual competency demonstrations for all skills related to their expected roles for 5 out of 5 personnel files reviewed. This had the potential to affect all 89 residents residing in the facility. Findings: Review of S12CNA's personnel file revealed S12CNA's date of hire was 05/21/2024. Further review revealed no documented evidence of any competencies being completed upon hire. Review of S13CNA's personnel file revealed S13CNA's date of hire was 01/22/2024. Further review revealed no documented evidence of any competencies being completed upon hire. Review of S14LPN's personnel file revealed S14LPN's date of hire was 10/08/2021. Further review revealed no documented evidence of any competencies being completed annually. Review of S15LPN's personnel file revealed S15LPN's date of hire was 03/11/2024. Further review revealed no documented evidence of any competencies being completed upon hire. Review of S16CNA's personnel file…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-30 · tag F0641 — pattern
    Ensure 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 resident MDS assessments accurately reflected the resident's status for 2 of 2 (#13 and #18) residents reviewed for PASRR by failing to correctly code the residents PASRR evaluations. Findings: Resident #13 Review of Resident #13's Clinical Record revealed he was admitted on [DATE] with diagnoses which included Major Depressive Disorder, Bipolar Disorder, Persistent Mood Affective Disorder, and Generalized Anxiety Disorder. Further review revealed an approved Level II PASRR. Review of Resident #13's Annual MDS with ARD of 12/21/2023 revealed question A1500, Resident evaluated for PASRR, was answered as no. Resident #18 Review of Resident #18's Clinical Record revealed he was admitted on [DATE] with diagnoses which included Schizoaffective Disorder, and Bipolar Disorder. Further review revealed an approved Level II PASRR. Review of Resident #18's Annual MDS with ARD of 01/04/2024 revealed question A1500, Resident evaluated for PASRR, was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-30 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure nurse staffing data, including resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 90 residents residing in the facility. Findings: On 05/28/24 at 11:55 a.m., an observation was conducted of the daily nursing staff sheet located behind the nurses' station in the medical record room which was restricted to staff only. On 05/28/24 at 12:18 p.m., an interview was conducted with S2DON. She confirmed the daily nursing staff sheet was posted behind the nurses' station and was not accessible for residents or visitors to view.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-30 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 4 (#17, #35, #58, and #69) of 5 (#17, #35, #58, #64, and #69) residents reviewed . Findings: Resident #17 Review of Resident #17's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Generalized Anxiety Disorder, and Insomnia. Review of Resident #17's May 2024 Physician's Orders revealed an order written on 10/30/2023 for Lorazepam 1 mg tablet, one tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date. Review of Resident #17's May 2024 MAR revealed Lorazepam 1 mg tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date. Resident #35 Review of Resident #35'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · tag F0585 — failed to handle grievances — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to make prompt efforts to resolve grievances for 1 (#3) of 2 (#3 and #29) residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #3 reported a missing blanket and clothing to staff. Findings: Review of the facility's policy titled, Grievances/Complaints, Filing with a revision date of 04/2017 revealed the following, in part: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident . Policy Interpretation and Implementation: 1. Any resident .may file a grievance or complaint concerning care . or any other concerns regarding his or her stay at the facility. 8. Upon receipt of a grievance and/or complaint, the designee will review and investigate 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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, observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were administered safely and timely by leaving the medications at the bedside for 1 (#64) of 24 residents observed during the initial screening of residents upon facility entrance. Findings: Review of the facility's policy titled, Medication Administration Policy with a revision date of 04/2019 revealed the following, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Review of Resident #64's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Polyneuropathy, Acquired Absence of Right Leg Above Knee, Acquired Absence of Left Leg Above Knee, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Moderate Protein Calorie Malnutrition, Peripheral Vascular Disease, and Unspecified Pain. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#13) of 2 (#13, and #23) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #13. Findings: Review of the facility's policy titled, Care of Fingernails/Toenails and dated February 2018, revealed the following, in part: General Guidelines 1. Nail care includes daily cleaning and regular trimming. Review of Resident #13's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Non-traumatic Intracerebral Hemorrhage Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus. Review of Resident #13's Quarterly MDS with an ARD of 03/08/2024 revealed Resident #13 had a BIMS of 15, which indicated intact cognition. Further review revealed Resident #13 required moderate assistance for ADLs.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a nutritional supplement for 1 (#3) of 5 (#3, #35, #44, #64 and #79) residents reviewed for nutritional status. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnosis, which included Unspecified Protein-Calorie Malnutrition. Review of Resident #3's MDS with an ARD of 04/05/2024, revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed Resident #3 received a therapeutic diet. Review of Resident #3's current Physician Orders revealed the following, in part: Start date 05/17/2024 House Shake Supplement three times a day related to Unspecified Protein-Calorie Malnutrition; give 1 carton strawberry with all meals. Review of Resident #3's Nutrition Assessment Notes, dated 05/16/2024, revealed, in part, the following: She is a very picky eater . She is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-06 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop 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 implement a comprehensive person-centered care plan for 1 (#88) of 28 residents reviewed in the final sample. The facility failed to provide a psychiatric consult. Findings: Review of the medical record for Resident #88 revealed the resident was admitted to the facility 02/09/2023 and had diagnoses that included Major Depressive Disorder, Anxiety Disorder, and Memory Deficit following Cerebral Vascular Accident. Review of the baseline MDS (Minimum Data Set) for Resident #88 with an ARD (Assessment Reference Date) of 02/13/2023 revealed that resident had a BIMS (Brief Interview for Mental Status) of 99 which indicated the resident was severely cognitive impaired. Review of Physician's Orders for Resident #88 revealed the following, in part: Zoloft 25 mg every day. Review of the Care Plan for Resident #88 revealed the following, in part: Problem: Alteration in behavior, refuses care and medications, combative, socially inappropriate/disruptive behavior,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-06 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards by failing to ensure documentation was accurate and complete for 2(#58 and #88) of 28 resident reviewed in the final sample. Findings: Resident #58 Review of the medical record for Resident #58 revealed the resident was admitted to the facility on [DATE], and had diagnoses which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of Resident #58 Physician's Orders revealed the following, in part: Local Dialysis Center on Mondays, Wednesdays, and Fridays at 10:30 a.m. Review of Resident #58's nurses notes revealed there was no documentation on 03/20/2023 of this resident having diarrhea, or missing dialysis. 04/03/2023 at 12:30 p.m., an interview was conducted with Resident #58's. Representative. She stated on the evening of 03/20/2023, she was informed by S8LPN Resident #58 had…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-04-06 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#54 and #57) of 5 (#4, #12, #47, #54, and #57) residents reviewed for ADL's. The facility failed to comb and shampoo hair for Resident's (#54 and #57). Findings: Review of the facility's policy, Bath, Bed revealed the following, in part: Equipment and Supplies 9. Comb and/or hairbrush Review of the facility's policy, Shampooing Hair revealed the following, in part: Purpose: The purpose of this procedure is to clean the resident's hair and scalp. Equipment and Supplies 5. Resident's personal hair care products After Shampooing: 1. Comb and style the resident's hair. Resident #54 Review of the Medical Record for Resident #54 revealed the resident was admitted to the facility on [DATE], and had diagnoses which included, Morbid Obesity, Congestive Heart Failure, Diabetes Mellitus 2, Major Depressive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-04-06 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards, by failing to maintain on-going communication with the dialysis facility for 1 (#58) of 4 (#33, #46, #58, and #390) residents reviewed for dialysis. Findings: Review of the Clinical Record for Resident #58 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of the current March Physician's Orders for Resident #58 revealed the following, in part: Start date: 03/28/2023 Local Dialysis Center on Mondays, Wednesdays, and Fridays at 10:30 a.m. Review of the Dialysis Communication Binder for Resident #58 from March 2023 to April 2023 revealed no documentation of communication between the facility and the dialysis center for the following dialysis dates: 03/08/2023, 03/10/2023, 03/13/2023,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 interviews and record review, the facility failed to maintain resident's dignity for 1(#72) of 28 residents reviewed during the initial pool process. Findings: Review of Resident #72's Medical Record revealed she was admitted to the facility on [DATE]. Further review revealed diagnoses which included Depression, Femur Fracture, Muscle Wasting, Generalized Muscle Weakness, and Other Abnormalities of Gait and Mobility. Review of Resident #72's MDS with an ARD of 03/17/2023 revealed Resident #72 had a BIMS of 15 which indicated she was cognitively intact. Further review revealed Resident #72 required extensive assistance with bed mobility and ADL's, total dependence for bath, and was always incontinent of bowel/bladder. Review of Resident #72's current Care Plan revealed, in part: Self-Care deficit related to needs assistance with ADL's due to decreased mobility and bilateral numbness to hands. On 04/04/2023 at 9:15 a.m., an interview was conducted with Resident #72. Resident #72 stated S11CNA called her 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    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 maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection by 1 (S13CNA) of 2 (S10CNA and S13CNA) staff members failing to perform hand hygiene during dining service. Findings: Review of the facility's Handwashing/Hand Hygiene policy revealed the following, in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow procedures to help prevent the spread of infections to residents 6. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: b. Before and after direct contact with residents p. Before or after assisting a resident with meals On 04/03/2023 at 11:50 a.m., an observation was made of S13CNA in the dining area. S13CNA pulled her face mask down, rubbed her nose with her right hand, then without sanitizing her hands, received food a lunch tray from 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$10,748 in federal fines across 1 penalty.

  • $10,748 — penalty dated 2024-05-30

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.

Who owns this facility

Owner / managerTypeRoleShareSince
PB HEALTHCARE OPERATIONS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/01/2015
BALL, WILLIAMIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/01/2015
PRICE, MALCOLMIndividual5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/01/2015
STOTT, JOHNIndividualW-2 MANAGING EMPLOYEEsince 12/26/2019
DIVERSIFIED HEALTHCARE, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 11/01/2015

2 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.

$8.8M
Net patient revenuemost recent cost report
-8.2%
Operating marginrevenue minus expenses
$1.2M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 8%Other / private 35%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$306per resident / day
operating cost
$9,291per month
≈ monthly operating cost
$283per day
avg. revenue, all payers

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

What families pay in LA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195472. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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