Southwind Nursing & Rehabilitation Center
804 Crowley-Rayne Hwy, Crowley, LA 70526 · Non profit - Corporation · 112 certified beds · (337) 783-2740 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- 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 1 serious finding 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 (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.4% | 17.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.2% | 5.2% | 5.4% | worse |
| 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 | 1.6% | 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 | 4.5% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 12.3% | 17.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.7% | 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 | 3.6% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.5% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.6% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.9% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 92.1% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.4% | 28.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.5% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.30 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.03 | 2.74 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.1% 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 52 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.7%CMS range 45.3–63.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 7.2–12.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 36.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 44.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 4.2–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| 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 112 beds and averages 101.4 residents a day — about 91% occupied, or roughly 11 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.19 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 2.99 hrs/resident/day on weekends vs 4.03 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.23 to 0.09 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. 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.
29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2023-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and observation the facility failed to ensure residents remain free from accidents and hazards for 1(#64) out of 4 (#16, #18, #45, #64) residents investigated for falls by failing to secure Resident #64's wheel chair during transportation. This deficient practice resulted in a harm on 08/02/2023 at 4:00 p.m., when Resident #64's wheelchair was not properly secured in the facility's transportation van. The resident's wheelchair flipped backwards and caused the resident to hit her head. Resident #64 was sent to the hospital for evaluation and was diagnosed with a new small acute subdural hemorrhage. Upon completion of evaluation, Resident #64 was transferred from a local hospital to another hospital for a higher level of care. She was hospitalized from [DATE] and returned back to the facility on [DATE]. 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:…
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 before2025-09-17 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 a resident was safe to perform self-administration of medication for 1 (#25) of 54 sampled residents This deficient practice had the potential to affect a census of 110 Residents. Record review revealed Resident #25 was admitted to the facility on [DATE]. The resident had a BIMS (Brief Interview for Mental Status) Score was 10 meaning she had moderate cognitive impairment. Record review of Resident #25's medical record revealed the resident did not have an assessment to self-administer her medications.On 09/15/2025 at 9:03 a.m., an observation in Resident #25's room revealed a bottle of Advanced Eye Relief (Over the counter) eye lubricant on her bedside table. Resident #25 stated she used the medication to relieve her dry eyes. She stated she asked her daughter to bring her this medication. On 09/16/2025 at 10:08 a.m., an observation in Resident #25's room with S6LPN (Licensed Practical Nurse) revealed that the resident had 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.
- Potential for harm · Dcited before2025-09-17 · 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 and interview, the facility failed to ensure a safe, clean, and homelike environment for 3 (#79, #88, and #90) out of 5 (#8, #33,#79, #88, and #90) residents investigated for environment. The facility failed to ensure: 1. Wheelchairs were clean for Residents #79 and Resident #90; and 2. The toilet support arm was in good working condition for Resident #88. Findings: A review of the facility's policy titled, Homelike Environment Policy and Procedure, with a last reviewed date of 06/12/2025, read in part Procedure: 1. Physical Environment a. Resident Rooms, ii. Maintain a clean and safe living space according to resident wishes. Resident #79 On 09/15/2025 at 10:15 am, an interview and observation of Resident #79's wheelchair was made with S14LPN (Licensed Practical Nurse). Her wheelchair was observed to have a large amount of dust and grime on the spokes of the wheels and on the bottom bars. S14LPN stated that the wheelchair 100 percent needed to be cleaned. Resident #90 On 09/15/2025 at 10:20 a.m., an interview and observation of Resident #79's wheelchair was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-17 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 discharge summary was completed for a resident with a planned discharge to the community for 1 (#112) of 3 (#9, #111, and #112) closed records reviewed.Findings:On 09/16/2025, a review of the facility's policy titled, Discharge Summary Policy and Procedure with a revision date of 05/22/2025, read in part, Purpose: To document the resident status throughout the resident stay and on the resident discharge. Policy: Discharge Summary is to be completed within a timely manner of discharge. Procedure.2. Discharge Summary will be completed within a timely manner of discharge. 3. The discharge summary will include the following: 1. Type of discharge 2. A recapitulation of the resident's stay 3. A final status of the resident's status at the time of discharge 4. Reconciliation of medications via discharge instructions form when applicable. 5. Post discharge plan of care.Resident #112 was admitted to the facility on [DATE] with diagnoses that included,…
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 · D2025-09-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure a resident received a nutritional supplement as ordered for 1 resident (#84) of 9 (#1, #11, #23, #30, #55, #72, #84, #89 and #94) residents investigated for dining.Findings: Resident #84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to unspecified protein-calorie malnutrition and ataxia following cerebral infarction.A review of Resident #84's current Order Summary Report revealed a physician's order with a start date of 03/28/2025 that read Mighty Shake (nutritional supplement) with meals for weight loss related to unspecified protein calorie malnutrition, add ice cream. A review of Resident #84's meal card revealed Personal Menu Item: 4 fluid ounce Mighty Shake. On 09/17/2025 at 7:30 a.m., an observation was made of Resident #84 in the dining room with his breakfast tray and meal card in front of him. No Mighty shake supplement was observed. On 09/17/2025 at 8:00 a.m., an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that residents were provided respiratory care, consistent with professional standards of care for 2 (#61 and $113) of 5 (#8, #49, #61, #108 and #113) residents investigated for respiratory care. The facility failed to:1. Change an empty humidifier bottle for Resident #61, and2. Label oxygen equipment for Resident #113 Findings: On 09/17/2025, a review of the facility's policy titled, Oxygen Administration Policy and Procedure with a last reviewed date of 03/15/2025, read in part, Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissue. Procedure.5. Prefilled, sealed, disposable humidifiers may be changed per facility procedure, weekly and as needed.g. Label humidifier with date and time opened .9. At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier. Resident #61: Resident #61 was admitted to the facility on [DATE], with diagnoses…
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 · D2025-09-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 the medication error rate was less than 5%. A total of 27 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 7.41%. The facility failed to ensure: 1. Resident #8 was administered the correct medication for Guaifenesin ER (Extended Release) as ordered, and 2. Resident #47 was administered Cyanocobalamin as ordered.Findings: Resident #8Review of Resident #8's health record revealed that he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to quadriplegia, encounter for attention to tracheostomy, and cough, unspecified. Review of Resident #8's Order Summary Report, revealed a physician's order for Guaifenesin ER Tablet Extended Release 12 hour 600 mg (milligrams), give 1 tablet via PEG (percutaneous endoscopic gastrostomy) tube two times a day for cough, related to cough, unspecified with a start date of 02/20/2025. On 09/16/2025 at 4:00 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 · Dcited before2025-09-17 · 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 and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles as evidenced by failing to: 1. Discard an expired medication in 1 (Med Cart A ) of 2 (Med Cart A and Med Cart B) medication carts inspected for medication storage; 2. Discard loose tablets in 2 (Med Cart A and Med Cart B) of 2 (Med Cart A and Med Cart B); and3. Properly secure medications for Med Cart C at all times during medication pass.Findings: A review of the facility's policy titled, Medication Storage Policy and Procedure with a last review date of 08/12/2025, read in part, Purpose: To properly secure medications and biologicals according to CMS guidelines. Policy: 1. Medications and biologicals will be maintained in a secured location only accessible to designated staff. Procedure: 2. Medications carts will be checked weekly for expired medications, loose pills. a. Any expired medications or loose pills will be destroyed according to the standard guidelines. On 09/17/2025 at 9:05 a.m., an…
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 before2025-09-17 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure the provided diet met the nutritional needs of each resident as evidenced by failing to ensure dietary staff used the appropriate portion size serving utensils when serving the lunch meal. Review of the facility's policy titled Accuracy and Quality of Tray Line Service Policy and Procedure, with a last reviewed date of 05/14/2025, read in part. 7. Each meal will be checked for: Proper portion sizes. On 09/15/2025 at 12:23 p.m., an observation was made of the food service line during lunch. The red beans and sausage were being served with a green handle spoodle, which was 4 ounces. The okra and tomatoes were being served with a green handle scoop, which equaled to 1/3 cup. A review of the Diet Extensions: Monday, Week 3,. 2025 for a regular diet revealed beans and sausage were to be served with a 6 ounce spoodle and the okra and tomatoes were to be served with a 4 ounce spoodle. On 09/15/2025 at 12:28 p.m., an observation of the serving utensils was conducted with S16DM (Dietary Manager). She stated…
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 · D2025-09-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices for 1 (Resident #49) out of 54 sampled residents by failing to ensure the resident's EMAR (Electronic Medication Administration Record) was accurately documented.Findings:A review of the facility's policy titled Charting and Documentation Policy and Procedure with a last review date of 02/18/2025, revealed in part, Purpose: The purpose of charting and documentation is to provide the following: a complete account to the resident's care, treatment, response to the care, signs, symptoms, and progress of resident care.A review of Resident #49's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, wheezing, coughing, and shortness of breath.A review of Resident #49's clinical physician orders revealed an active physician's order, with a start date of 03/21/2025,…
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 · D2025-02-18 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure a resident taking an anticoagulant medication was monitored for bruising and/or bleeding for 1 (#1) out of 3 (#1, #2 and #3) residents reviewed for unnecessary medications. Findings: On 02/18/2025, a review of the facility's undated policy entitled, Anticoagulant Therapy Bruising Bleeding Policy and Procedure revealed, in part, Purpose: 1. To monitor for possible bruising and/or bleeding due to anticoagulant medication therapy. Policy: It is the policy of this facility to have a special requirement or monitoring tool in place to monitor for possible side effects of anticoagulant therapy such as bruising and/or bleeding. Procedure: 1. Implement supplementary documentation or monitoring tool upon implementation of anticoagulant therapy. 2. The nurse is to assess the resident for any possible side effects such as bruising and/or bleeding daily or as needed. Review of Resident #1's admission Record revealed the resident was admitted to 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.
Show the remaining 18 citations
- Potential for harm · D2024-12-26 · 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 record reviews and interviews, the facility failed to ensure a resident was free from verbal and physical abuse for 1 (Resident #R1) out of 4 (Resident #1, Resident #2, Resident #3, and Resident #R1) sampled residents. Findings: On 12/26/2024, a review of the facility's policy titled, Abuse and Neglect Policy and Procedure with a last revision date of 12/19/2024, read in part: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse may include but…
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 · D2024-12-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to ensure an allegation of physical and verbal abuse was reported to the state survey agency no later than 2 hours after the allegation was made for 1 (Resident #R1) out of 4 (#1, #2, #3 and #R1) residents investigated for abuse. Findings: On 12/26/2024, a review of the facility's policy titled, Abuse and Neglect Policy and Procedure with a last revision date of 12/19/2024, read in part: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless…
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 · E2024-10-16 · tag F0644 — patternCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident identified with a qualified mental disorder was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2(#6, and #76) of 5 (#6, #8, #66, #76, and #81) residents sampled for PASARR, out of a total sample of 34 residents. Findings: On 10/16/2024, a review of the facility's policy titled, Pre-admission Screening and Resident Review, reviewed date of 07/05/2024, read in part, . The facility is to review resident diagnosis and medications upon admission and throughout the resident stay to determine if a Level II request for resident review is to be completed. Resident #6 A review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Depression, and Unspecified Psychosis. Further review of the resident's medical record revealed she was diagnosed 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 · E2024-10-16 · 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
Based on observation and interview, the facility failed to ensure food was prepared and served in a form to meet individual needs for residents who received pureed diets as evidenced by: 1. Failing to ensure food items were pureed to the appropriate consistency; 2. failing to ensure rice was pureed according to recipe, and 3. failing to ensure regular textured beans and sausage were not placed on Resident #33's meal tray. This deficient practice had the potential to effect the 7 residents who received pureed diets. Findings: Review of the facility's policy titled Accuracy and Quality of Tray Line Service Policy and Procedure, with a last reviewed date of 05/09/2024, read in part: 5. Staff will refer to the meal identification (ID) card/ticket for food dislikes, allergies, and other details and substitute appropriately for those items .7. Each meal will be checked for: Accuracy of following the therapeutic diet extension. On 10/14/2024 at 10:17 a.m., an observation was made of S10Cook puree parboiled rice for the 7 residents who received pureed diets. S10Cook added 5 and 3/4 cup 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 · D2024-10-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to provide reasonable accommodations of the resident's needs by failing to ensure the call bell in the resident's room was in reach for 1 (#88) resident. The deficient practice had the potential to effect a census of 101. Findings: Review of facility's policy titled Call lights-use of, with a review date of 04/06/2024, read in part, Purpose: to provide the resident with a call light to notify staff to meet the need of the resident. Procedure: 10. Be sure all call lights are placed in reach. Resident #88 was admitted to the facility on [DATE] with diagnoses including: Dysphagia, Shortness Of Breath, Protein-Calorie Malnutrition, Major Depressive Disorder, Anxiety, Dependent on Dialysis, Cervical Disc Disorder at C4 (Cervical) - C5 with Myelopathy, Fracture at 1st Lumbar Vertebra, Encephalopathy and Pain. Review of Resident #88's Quarterly MDS (Minimum Data Set) dated 07/18/2024 revealed the resident had a BIMS (Brief Interview of Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure all areas or equipment were in good repair as evidenced by failing to ensure a resident's toilet was secured to the floor for 1 (#305) out of 8 (#13, #53, #61, #69, #83, #88, #100, #305) residents investigated for environment. Findings: On 10/16/2024 a review of the facility's policy titled Preventive Maintenance of Resident Equipment with a review date of 4/06/2024 was done. The policy read in part, Purpose: To provide a safe environment for residents and to meet safety guidelines. Policy: It is the job of all staff to identify areas of concern regarding the maintenance of resident equipment and building. Procedure: Preventive maintenance will occur throughout the year. Review of Resident #305's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Shortness of Breath, Bipolar Disorder, Hypertensive Heart Disease Without Heart Failure and Anxiety.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-16 · 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 observation, interviews, and record reviews, the facility failed to develop and implement a person centered care plan for 1 (#100) out of 34 sampled residents, by failing to ensure Resident #100 was care planned for repeatedly pulling her call bell station off the wall. The facility's census was 101. Findings: On 10/16/2024, a review of the facility's policy titled Care Plan Policy and Procedure with a review date of 04/08/2024, revealed in part, Purpose: To provide a comprehensive person-centered plan of care addressing resident's needs, strengths, goals and approaches. Policy: each resident's care plan will remain current and inform staff of resident's needs, strengths, goals and approaches . A review of Resident #100's medical records revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Diabetes and Gastroesophageal Reflux Disease. Further review of the recent Quarterly Set (MDS) dated [DATE], revealed the resident had a BIMS (Brief Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 1 (Cart #4) of 2 (Cart #1, #4) medication carts observed. The facility had a total of four medication carts. Findings: Review of the facility's policy on 10/16/2024 titled Medication Storage Policy and Procedure dated 06/18/2024 read, in part, Purpose: To properly secure medications and biologicals according to CMS (Centers for Medicare & Medicaid Services) guidelines. Procedure: 2. Medication carts will be checked weekly for expired medications, loose pills, cleanliness and compliance with storage guidelines. a. Any expired medications or loose pills will be destroyed according to the standard guidelines. On 10/16/2024 at 11:08 a.m., Cart #4 was inspected with S9LPN (Licensed Practical Nurse). Two yellow oblong pills were observed loose on the bottom of the second drawer on the left side of the cart, one white oblong pill and a half of a white pill were observed loose on the bottom of the second to last drawer 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 · Dcited before2024-10-16 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to ensure the provided diet met the nutritional needs of each resident as evidenced by failing to ensure dietary staff provided the appropriate portion sizes according to the recipe for 2 (#33, #97) out of 7 residents who received pureed meals. Findings: Review of the facility's policy titled Accuracy and Quality of Tray Line Service Policy and Procedure, with a last reviewed date of 05/09/2024, read in part: 7. Each meal will be checked for: .Proper portion sizes. On 10/14/2024 at 11:40 a.m., an observation was made of the food service line during lunch. Pureed food items (rice, turnip greens, beans and sausage, cornbread) were being served with a 1/2 cup scoop. Review of the recipe and diet spread sheet revealed pureed beans and sausage were to be served with a 3/4 cup or 6 oz (ounce) spoodle. S10Cook stated that she was instructed to serve all pureed food items with a half cup scoop. S8DM (Dietary Manager) was asked how the staff knew which serving scoops to use, and she stated the staff should have…
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 · D2024-06-11 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 record reviews and interviews, the facility failed to obtain the recertification of terminal illness for 3 (Resident #1, #2, and #3) out of 6 (Resident #1, #2, #3, #R1, #R2, and #R3) sampled residents reviewed for hospice. Findings: On 06/11/2024, a review of the facility's agreement with the Contracted Hospice Agency dated 12/21/2022 read in the part, the following V. Records (a) Nursing facility . shall prepare and maintain complete and detailed clinicals records . Each clinical record shall completely, promptly and accurately documents all services provided to, and events concerning each Residential Hospice Patient . Resident #1 Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Senile Degeneration of Brain and Encounter for Palliative Care. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 03/19/2024 revealed the Brief Interview for Mental Status (BIMS) of 3, indicating her cognition was severely…
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 · D2024-05-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that a resident's physician and resident representative (RP) were immediately notified of a change in the resident's condition for 1(#1) of 3 (#1, #2, and #3) sampled residents by failing to notify the physician and RP that the resident had nausea and refused to take her medications in two days. Findings: On 05/07/2024, a review of the facility's undated policy titled Medication Administration - General Guidelines .Policy: Medications are administered in accordance with good nursing principles and practices .Refusals of Medication b. Medication refusal must be reported to the prescriber . Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Constipation, Nausea with Vomiting, Dementia, Overactive Bladder, Muscle Weakness, Protein Calorie Malnutrition, and Atrial Flutter. A review of the resident's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/30/2024 revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-20 · 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 records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#34) of 38 sampled residents. This was evidenced when: 1. Facility staff failed to apply compression stockings. 2. Facility staff failed to place a hand roll in Resident #34's left hand to prevent further contractures; and 3. Failed to apply pneumatic compression device to left leg daily for one hour a day. Findings: Review of Resident #34's electronic clinical record revealed an admit date of 07/08/2013 with diagnoses that included Hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, Age related osteoporosis, Contracture left elbow, Glaucoma, Dementia without behavioral disturbance, Peripheral vascular disease, and Contracture left hand. Review of physician orders dated September 2023 revealed the following orders: Calf compression stocking to left lower extremity-apply in the morning and remove at night .Hand roll to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-20 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 2 (Cart A, B) of 2 (Cart A, B) medication carts observed. The facility had a census of 105 residents. Findings: Review of the facility's policy titled Medication Storage Policy and Procedure read, in part, Purpose: To properly secure medications and biologicals according to CMS (Centers for Medicare & Medicaid Services) guidelines. Procedure: 1. Medication carts will be checked weekly for expired medications, loose pills, cleanliness and compliance with storage guidelines. a. Any expired medications or loose pills will be destroyed according to the standard guidelines. On 09/20/2023 at 9:23 a.m., Cart A was inspected with S14IPQA(Infection Preventionist, Quality Assurance) and S2DON (Director of Nursing). 1 white oblong pill, 2 small oblong white pills, 1 round white pill, 1/2 of a white pill, and 1 yellow oblong pill were observed loose on the bottom of the first and second drawer. The pills were observed underneath…
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 before2023-09-20 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess 1 (#59) resident investigated to self -administer medication out of a finalized sample of 38 residents. The right to self-administer medications is the responsibility of the interdisciplinary team to assess and determine that this practice is clinically appropriate. Findings: Review of the facility's policy titled, Medications-Self Administration Policy and Procedure, revealed in part: If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process, A. Complete Self Administration Assessment . Resident #59 was admitted to the facility on [DATE] with diagnoses that included, Lack of Coordination, Generalized Muscle Weakness, Allergic Rhinitis, and Essential Hypertension. Review of Resident #59's September 2023 Medication Administration Record (MAR) revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 2 (#16 and #69) residents investigated out of a finalized sample of 38 residents as evidenced by: 1. Failing to ensure that Resident # 16's MDS (Minimum Data Set) assessment reflected recent falls and the presence of a wander guard (monitoring device) and 2. Failing to identify a PASARR (Preadmission Screening and Resident Review) Level II for Resident #69. Findings: Resident # 16 Resident #16 was admitted to the facility on [DATE] with diagnoses that included, Aphasia, Anxiety Disorder, Major Depressive Disorder, and Tobacco Use. Record review of Resident #16's Care Plan, dated 04/10/2023, read in part, Place monitoring device on me that sounds alarms when I leave building. Further review of Resident #16's Care Plan dated 04/10/2023, read in part a fall on 05/02/2023 and on 05/20/2023. Record review of Resident #16's MDS (Minimum Data Set), dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review ) Level I and/or Level II for 1 (#45) of 5 (#34, #37, 45 #77, #95) residents reviewed for PASARR screening out of a total sample of 38 residents. Findings: Review of the facility's policy titled Pre-admission Screening and Resident Review (PASARR) Policy and Procedure read in part .Policy: The facility is to review resident diagnosis and medications upon admission and throughout the resident staty to deterine if a level two request for resident review is to be completed. Resident #45 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder. Review of Resident #45's medical record revealed a Level I PASARR screening dated 09/13/2021. Further review of the PASARR screening revealed, in part, Major Depressive Disorder was not documented. On 09/19/2023 at 10:53 a.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 · D2023-09-20 · 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 interview and record review, the facility failed to facilitate the resident's, and if applicable, the resident representatives' participation in the care planning process for 3 (#2, #34, #46) of 5 (#1-#5) residents investigated for care planning out of a total sample of 8 residents. Findings: Resident #2 Review of Resident #2's medical records revealed she was admitted on [DATE]. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. On 09/18/2023 at 2:30 p.m., during an interview with Resident #2, the resident stated that she was not sure what a care plan meeting was and that she had not been invited to attend. On 09/19/2023 at 1:41 p.m., a telephone interview was conducted with Resident #2's Responsible Party (RP), he stated that he was not aware of a care plan meeting for 08/23/2023. On 09/19/2023 at 2:27 p.m., an interview was conducted with Resident #2 and S3SSD…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-20 · 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 observation, interview and record review the facility failed to ensure a resident received the necessary treatment and services to promote healing and prevent new ulcers from developing by failing to turn a resident every two hours to prevent development or worsening of pressure ulcers for 1 (#56) out of 3 (#56, #90, #101) residents investigated for pressure ulcers out of a total sample of 38 residents. Findings: Review of the facility's policy titled Physician's Orders Policy and Procedure read in part .1. Nurse is to follow physician's order according to the order. Resident #56 was admitted to the facility on [DATE] with diagnoses that included Gastrostomy Status, [NAME] Syndrome, Abnormal Weight Loss, and Major Depressive Disorder. Review of the facility's wound log revealed Resident #56 had an Unstageable/Suspected DTI (Deep Tissue Injury) to her right buttock. Review of Resident #56's September 2023 current Physician's Orders revealed an order dated 07/20/2023 that read Turn/reposition q 2 hours…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to ELDER OUTREACH NURSING & REHABILITATION — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 3.6 | -0.6 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 2 of 5 | 2.4 | -0.4 vs chain |
The other 4 homes this chain runs (chain average 3.2★, 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 | Since |
|---|---|---|---|
| LANGLEY, JERAD | Individual | W-2 MANAGING EMPLOYEE | since 08/03/2015 |
| COLE, TODD | Individual | CORPORATE DIRECTOR | since 09/16/2015 |
| GATTE, CORY | Individual | CORPORATE DIRECTOR | since 11/29/2017 |
| PRESAS, KATI | Individual | CORPORATE DIRECTOR | since 12/15/2021 |
| SITTIG, JUDE | Individual | CORPORATE DIRECTOR | since 02/17/2010 |
| WALSH, DOUGLAS | Individual | CORPORATE DIRECTOR | since 12/26/2002 |
| QUIBODEAUX, BONNIE | Individual | CORPORATE OFFICER | since 02/01/2018 |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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 76% 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 $448K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in LA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195563. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-17, 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.