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The Encore Healthcare And Rehabilitation Center

19110 Crowley-Eunice Hwy, Crowley, LA 70526 · Non profit - Corporation · 73 certified beds · (337) 783-5533 Medicare & Medicaid certified

Call the home — (337) 783-5533 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609) — most recent Sep 2024
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (28) — 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)
  • nursing-staff turnover (61%) runs well above the national median (45%)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
155 Odd Fellows Rd · (337) 514-5200 · Call to confirm hours
Pharmacy
2004 N Parkerson Ave · (337) 785-2421 · Call to confirm hours
Grocery
4668 Roberts Cove Rd · (337) 739-3385 · Call to confirm hours
Park
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 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
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 increased9.9%17.8%15.4%better
Long-stay residents who lose too much weight2.8%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.2%0.9%better
Long-stay residents with a urinary tract infection0.0%2.1%2.0%better
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 injury2.1%3.5%3.3%better
Long-stay residents whose ability to walk worsened9.7%17.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication22.1%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.9%95.3%typical
Long-stay residents with pressure ulcers4.2%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control16.7%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.8%22.7%17.1%better
Short-stay residents who newly got an antipsychotic medication4.0%3.1%1.4%worse than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine96.7%76.3%79.4%better
Short-stay residents rehospitalized after admission19.4%28.0%22.6%better
Short-stay residents with an outpatient ER visit16.5%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.452.561.67worse
Long-stay outpatient ER visits per 1,000 resident days3.802.741.80worse

* 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.

50.8% 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 87 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.8%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
38.1%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 38.1% 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 42 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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 SNF50.8%CMS range 40.4–62.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.3–15.310.7%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 discharge38.1%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 discharge45.2%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 discharge28.6%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 hospitalization7.6%CMS range 4.5–14.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 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

0.16
RN hours/ resident / day
1.25
LPN hours/ resident / day
2.71
Aide hours/ resident / day
4.12
Total nurse hours/ resident / day
0.13
RN hoursweekends
60.8%
Total nursing turnover
71.4%
RN turnover

How full it usually is: this home is certified for 73 beds and averages 67.6 residents a day — about 93% occupied, or roughly 5 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 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.16 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 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 3.55 hrs/resident/day on weekends vs 4.36 on weekdays — 19% thinner on weekends. RN hours go from 0.17 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 61% is well above 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 (2025-07-23)
9
at the previous standard inspection (2024-06-20)

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.

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Ecited before2025-07-23 · 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

    Based on record review and interview, the facility failed to develop a person-centered comprehensive plan of care for 3 (#9, #73, #75) out of a final sample of 37 residents as evidenced by:1. Failing to develop a plan of care for Resident #9's hospice status, and;2. Failing to develop a resident centered comprehensive care plan for Resident #73 and #75.On 07/23/2025, a review of the facility's policy titled, Care Plan Policy and Procedure with a last reviewed date of 02/09/2025 read in part; A comprehensive person-centered care plan will be completed according to the RAI (Resident Assessment Instrument) manual upon admission, significant change, annual and as needed. Resident #9A review of Resident #9's EMR (Electronic Medical Record) revealed an admission date of 07/23/2020 with diagnoses that included, Hemiplegia and Hemiparesis Following Cerebral Infarction, Acute Kidney Failure, and Hypertensive Heart Disease. Review of Resident #9's MDS (Minimal Data Assessments) assessments revealed a comprehensive assessment indicating hospice services completed on 06/05/2025.Review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · 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 record review, observation, and interviews, the facility failed to promote resident's dignity during dining by standing over residents while assisting them to eat for 1 (Resident #67) of 37 sampled residents.Findings: A review of the facility's policy titled, Dining and Meal Service Policy and Procedure with a last review date of 02/09/2025, read in part, The dining experience will be person centered with the purpose of enhancing each individual resident's quality of life and being supportive of each individual's needs during dining. The policy also indicated general guidelines, Appropriate staff will assist as needed to assure adequate intake of food and fluids at the meal while maintain the resident's dignity (staff to sit eye level with resident while assisting to feed).A review of Resident #67's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's Disease, Dysphagia, and Gastro-Esophageal Reflux Disease,A 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0554 — isolated
    Allow 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 residents were safe to perform self-administration of medication for 1 (#61) out of 4 residents observed for medication administration. Findings:A review of the facility's policy titled Meds-Self Administration Policy and Procedure which was last reviewed on 02/09/2025, read in part, Policy: To maintain the residents' high level of independence, residents who desire self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the residents and other residents of the facility and there is a prescriber's order to self-administer. 1. 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. 2. For those residents who self-administer, the interdisciplinary team verifies 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 · D2025-07-23 · 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, record review and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming for 1 (#25) out of 37 sampled residents. Findings:Review of Resident #25's electronic medical record revealed she was admitted on [DATE] with diagnosis included, but not limited to, Vascular Dementia, Psychotic Disturbance, Cognitive Communication Deficit, Anxiety and Major Depression.Review of Resident #25's quarterly MDS (Minimum Data Set) dated 06/24/2025 revealed her BIMS (Brief Interview for Mental Status) score was 5, indicating her cognition was severely impaired. Review of Resident #25's current Care Plan Report read in part, I require staff assistance for ADL's (Activities of Daily Living) due to Impaired Cognition. Assist me with hygiene and grooming tasks. On 07/22/2025 at 8:57 a.m., Resident #25 was observed in the Beauty Shop. She had multiple hairs growing on her chin approximately 1/2 inch long.…

    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 · Dcited before2025-07-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including accurate administration of all drugs and accurately documenting controlled medication reconciliation as evidenced by:1 (#9) of 4 (#9, #36, #41, and #61) residents observed for administration of drugs, the facility failed to ensure Resident #9's Nifedipine was administered per manufacturer's recommendations, andin Med Cart C the facility failed to ensure Resident #79's controlled medication reconciliation was accurately maintained.Findings: Resident #9: A review of the facility's policy titled Medication Administration-General Guidelines which was last reviewed on 02/09/2025, read in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. vi. Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order. 1. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought. Review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-23 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 33 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 6.06%. FindingsA review of the facility's policy titled Medication Administration-General Guidelines which was last reviewed on 02/09/2025, read in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. vi. Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order. 1. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought. 2. Administration: b. Medications are administered in accordance with written orders of the prescriber. Review of Pfizer Medical.com (Procardia XL Manufacture website), in part: Dosage and Administration. Procardia XL extended release tablets should be swallowed whole and should not ne bitten or divided.Resident #9Review 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-23 · 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 — the official record, unedited, 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 by failing to discard an expired medication in 1 (Med Cart C) of 2 (Med Cart B and Med Cart C) medication carts sampled for medication storage. Findings:On 07/23/2025 at 1:15 p.m., observation was conducted of Med Cart C with S10LPN (Licensed Practical Nurse) which revealed the following: 1 Aspirin 325 mg (milligram) bottle with an expiration date of 06/2025On 07/23/2025 at 1:21 p.m., an observation and interview was conducted with S10LPN who confirmed the expiration date on the Aspirin 325 mg bottle was 06/2025, and it should have been discarded and not in the med cart.On 07/23/2025 1:24 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed that no expired medications should be in any med carts.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-17 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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, policy review, and interviews, the facility failed to implement its policy for incident investigation and reporting when staff failed to immediately report alleged staff-to-resident physicall abuse to administrative staff and failed to notify the resident's responsible party (RP) for 1 (#3) out of 7(#1, #2, #3, #R1, #R2, #R3 and #R4) sampled residents. Findings: On 09/16/2024 at 1:45 p.m., a review of the facility's undated policy, Abuse and Neglect Policy and Procedure revealed, in part, the following: To provide a safe environment for all residents free of abuse .Administrator or designee will complete a thorough investigation .If the resident is not interviewable, the resident's family may be questioned. 7. Reporting/Response- The facility employee or agent, who becomes aware of abuse .shall immediately report the matter to the facility administrator or Director of Nurses .The administrator or designee will notify the resident's representative of the matter. Follow up contact must be…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-17 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review and interviews, the facility failed to ensure reportable incidents of an allegation of staff to resident physical abuse was reported to the State Survey Agency within 2 hours after the allegation was made for 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3 and #R4) sampled residents. Findings: On 09/16/2024 at 1:45 p.m., a review of the facility's undated policy, Abuse and Neglect Policy and Procedure revealed, in part, the following: The facility administrator or designee shall complete a report to be made to the mandated state agency according to state guidelines upon notification of alleged abuse .Immediately means as soon as possible .but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of Resident #3's electronic health record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Malignant Neoplasm of Endometrium, Unspecified Dementia, Aphasia, Other Schizoaffective…

    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 · E2024-06-20 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, 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 Discharge Minimum Data Set (MDS) assessment was completed timely for 1(Resident #38) out of 35 sampled residents investigated. Findings: Resident #38 was admitted to the facility on [DATE] with diagnoses including Cord Compression, Aural Vertigo, Spinal Stenosis, Diabetes Mellitus, Hypertension, and Displaced Fracture of Right Femur. Review of Resident #38's medical record, revealed Resident #38 was admitted on [DATE] and discharged from the facility on 02/19/2024. Review of Resident #38's Discharge MDS assessment dated [DATE], revealed a transmission date of 06/20/2024. On 06/20/2024 at 12:30 p.m., an interview was conducted with S9MDSLPN. S9MDSLPN reviewed Resident #38's record and confirmed that an MDS discharge assessment should have been completed and transmitted within the 120 days after the resident was discharged from the facility and was not.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · Ecited before2024-06-20 · 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 interview, the facility failed to ensure accuracy of the documentation entered into the resident's record for 2 (#35, #71) residents in a final sample of 35 residents evidenced by: 1. inaccurately documenting a presence of a PEG (Percutaneous Endoscopic Gastrostomy) tube for Resident #35; 2. the nurse failing to document the correct reason as to why Resident #71 did not receive a scheduled medication, and another nurse failing to document that Resident #71 received an antibiotic injection immediately after administration per the facility's policy for medication administration. Findings: 1. Resident #35 Resident #35 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Urinary Incontinence, Edema, Depression, Anxiety Disorder, Congestive Heart Failure, Allergic Rhinitis, Insomnia, Restless Leg Syndrome, and Pain. A review of the physician's orders for Resident #35 revealed 03/04/2024: Regular Diet, Meat Finely Cut, no rice. Review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 the resident and/or resident's representative (RP) exercised the right to appropriately make informed decisions regarding the right to choose a provider of their preference for hospice services for 1 (#28) of 4 (#5, #7, #28, #42) residents investigated for hospice services in a final sample of 35 residents. Findings: Review of the facility's policy titled, Resident Rights and Quality of Life Policy and Procedure reviewed and approved by the facility on 08/22/2022 revealed in part: Resident's rights will be explained to the responsible party or legal guardian as appropriate. The resident has the right to .be informed in advance about care and treatment .freedom of choice of providers. Resident #28 Review of the resident's record revealed she was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. The resident's diagnoses included Heart failure, Chronic obstructive pulmonary disease (COPD), Respiratory…

    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 · D2024-06-20 · tag F0641 — isolated
    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 record review and interview, the facility failed to accurately code all applicable diagnoses on two consecutive comprehensive MDS (Minimum Data Set) assessments for 1 (#41) of 35 final sampled residents. Findings: Review of Resident #41's record revealed she was admitted to the facility on [DATE] with diagnoses including Dementia. Review of Resident #41's Psychiatric Evaluation by the psychiatrist dated 09/15/2020 revealed the resident was diagnosed with Depression, Dementia without behavior disturbances, and Schizoaffective Disorder. According to the resident's updated billing diagnosis code report, the resident's diagnoses of Dementia had a documented onset date of 09/11/2020; Schizoaffective Disorder had a documented onset date of 09/30/2020. Review of Section I-Active Diagnoses of the resident's admission MDS assessment dated [DATE] revealed the listed diagnoses of Non-Alzheimer's Dementia and Schizophrenia (Schizoaffective disorders) were unchecked. Review of Section I-Active Diagnoses of 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0644 — isolated
    Coordinate 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 refer a resident with a newly evident serious mental disorder to the appropriate state designated authority for Level II PASARR (Pre-admission Screening and Resident Review) evaluation and determination for 1 of 1 (#41) residents investigated for PASARR review in a final sample of 35 residents. Findings: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR) Policy and Procedure reviewed and approved by the facility on 04/12/2023 revealed in part: The purpose of the policy was to ensure completion of Pre-admission Screening and Resident Review Level II evaluations to assess the need for .and facilitation of behavioral health services. Policy: The facility is to review the 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 .2. Referring all residents with newly evident or possibly serious mental disorder .5. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · tag F0656 — failed to write and follow a full care plan — isolated
    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 observations, record review and interview, the facility failed to develop a comprehensive resident centered care plan for 1 (#324) of 35 final sampled residents by failing to develop nursing interventions to address edema to both lower extremities present upon Resident #324's nursing admission assessment. Findings: Review of the facility's policy titled, Care Plan Policy and Procedure reviewed and approved by the facility on 09/28/2023, read in part: a comprehensive person-center care plan will be completed .upon admission .and as needed. It is the policy of this facility to utilize an advanced care planning approach to review and determine patient centered care plans based on the following areas .active disease process .services furnished to attain or maintain the resident's highest practicable physician, mental, and psychosocial well-being; the resident individual goals. Review of Resident #324's record revealed she was admitted to the facility on [DATE] for skilled services. The resident 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 · D2024-06-20 · 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 observation, record review and interview, the facility failed to provide necessary care and services that is in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 1 (#42) out of 3 (#12, #42, #71) resident reviewed for respiratory care out of a total sample of 35 residents. Findings: Resident #42 was admitted on [DATE], with diagnoses not limited to Chronic Respiratory failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Aphasia and Cognitive Communication Deficits. Review of the Resident #42's physician's orders for June 2024 revealed on 10/19/2023 an order for Oxygen (O2) at 2 L/NC (Liters per Nasal Cannula) continuous to relieve hypoxia; document oxygen saturation every shift. On 06/17/2024 at 9:18 a.m., an observation of resident lying in bed, with contractures to bilateral arms and hands, with O2 resting on resident's shoulder, a knot/kink in O2 tubing, midway between concentrator and end of nasal cannula tubing. On 06/17/2024…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure medications were labeled to reflect medication adjustments as the physician ordered for 1 (#55) resident. The deficiency had the potential to affect a census of 69 residents. Findings: On 06/20/2024 a review of the facility's policy titled, Medication Storage with a last reviewed date of 09/28/2023, read in part, Policy: . 5. Medications will be labeled in accordance with currently accepted professional principles including expiration dated .Procedure: 1. Designated personnel will perform weekly and as needed review of medication storage areas and carts for compliance of policy Review of Resident #55's electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, Hypertensive Heart Disease with Heart Failure, Cognitive Communication Deficits and Unspecified Pain. On 06/20/2024, a review of Resident #55's Physician Orders for June 2024 revealed the following order: Order date:…

    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 · Dcited before2024-06-20 · 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 interview, observations and record review the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice as evidenced by failing to ensure medication was labeled as per physician orders for 1 (#20) resident. The deficiency had the potential to affect a census of 69 residents. Findings: Review of the facility's policy titled, Medication Administration-General Guidelines, read in part: Procedure: 1. Preparation: d. eight rights - right resident, right drug, right dose .A triple check of these rights is recommended at three steps in the process of preparation of medication administration: .3. Check #3: complete the preparation of the dose and re-verify the label against the MAR .e. prior to administration, the medication dosage schedule on the resident's electronic medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change on the direction…

    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 · E2023-05-24 · tag F0726 — failed to have competent, trained nursing staff — pattern
    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 Resident #39 Review of the resident electronic record revealed an admit date of 03/08/2022 with diagnoses that included Acute on chronic systolic congestive heart failure, and Unspecified protein calorie malnutrition. Review of Resident #39's physician orders dated 05/2023 read in part Metoprolol Tartrate 50 mg (milligrams) give 1 tab by mouth twice daily. Hold if blood pressure is less than or equal to 100 and or pulse is less than or equal to 60. Review of the Electronic Medication Administration Record (EMAR) dated 05/2023 revealed that on 05/02/2023, 05/07/2023, 05/10/2023, 0512/2023, 05/15/2023, 05/16/2023, and 05/23/2023 Resident #38 was administered Metoprolol Tartrate 50 mg when her pulse was 60. On 05/24/2023 at 3:00 p.m., an interview was conducted with S14LPN (License Practical Nurse) who stated that the order for metoprolol is if the pulse is less than 60, then hold metoprolol. A review of the physician orders and vital signs sheet for 05/2023 was conducted with S14LPN, who confirmed that when 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-24 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 observation, record review and interview, the facility failed to ensure its medication rate was not 5 percent or greater as evidenced by a calculated medication error rate of 41.68%. Findings: Review of the facility's policy titled, Medication Administration: General Guidelines. The policy read in part: d. Eight Rights--right resident, right drug, right dose, right route, right time, right reason, right documentation and right response are applied for each medication being administered . f. Tablet splitting: if breaking tablets is necessary to administer the proper dosage .the following guidelines are followed: . iv. since un-scored tablets may not be accurately broken, their use is discouraged if a suitable alternative is available. v. Where possible, the provider pharmacy is requested to package half tablets or the prescriber is contacted for an alternative dosage form (e.g. liquid) or therapeutic equivalent that does not require splitting k. A scheduled of routine dose administration times 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, policy review and interview, the facility failed to ensure food products that were stored in compromised cans in the dry storage room were disposed of cans of seasonings were dated after being opened. This deficient practice has the potential to effect the 67 residents that eat meals in the facility. Findings: Review of Dry Storage Areas Policy and Procedures read in part 4. leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. Review of policy Receiving and Storage Safety Policy and Procedure read in part 3. All containers will be clearly labeled. On 05/22/2023 at 8:30 a.m., an interview and observation of the dry storage room was conducted with S3DM (Dietary Manager). On the shelves in the dry storage room revealed the following canned goods that were compromised goods: 1 can of tuna, 3 Cans of Mild Cheddar Cheese, 3 Cans tropical fruit salad, 1 can of motida de pina, 1 can 100% pure pumpkin and 1 can diced pears. S3DM stated the cans on the shelf that were compromised were on the shelf for…

    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 · E2023-05-24 · tag F0880 — failed to prevent and control infections — pattern
    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 record review and interview, the facility failed to maintain an effective infection control and prevention program as evidenced by: 1. Failing to have an assessment process of the facility's water system in order to implement specific measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water systems; 2. S15LPN(Licensed Practical Nurse) failing to apply gloves prior to administering Resident's #45 nasal spray and failing to perform appropriate hand hygiene prior to donning gloves during the medication pass, and 3. S13TX (Treatment Nurse) failing to maintain a sterile field, change gloves and sanitize her hands appropriately while performing tracheostomy care on Resident #11. The facility had a census of 68 residents. Findings: 1. Review of the facility's Legionella Surveillance and Detection Policy and Procedure failed to provide a method for detection of Legionella. On 05/22/2023 at 2:42 p.m., an initial interview was conducted with S1ADM (Administrator), and S9CorporateRN (Registered Nurse). S1ADM stated the map 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-24 · 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 interview and record review, the facility failed to ensure each resident's plan of care reflected their advance directives for 2 (#39, #48) residents out of 2 residents investigated for advance directives. Resident #39 Resident #39 was admitted to the facility on [DATE] with diagnoses including Acute on Chronic Heart Failure, Essential Hypertension and Type 2 Diabetes. Review of Resident #39's EHR (Electronic Health Record) revealed the resident was a DNR (Do Not Resuscitate) and to allow natural death if she was unresponsive, pulseless and not breathing. Review of Resident #39's a LaPost (Louisiana Physician Orders for Scope of Treatment) dated [DATE] and advance directive declaration dated [DATE] revealed the resident's code status was DNR. Review of Resident #39's plan of care printed on [DATE] at 1:58 p.m. read the resident's care planned advance directive/code status read I am a full code. Resident #48 Resident #48 was admitted to the facility on [DATE] with diagnoses including COPD (Chronic…

    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 · D2023-05-24 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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

    Based on observation, record review, and interview, the facility failed to: 1. The nurse failed to notify a resident's physician of change in the resident's physical status when nurse failed to inform the physician of the recurrence of oral lesions; and 2. The CNA (Certified Nurse Assistant) failed to notify the nurse of multiple scratches to the abdomen and arm for 1 (#12) resident out of 45 sampled residents, of a total census of 68 residents. Findings: A review of the facility's policy and procedure titled Change in Condition Policy and Procedure included in part Procedure: 1. Licensed nurse to document per below guidelines: a. ii Notify physician and document result of physician contact. A review of Resident #12's care plan included: I have an ulcer on my tongue, monitor for changes, and consult md as appropriate. A review of Resident #12's annual MDS (Minimum Data Set) assessment dated 4/172023 revealed that for bathing she was assessed as 3/2, indicating she required physical assistance by one person. On 05/22/2023 at 12:00 p.m., and observation and interview were conducted…

    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 before2023-05-24 · tag F0656 — failed to write and follow a full care plan — isolated
    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 observation, interviews, and record review, the facility failed to follow the plan of care for 1(#48) of 45 sampled residents. The deficient practice was evidenced by the facility failing to place Resident #48's O2 (oxygen) concentrator against the wall and securing the O2 concentrator cord. Findings: Review of the resident's medical record revealed she was admitted to the facility on [DATE]with diagnoses that included in part, Age Related Osteoporosis Without Current Pathological Fracture, Unspecified Lack of Coordination, and Unspecified Abnormalities of Gait and Mobility. Review of the resident's progress notes revealed a nurse's note written on 03/07/2023 at 10:18 p.m. by S10LPN (Licensed Practical Nurse) . Resident was noted lying on the floor .Nasal cannula and electrical cord from concentrator wrapped around upper torso. Resident stated she tripped over the electrical cord of the concentrator while walking back from refrigerator. She was transferred to hospital. Further review of progress note…

    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 · D2023-05-24 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who require such services, for 1 (#12) of 3 (#12, 23, 54) residents investigated for pain, of a total of 45 sampled residents. Findings: A review of Resident #12's care plan included: I have an ulcer on my tongue. A review of Resident #12's annual MDS (Minimum Data Set) assessment dated 4/172023 revealed that she had occasional pain. A review of Resident #12's physician's diagnoses included Pain, and recurrent oral aphthae ulcer. A review of Resident #12's orders revealed an order dated 5/4/2023 to start magic mouthwash (nystatin/Benadryl, Maalox 1:1:1) give 10 ml TID (three times daily) swish and swallow for 1 week. Diagnosis: recurrent oral aphthae ulcer. A discontinue dated of 5/11/2023 was noted on the order. Further review of Resident #12's orders failed to reveal a new order to address the painful oral lesion. A review of Resident #12's May 23 MAR (Medication Administration Record) revealed the following: Magic mouthwash (Nystatin/Benadryl/Maalox) 10…

    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 · D2023-05-24 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure staff served the therapeutic diet prescribed by the physician for 1 (#28) of 4 (#12, #18, #28, #51) residents sampled for nutrition. Findings: Review of Resident #28's clinical record revealed she had diagnoses including Dementia and Dysphagia. Review of Resident #28's Nutritional Screening dated 05/02/2023 revealed the resident required a mechanically soft with chopped meat diet with thin liquids. Review of Resident #28's physician orders dated 04/19/2021 revealed an order for Mechanical soft with chopped meats, no added salt. Review of Resident's #28's care plan revealed Intervention: Serve me the diet as ordered by my physician. On 05/24/2023 at 11:23 a.m., an observation was conducted inside of Resident #28's room during the lunch meal. Resident #28 was observed feeding herself. Further observation revealed that the resident was served bar b que ribs that were cut in half. On 05/24/2023 at 11:24 a.m., an observation and interview was conducted with S11RN (Registered Nurse), who confirmed that 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 before2023-05-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 observation and interview, the facility failed to protect confidential information for Resident #46 by failing to initiate the computer's privacy screen during a medication pass. Findings: Review of the facility's policy and procedure titled Medications- Administration Policy and Procedure read in part .2. Privacy: a. Secure (cover) records containing protected health information, (e.g. , Medication Administration Records (MARs)) . Resident #46 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Gastroparesis and Type 2 Diabetes Mellitus. Review of Resident #46's current physician's orders revealed the following medications to be administered at 4:00 p.m.: 1.Methocarbamol 750 mg (milligram) tablet - 1 tab PO Q8 (By Mouth, Every Eight) Hours 2.Glipizide 10 mg tablet- Administer One Tablet By Mouth Twice Daily 3.Metoclopramide 10 mg- Administer One Tablet By Mouth Four Times Daily AC and HS (With Meals and Hours of Sleep) On 05/23/2023 at 3:24 p.m., an observation 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

“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

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 →

RatingThis homeChain avg
Overall 4 of 53.2+0.8 vs chain
Health inspection 4 of 53.6+0.4 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 3 of 52.4+0.6 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 / managerTypeRoleSince
GATTE, CORYIndividualW-2 MANAGING EMPLOYEEsince 05/08/2013
COLE, TODDIndividualCORPORATE DIRECTORsince 09/16/2015
PRESAS, KATIIndividualCORPORATE DIRECTORsince 12/15/2021
SITTIG, JUDEIndividualCORPORATE DIRECTORsince 02/17/2010
WALSH, DOUGLASIndividualCORPORATE DIRECTORsince 01/01/2010
QUIBODEAUX, BONNIEIndividualCORPORATE OFFICERsince 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.

$7.6M
Net patient revenuemost recent cost report
+9.6%
Operating marginrevenue minus expenses
$263K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 10%Other / private 16%

About 74% 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 $263K 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

$275per resident / day
operating cost
$8,371per month
≈ monthly operating cost
$304per 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 195426. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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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