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Deerfield Nursing and Rehabilitation Center

522 Main Street, Delhi, LA 71232 · For profit - Limited Liability company · 103 certified beds · (318) 878-2417 Medicare & Medicaid certified

Call the home — (318) 878-2417 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,281 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,281 in federal fines (most recent 2025-09-23)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (56%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
129 Christian Dr · (318) 728-7149 · Call to confirm hours
Pharmacy
213 Depot St · (318) 878-2261 · Call to confirm hours
Grocery
504 First St · (318) 488-6059 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
506 Main St · (318) 878-2141

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 1 of 5
Long-stay residentspeople who live here 1 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 fell from 2 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased27.4%17.8%15.4%worse
Long-stay residents who lose too much weight0.0%5.2%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder2.7%1.2%0.9%worse
Long-stay residents with a urinary tract infection6.0%2.1%2.0%worse
Long-stay residents with depressive symptoms0.5%2.3%6.5%better than state — see note marked double-dagger 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 worsened24.2%17.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.2%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine96.8%94.9%95.3%typical
Long-stay residents with pressure ulcers10.7%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control14.0%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.9%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication6.2%3.1%1.4%worse than state — see note marked double-dagger below the table
Short-stay residents rehospitalized after admission19.4%28.0%22.6%better
Short-stay residents with an outpatient ER visit20.2%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.362.561.67worse
Long-stay outpatient ER visits per 1,000 resident days4.022.741.80worse

* 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.

46.3% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.3%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
39.3%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 39.3% 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 28 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 SNF46.3%CMS range 34.5–58.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 6.3–15.510.7%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 discharge39.3%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 discharge50.0%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 discharge53.6%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened12.5%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 hospitalization7.2%CMS range 4.8–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.191.02Oct 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

0.28
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.36
Total nurse hours/ resident / day
0.29
RN hoursweekends
56.3%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 62.1 residents a day — about 60% occupied, or roughly 41 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 2.96 hrs/resident/day on weekends vs 3.52 on weekdays — 16% thinner on weekends. RN hours go from 0.27 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% 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

8
deficiencies at the latest standard inspection (2025-05-14)
7
at the previous standard inspection (2024-04-11)

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.

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible by not locking the door to the kitchen giving residents direct and full access to the kitchen and the ability to elope from the facility through an exterior door at the back of the kitchen for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement.This deficient practice resulted in an Immediate Jeopardy (IJ) for Resident #1 on 08/29/2025 at 11:35 p.m. when Resident #1 exited out of the facility. Resident #1 was able to access the kitchen through an unlocked kitchen door, walk through the kitchen and leave through an exterior door at the back of the kitchen. Resident #1 was located by the police two blocks away from the facility on a two-lane road. Resident #1 was returned to the facility on [DATE] at 12:20 a.m. without injury. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 09/09/2025.…

    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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Ecited before2025-10-16 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop comprehensive person centered care plans for each resident that met each residents' nursing needs for activities of daily living (ADLs) for 5 (#1, #2, #3, #4, #5) of 6 sampled residents.Findings:Resident #1Review of the medical record of Resident #1 revealed an admission date of 10/15/2001 and diagnoses which included dementia, psychosis, hypertensive heart disease and anxiety.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was dependent for toileting, personal hygiene and transfers from bed to chair. Review of the Resident #1's plan of care revealed impaired cardiac output - may use 2 person assist with ADL tasks as needed. Further review failed to identify the required assistance of 1 or more staff for each ADL.Resident #2Review of the medical record of Resident #2 revealed an admission date of 10/11/2003 and diagnoses which included dementia, psychotic disturbance, mood disturbance 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-23 · 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 record review and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (#7) of 3 (#7, #8, #9) residents reviewed for falls. The facility failed to implement Resident #7's fall care plan intervention. Findings: Record review revealed Resident #7 was admitted to the facility 10/18/2022 with diagnoses that include Alzheimer's disease, dementia with agitation, osteoporosis without current pathological fracture, edema, dementia with other behavioral disturbance, other schizoaffective disorder, protein- calorie malnutrition, osteoarthritis, and muscle wasting and atrophy. Review of quarterly Minimum Data Set (MDS) assessment 07/07/2025 revealed a Brief Interview of Mental Status (BIMS) score of 1 which indicated Resident #7 had severe cognitive impairment for daily decision making. Resident #7 had no range of motion impairment to upper or lower extremities. Resident #7 was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-23 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure the nursing staff had appropriate competencies and skill set to provide care for 1 (#7) of 3 (#7, #8, #9) residents reviewed for falls. A nurse failed to send Resident #7 to the hospital after an unwitnessed fall.Review of the facility's policy and procedure related to Accidents and Incidents - Investigating and Reporting policy with a revised date of 06/9/2025 revealed in-part: Policy Interpretation and Implementation1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.2. The following data, as applicable, shall be included on the Report of Incident/Accident form:a. The date and time the accident or incident took place;b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);c. The circumstances surrounding the accident or incident;d. Where the accident or incident took place;e. The name(s) of witnesses and their accounts 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-14 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews the facility failed to develop a plan of care for 1 (#28) of 1 (#28) residents for discharge planning and failed to implement the plan of care for 1 (#46) of 1 (#46) residents by failing to place a fall mat on the floor at the bedside. Findings: Resident #28 On 05/12/2025 at 1:18 p.m., an interview with resident #28 revealed she spoke with S7Business Office Manager (BOM), whom was previously the social service director, over 6 months ago about getting her own apartment but she had not heard anything else about it. Review of the record for resident #28 revealed diagnoses including cerebral infarction, non-traumatic intracerebral hemorrhage with dysarthria and dysphagia, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #28 had a brief interview for mental status (BIMS) score of 13 which indicated the resident was cognitively…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-14 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure 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 review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to administer insulin as ordered for 1 (#32) of 5 (#3, #4, #8, #32, and #36) residents reviewed for unnecessary medications. Findings: Review of the facility's policy and procedure for Administering Medications Policy revised April 2019 revealed the following, in part: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including required time frame. Review of the medical record for resident #32 revealed diagnoses of schizoaffective disorder, edema, hypokalemia, dementia, muscle wasting, altered mental status, hypothyroidism, diabetes mellitus, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #32's Brief Interview for Mental Status indicated the resident had severe cognitive impairment for daily decision…

    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 · E2025-05-14 · 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 and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure: 1) freezer temperatures were maintained at a level to keep frozen food solid; 2) frozen foods and noodles were properly sealed and not left open to air; 3) storage containers for flour, corn meal, and sugar were free from spills and splatters; 4) frozen chopped meat was thawed appropriately, and 5) hygienic practices were followed during food service. S4Dietary Manager (DM) reported that 53 residents were served meals from the kitchen. Findings: Observation of the kitchen on 05/12/2025 at 8:18 a.m. revealed the following: -the freezer had multiple thawed items including: 2 packs of onion rings, 1 box of waffles, 1 box of egg patties open to air, 1 box of waffles, 1 box of oatmeal raisin cookies, and 1 box of omelets open to air; -the dry storage area had an opened bag of noodles stored in an opened plastic zip bag; -storage containers for flour, corn meal, and sugar were visibly soiled…

    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 · E2025-05-14 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to have quarterly quality assessment and assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s lack of documentation of 4th quarter of 2024 and 1st quarter of 2025 QAA meetings. Findings: Review of the QAA meetings revealed that the facility held meetings in the second and third quarters of 2024. Further review of the QAA meetings binder revealed that the facility did not have QAA meetings in the 4th quarter of 2024 and 1st quarter of 2025 with required participants. Interview with S1Administrator and S2DON on 05/14/2025 at 4:00 p.m. confirmed that the facility was not able to provide documentation of QAA meetings with required participants during the 4th quarter of 2024 and the 1st quarter of 2025.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1) implement policies and procedures for Enhanced Barrier Precautions (EBPs) by not wearing the appropriate personal protective equipment during care for 4 (#7, #8, #11, and #46) of 4 residents, 2) have signage or an indicator outside of rooms to determine residents that should be on EBPs for 6 (#2, #7, #8, #11, #46, and #50) of 6 residents that required EBPs, and 3) ensure infection control practices were maintained during catheter care for 1 (#16) of 1 residents observed for catheter care. Findings: Review of the facility's Enhanced Barrier Precautions policy, not dated, revealed in-part: Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent spread of multi-drug resistant…

    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 · Dcited before2025-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 observation, record review and interview the facility failed to ensure the resident's environment remained free from accident hazards by not conducting a bed rail/mattress safety assessment prior to implementing the use of side rails for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for the use of side rails. Findings: On 05/12/2025 at 3:20 p.m., observation of resident #36 revealed she was up in the wheelchair. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/13/2025 at 8:20 a.m., observation of resident #36 revealed she was sitting up in a wheelchair asleep. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/14/2025 at 9:45 a.m., observation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interview, the facility failed to 1.) review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and 2.) assess the resident for risk of entrapment from bed rails prior to installation for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for bed rails. Findings: Review of the Bed Safety and Bed Rails policy and procedure revised August 2022: Policy Statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. Policy Interpretation and Implementation 1. The resident's sleeping environment is evaluated by the interdisciplinary team. 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement. 3. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 4. Bed dimensions are appropriate for the resident's size. 5. Regardless of mattress type, width, length, and/or depth, the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2025-05-14 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure that the licensed nurses have the competencies and skill sets necessary to care for residents' needs for 1 (#53) of 1 closed record review. S12Licensed Practical Nurse (LPN) failed to obtain vital signs after she was unable to obtain a pulse oximetry reading. Findings: Review of the medical record for resident #53 revealed an admission date of 02/20/2025 which diagnoses that included acute on chronic congestive heart failure, ischemic cardiomyopathy, atherosclerotic heart disease, hypertension, fluid overload, presence of coronary angioplasty implant/graft, and presence of cardiac defibrillator. Review of the nurses notes for resident #53 dated 02/21/2025 revealed an entry at 9:00 a.m. in which S12LPN documented a pulse oximetry reading was unable to be obtained due to resident #53's cold and swollen fingers. Further review revealed that resident #53 was administered his medications and then became nauseated. On 05/13/2025 at 2:30 p.m., an interview with S12LPN revealed she did not recall if vital signs were taken…

    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 · D2024-06-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The facility failed to protect resident #1 from physical and verbal abuse by staff. Findings: Review of the facility abuse and neglect policy dated April 2021revealed it defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. The policy also defined willful as the individual must have acted deliberately, not that the individual must have attended to inflict injury or harm. Review of the facility's incident investigation report dated 06/05/2024, at 5:30p.m., revealed the nurse was called to the smoking patio where she found resident #1 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-11 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (#12 and #38) of 4 (#12, #26, #38, and #59) sampled residents reviewed for activities of daily living (ADLs). Findings: Review of the facility's policy and procedure related to nail care, (revision date 02/01/2024), revealed the following, in part: General Guidelines 1. Nail care includes daily cleaning and regular trimming; 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments; 7. Diabetic nail care to be performed by a Registered Nurse or Provider Resident #12 Review of the record revealed an admission date of 09/26/2023 with diagnoses including myelopathy, chronic obstructive pulmonary disease, enlarged and hypertrophic nails, hammer toe, hyperlipidemia, hypertension, glaucoma, fusion of spine lumbar…

    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 · E2024-04-11 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#23) of 1 resident reviewed for edema, 2 (#6 & #26) of 3 (#6, #26, #50) residents reviewed for Oxygen, and 1 (#6) of 1 resident observed during a Percutaneous Endoscopic Gastrostomy (PEG) tube medication administation. The facility failed to: 1. Apply compression stockings as ordered by the physician for resident #23, 2. Administer Oxygen as ordered by the physician for resident #6 and resident #26, and 3. Administer a 30 cubic centimeters (cc) water flush prior to the administration of resident #6's medications as ordered by the physician. Findings: Resident #23 Review of the medical record for resident #23 revealed the resident was admitted on [DATE] with diagnoses including hypertension, dementia with behavioral disturbance, ventricular septal defect following acute myocardial…

    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 · Ecited before2024-04-11 · 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

    Based on record reviews and interviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nurses documented the site of subcutaneous diabetic injections for 3 (#26, #31, and #40) of 5 (# 23, #26, #31, #40, and #48) sampled residents reviewed for unnecessary medications. Findings: resident #31 Review of the medical record for resident #31 revealed an admission date of 04/12/2021 with diagnoses that included type 1 diabetes, hperlipidemia, anemia, upper respiratory infection, heart disease, chronic kidney disease, osteoarthritis, lack of coordination, convulsions, vascular dementia, and hypertension. Review of the active April 2024 Physician's orders revealed the following orders in regards to resident #31 taking the following medications for type 1 diadetes : Humalog 100 units/ml (milliliter) cartridge inject 10 units subcutaneous before…

    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 · E2024-04-11 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 2 (#26, #31) of 5 (#23,#26,#31,#40,#48) sampled residents reviewed for unnecessary medications and insulin administration. Findings: resident #31 Review of the medical record for resident #31 revealed an admission date of 04/12/2021 with diagnosis that include type 1 diabetes, hperlipidemia, anemia, upper respiratory infection, heart disease, chronic kidney disease, osteoarthritis, lack of coordination, convulsions, vascular dementia, and hypertension. Review of the April 2024 Physician's orders revealed the following orders in regards to resident #31 taking the following medications for type 1 diadetes : Humalog 100 units/ml (milliliter) cartridge inject 10 units subcutaneous before breakfast Ozempic dose pen inject 0.5 mg (milligram) subcutaneous every Friday Humalog 100 units/ml (milliliter) cartridge15 units before lunch and supper at 11:00 a.m. and 4:00 p.m. Administer 10 units of regular…

    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 · Ecited before2024-04-11 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, the facility failed to ensure the menus were followed for 4 (#25, #36, #55 and #113) of 4 residents who were prescribed pureed diets and 11 (#16, #18, #19, #22, #27, #40, #42, #51, #54, #58, and #363) of 11 residents who were prescribed mechanical soft diets. The facility failed to ensure the menus were followed for 8 (#14, #17, #23, #28, #39, #53, #54, and #58) of 8 residents by not providing 4 ounces of chicken during the 04/08/2024 lunch meal. Findings: Review of the lunch menu approved by the Registered Dietician dated 04/08/2024 revealed the residents receiving a pureed diet should receive pureed cornbread and the residents on a mechanical soft diet should receive moist cornbread. Further review revealed all diets should receive 4 ounces of chicken. Review of the medical records revealed residents #25, #36, #55 and #113 were ordered pureed diets and residents #16, #18, #19, #22, #27, #40, #42, #51, #54, #58, and #363 were ordered mechanical soft diets. Further review revealed residents #14, #17, #23, #28, #39, #53, #54, and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#39) of 3 (#12, #16, #39) residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device while in the wheelchair for resident #39. Findings: Review of the medical record for resident #39 revealed the resident was admitted on [DATE] with diagnoses including diabetes, depression, hypothyroidism, schizoaffective disorder, Vitamin D deficiency, dementia with behavioral disturbances, and muscle wasting with atrophy. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #39 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was dependent for toileting hygiene and required partial/moderate assistance with transfers. The resident was incontinent of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to ensure residents were free from unnecessary medication use for 1 (#26) of 5 (#23, #26, #31, #40, and #48) sampled residents reviewed for unnecessary medications. The physician failed to ensure a psychotropic medication (Alprazolam) was not ordered to be given as needed for a time period greater than 14 days for resident #26. Findings: Resident #26 Review of the record revealed resident #26 had an admission date of 01/31/2019 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, hypertension, unspecified dementia, and chronic obstructive pulmonary disease. Review of the April 2024 Physician's Orders revealed an order dated 11/27/2023 for Alprazolam 0.25 milligrams (mg) 1 tablet by mouth (po) as needed (prn) for anxiety. Review of the Pharmaceutical Consultant Report dated 01/23/2024 revealed pharmacist recommended that Alprazolam (Xanax) prn psychotropic medication should be limited to 14 days. Physician denied the gradual dose reduction and rationale was minimally effective dose…

    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 · E2023-05-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment for the interior of the building. The failed practice was evidenced by a blanket over the dryer vent duct, a hole in the wall behind the dryer, and heavy lint buildup behind dryers. Findings: On 05/09/2023 at 2:10 p.m. an observation of the laundry room revealed a hole was noted in the wall behind the dryer with a cotton blanket wrapped around a dryer vent duct. The blanket and the floor behind dryers had heavy lint buildup. On 05/09/2023 at 2:25 p.m. an observation with S1Administrator of the laundry room confirmed the hole in the wall should be sealed, the cotton blanket should not be covering the dryer vent duct, and the blanket and the floor should not have heavy lint buildup.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-05-10 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure 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

    Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure lab work was obtained as ordered by the physician for 1 (#27) of 5 (#5, 19, 27, 37, 50) residents whose drug regimens were reviewed. Findings: Review of the medical record revealed resident #27 had diagnoses which included paranoid schizophrenia, depression, hyperlipidemia, chronic venous hypertension, diabetes, insomnia and atrial fibrillation. The resident also had medication orders which included glipizide, Eliquis, trazadone, duloxetine, Depakote, Risperdal, Lasix, potassium chloride, atorvastatin, Lantus insulin, Ozempic, levothyroxine and Humulin R. Review of the physician orders revealed there was an order written on 09/16/2022 to obtain a lipid panel, TSH (Thyroid Stimulating Hormone), Vitamin D, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and a Hemoglobin A1C in March 2023. Review of resident #27's medical record revealed there was no results for the lab due in March. On 05/09/2023 at 11:30 a.m., 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-10 · 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 reviews, and interviews the facility failed to provide assistance for residents who were unable to carry out activities of daily living and received the necessary services to maintain good grooming and personal hygiene for 2 (#1, #50) of 2 (#1, #50 ) residents investigated for ADL (activities of daily living) care. 1) The facility failed to ensure nail care was provided for resident #1 and #50; and, 2) The facility failed to ensure resident #1 was appropriately dressed. Findings: Resident #1 Review of the record for resident #1 revealed he was admitted to the facility on [DATE] with diagnoses including the following: major depressive disorder, vascular dementia, glaucoma, legal blindness, peripheral vascular disease, and transient cerebral ischemic attack. Review of the 04/24/2023 quarterly MDS (Minimal Data Set) revealed the following: Vision: severely impaired, no vision and sees only light; Functional status for personal hygiene: self-performance limited assistance with one…

    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 before2023-05-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 observations, record reviews and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible. The facility failed to attempt appropriate interventions after a resident sustained falls for 1 (#15) of 6 (#7, 15, 25, 27, 29 and 41) residents reviewed for accidents. Findings: Review of the facility's Falls-Clinical Protocol Policy revealed in part -Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Review of the medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-10 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of the menus, and interviews the facility failed to ensure the menus were followed for 3 (#24, #34 and #35) of 3 (#24, #34 and #35) residents that had an order for a pureed diet. The facility failed to serve the correct dessert listed on the menu for the residents that had an order for a pureed diet. Findings: Review of the facility's Therapeutic Diet policy revealed in part - 14. Menus must be prepared in advance and followed. On 05/08/2023 at 11:30 a.m., observation of the lunch meal revealed sampled resident #24 was ordered a pureed diet. Further observation of the lunch meal revealed resident #24 received a prepackaged pudding cup for dessert. Review of the lunch menu for 05/08/2023 revealed the residents that were ordered a pureed diet should have received pureed bread pudding. On 05/08/2023 at 2:45 p.m., an interview with S6Dietary Manager revealed residents #24, #34 and #35 had a physician's order for a pureed diet and they received a prepackaged pudding cup instead of pureed bread pudding as listed on the menu. On 05/09/2023 at 3:00 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.

    Nutrition and Dietary 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

$8,281 in federal fines across 1 penalty.

  • $8,281 — penalty dated 2025-09-23

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
BUSBY, ERINIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 04/30/2024
BUSBY, RYMANIndividualDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; ADP OF THE SNFsince 04/30/2024
POVERTY POINT GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/20/2025
ALBRITTON, COREYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/29/2021
HARPER, HOLLYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2025

CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.3M
Net patient revenuemost recent cost report
-9.2%
Operating marginrevenue minus expenses
$914K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 9%Other / private 23%

This home reported $914K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$286per resident / day
operating cost
$8,707per month
≈ monthly operating cost
$262per 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 195393. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-14, 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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