Westwood Manor Nursing Home, INC
714 High School Drive, Deridder, LA 70634 · For profit - Limited Liability company · 132 certified beds · (337) 463-6293 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.5% | 17.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.4% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.1% | 2.3% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.5% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 27.5% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.1% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 15.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.4% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.8% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 68.2% | 76.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 25.8% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 18.9% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.33 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 2.74 | 1.80 | worse |
‡ 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.
38.1% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.4% 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 35 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.1%CMS range 23.5–55.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.3–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 71.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 68.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 65.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.2–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.44 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 132 beds and averages 93.2 residents a day — about 71% occupied, or roughly 39 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Weekend coverage: total nurse staffing is 3.06 hrs/resident/day on weekends vs 3.59 on weekdays — 15% thinner on weekends. RN hours go from 0.38 to 0.12 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
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Ecited before2025-07-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 90 residents that received meals prepared in the kitchen. Findings: Review of an undated facility policy on 07/30/2025 at 8:20 a.m. titled, Storage: Freezer revealed the following part.2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 3. Label and date all items. Review of an undated facility policy on 07/30/2025 at 8:20 a.m. titled, Storage: Refrigerator revealed the following in part.7. Keep refrigerated food wrapped or covered and in sanitary containers. Observation on 07/28/2025 at 8:55 a.m. of the facility kitchen accompanied by S11 Dietary Manager revealed the following: Walk-In Refrigerator: 1. One opened, unsealed, and undated cardboard box of breakfast sausage patties (over 25 individual sausage patties).2. One opened, unsealed, and undated cardboard box of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident received reasonable needs for 1 (Resident #32) of 1 residents reviewed for accommodation of needs. The facility failed to ensure Resident #32 received a Geriatric chair as requested.Findings:Review of the Facility's undated policy titled Accommodation of Needs read in part.Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. 4. Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. Review of Resident #32's medical records revealed an admit date of 04/02/2024 with diagnoses that included: Type 2 Diabetes Mellitus, Unspecified Osteoarthritis, Morbid Obesity, Muscle Spasms of Back, Chronic Pain Syndrome, and Restless Leg Syndrome. Review of Resident #32's Quarterly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-30 · tag F0640 — isolatedEncode 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
Based on record review and interview, the facility failed to transmit an admission MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #33) of 1 sampled residents with a MDS record over 120 days old. Findings:Review of the Facility's undated policy titled: MDS 3.0 Completion read in part Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. 2. admission Assessment- completed 14 days of admission counting the day of admission as day #1. The admission assessment must be accepted with a transition time line of 14 days. Review of Resident #33's medical record revealed an admission date of 07/03/2025. Review of Resident #33's MDS on 07/29/2025 revealed the admission MDS with ARD (Assessment Reference Date) of 07/09/2025 was open and had not been transmitted. An interview on 07/29/2025 at 2:10 p.m. with S10 LPN confirmed that Resident #33's admission MDS with ARD of 07/09/2025 should have been signed as completed and transmitted by 07/22/2025, but had not been.
- Potential for harm · D2025-07-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's comprehensive care plan was revised after each assessment for 1 (Resident #22) of 30 sampled residents. Review of Resident #22's medical record revealed an admission date of 03/26/2018 with diagnoses including Alzheimer's Disease, Epilepsy, Gastrostomy, and Quadriplegia. Review of Resident #22's Discharge with Return Anticipated MDS with ARD of 07/15/2025 revealed a BIMS Score was not conducted. Resident #22 did not receive Oxygen. Review of Resident #22's previous physician's orders revealed Oxygen at 2-4L NC PRN SOB and O2 sat below 95% RA as needed was discontinued on 01/29/2025.Review of Resident #22's care plan revealed the following interventions: Oxygen settings: O2 via NC at 2-4L PRN SOB or O2 less than 95% on RA; and Oxygen: Administer as ordered.Interview was conducted with S10 MDS and S13 MDS on 07/30/2025 at 1:35 p.m. S10 MDS revealed Resident #22 did not have an order for Oxygen, but was care-planned for Oxygen. S13 MDS confirmed Resident #22's care plan was not revised after each…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the Facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide nail care for 1 (#5) out of 30 sampled residents. Findings:Review of Resident #5's medical record revealed an admit date of 05/01/2025 with a re-entry date of 06/20/2025 with diagnoses which included: Disruption of Dehiscence of Closure of Internal Operation (Surgical) Wound of Abdominal Wall Muscle or Fascia, Chronic Respiratory Failure, Partial Intestinal Obstruction, Severe Protein-Calorie Malnutrition, and Hypertensive Heart Disease without Heart Failure. Review of Resident #5's admission MDS with an ARD of 05/01/2025 revealed Resident #5 had a BIMs score of 6, indicating severe cognitive impairment. Review of Resident #5's Care Plan dated 05/02/2025 revealed in part. ADL assistance needed: Moderate assist needed with toileting, personal hygiene, and staff x 1 with transfers. Observation on 07/28/2025 at 10:30 a.m. revealed Resident #5's fingernails were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure expired medications were not available for administration to residents in 1 (Room A) of 1 medication room checked for safe and secure storage.Observation of Room A on 07/29/2025 at 10:00 a.m. accompanied by S14 LPN revealed Room A was used to store medications and supplements to be provided to residents. Observation revealed 2 unopened bottles of Ocuvite Adult 50+ Soft Gels with an expiration date of 06/2025, and 3 DiabetiSource AC Complete Nutrition 250mL supplements with an expiration date of 05/23/2025. An interview was conducted at this time with S14 LPN who confirmed expired medications and supplements were in Room A, but should not have been.Interview with S3 ADON on 07/29/2025 at 10:45 a.m. confirmed expired medications and supplements should not have been in Room A, available for administration to residents, but were.
- Potential for harm · D2025-07-30 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident received and the facility provided liquids consistent with resident needs for 1 (Resident #52) resident investigated for hydration. The sample size was 30 residents.Review of Resident #52's medical record revealed an admission date of 12/16/2020 with diagnoses including, in part.Dementia, Mild Protein-Calorie Malnutrition, and Aphasia. Review of Resident #52's Quarterly MDS with ARD of 06/06/2025 revealed a BIMS Score of 99. Resident #52 required substantial/maximal assistance with eating and did not have a swallowing disorder. Review of Resident #52's active physician's orders revealed the following: 09/03/2024: 360mL fluid of choice po TID with med pass; and 09/03/2024: Give 360mL fluid of choice po BID at snack times. Review of Resident #52's care plan revealed the following: 12/01/2021: 360mL fluid of choice po TID with med pass; and 12/07/2021: Give 360mL fluid of choice po BID at snack times. Review of Resident #52's 07/2025 MAR revealed the following: 360mL fluid of choice po TID with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-30 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 95 residents who resided in the facility.Findings: Review of an undated facility policy on 07/30/2025 at 8:20 a.m. titled, Trash revealed the following part.All garbage and trash will be placed in a dumpster in a convenient area near the facility. The lid to the dumpster is to be kept closed at all times. Observation on 07/28/2025 at 9:36 a.m. of the facility dumpsters accompanied by S11 Dietary Manager and S12 Maintenance Supervisor revealed 3 facility dumpsters. Observed dumpster #1 with the top lid opened, dumpster #2 with the side lid open, and dumpster #2 with 1 full, large black garbage bag placed directly on the ground in front of the dumpster. Observed multiple pieces of debris/trash on the ground in the surrounding dumpster area such as straws, plastic lids, silver spoons, napkins, and other paper products. S12 Maintenance Supervisor revealed the facility occasionally has raccoons in the dumpster area and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident was treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 1 (#96) of 2 (#45, #96) Residents reviewed for dignity in a total sample of 29. The facility failed to ensure Resident #96 was dressed appropriately. Findings: Review of Resident #96's EHR (Electronic Health Record) revealed an admit date of 01/10/2024 with diagnoses including in part . Hypertensive Heart Disease, Chronic Kidney Disease Stage 2, Gastrostomy Status, Parkinson's Disease, Adult Failure to Thrive, Major Depressive Disorder, Unspecified Severe Protein- Calorie Malnutrition, Anxiety Disorder, and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease. Review of Resident #96's Quarterly MDS with ARD of 04/17/2024 revealed Resident #96 was non-interviewable with a BIMS of 99 (unable to assess mental status). Resident #96 was dependent on staff for oral hygiene, toileting, showering/bathing, dressing upper and lower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#96) of 2 (#96, #352) Residents reviewed for advance directives. The total sample size was 29. The facility failed to ensure all medical records regarding code status consistently reflected the Resident's wishes to be a DNR (Do Not Resuscitate). Findings: Review of Resident #96's EHR (Electronic Health Record) revealed an admit date of [DATE] with diagnoses including in part . Hypertensive Heart Disease, Chronic Kidney Disease Stage 2, Gastrostomy Status, Parkinson's Disease, Adult Failure to Thrive, Major Depressive Disorder, Unspecified Severe Protein- Calorie Malnutrition, Anxiety Disorder, and Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease. Further review of Resident #96's EHR- Bed board revealed a code status of CPR. Review of Resident #96's Quarterly MDS with ARD of [DATE] revealed Resident #96 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.
Show the remaining 17 citations
- Potential for harm · D2024-05-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment, by failing to ensure a resident's bed linens were clean for 1 (Resident #18) of 4 (Resident #10, Resident #18, Resident #49 and Resident #55) sampled Residents. Total sample size was 29. Findings: Review of Resident #18's medical record revealed an admit date of 10/04/2021, with diagnosis which included: Major Depressive Disorder, Heart Failure Unspecified, Vascular Dementia Unspecified, Overactive Bladder and Unspecified Dementia. Review of Resident #18's Quarterly MDS with an ARD of 04/03/2024 revealed a BIMS score of 12 indicating mildly impaired cognition. The MDS revealed Resident #18 required supervision or touching assistance with bathing, independent with eating and toileting hygiene; set-up or clean up assistance with personal hygiene. Review of Resident #18's Care Plan with a review date of 07/31/2024, revealed he required supervision to limited assistance with ADL's with interventions to assist as needed. Observation and interview on 05/13/2024 at 10:44 a.m.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a prompt resolution of an allegation of missing property for 1 (Resident #13) of 1 resident reviewed for grievances by failing to initiate a grievance for Resident #13. Total sample size was 29. Findings: Review of the Facility's Grievance/Complaint Policy (no review date) revealed in part . 1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint to the facility other entity that hears grievances concerning treatment, medical care, behavior of other residents, staff members, theft of property, and other concerns regarding their LTC facility stay without fear of threat or reprisal in any form. 4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations. Review of Resident #13's clinical record revealed an admit date of 12/21/2023 with diagnosis which included: Neuromuscular Dysfunction of Bladder, Multiple Sclerosis, Hypertensive Heart Disease, Anxiety Disorder and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a CPOC (Comprehensive Person Centered Care Plan) to meet Resident's medical needs for 2 (#47, #96) of 29 sampled residents. The facility failed to: 1. Ensure Resident #47 was transferred with a mechanical lift by 2 person assist as specified in the resident's physician's orders and CPOC, and 2. Ensure Resident #96 had a CPOC to address the Resident's code status of DNR. Findings: Resident #47 Review of Resident #47's medical record revealed an admit date of [DATE] with diagnoses that included in part .Urinary Tract Infection, Acquired absence of left and right leg above knee, Hemiplegia, COPD, Major Depressive Disorder, Morbid Obesity, and Muscle Weakness. Review of Resident #47's current physician's orders revealed the following: [DATE]: X 2 mechanical lift with transfers Review of Resident #47's Quarterly MDS with an ARD of [DATE] revealed a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, 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 and personal hygiene for 2 (#47, #49) of 2 residents reviewed for Activities of Daily Living (ADLs). Findings: Resident #47 Review of Resident #47's medical record revealed an admit date of 02/07/2024 with diagnoses that included in part .Urinary Tract Infection, Acquired absence of left and right leg above knee, Hemiplegia, Major Depressive Disorder, Morbid Obesity, and Muscle Weakness. Review of Resident #47's Quarterly MDS with an ARD of 04/15/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. The MDS revealed rejection of care was coded as behavior not exhibited. The MDS revealed the resident required substantial/maximal assistance with showering/bathing self and chair/bed to chair transferring and was always incontinent of bladder and bowel. Review of Resident #47's care plan with a start date of 02/07/2024 and a review date of 07/25/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to administer the Pneumococcal Vaccine after receiving consent for 1 (#45) of 5 (#2, #45, #57, #66 and #352) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations. Findings: Review of the facility's policy titled Pneumococcal Vaccine (Series) with a review date of 05/2024 revealed in part .It is our policy to offer our residents, staff and volunteer workers immunization against Pneumococcal disease in accordance with current CDC guidelines and recommendations. Policy Explanation and Compliance Guidelines: 2. Each resident will be offered a Pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered. Review of Resident #45's clinical record revealed an admission date of 11/29/2018 with diagnosis which included: COVID-19, Heart Failure Unspecified, Acute Upper Respiratory Infection Unspecified, and Other General Symptoms and Signs. Review of Resident #45's clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-14 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to provide a safe, functional, sanitary, comfortable environment for residents by failing to adequately clean the community shower and bath rooms in the facility. This had the ability to affect all 92 residents in the facility. Findings: Review of the facility's Routine Cleaning and Disinfection Policy revealed in part . Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Observation on 08/14/2023 at 9:17 a.m. of the shower room on Hall X revealed 2 dirty towels and a dirty diaper on the floor. Interview at this time with S4 LPN confirmed these findings. She stated these items should not be on the floor. Observation on 08/14/2023 at 11:20 a.m. of the shower room on Hall X revealed a dirty towel on the floor. Observation on 08/14/2023 at 11:27 a.m. of the community shower/bath room on Hall W revealed a hair brush full of hair in the sink. There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-14 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 maintain an effective pest control program to ensure the residents had a pest free environment. The deficient practice had the potential to affect all residents in the facility. Findings: Review of Resident #2's EHR Annual MDS with an ARD of 07/18/2023 revealed a BIMS of 15 (cognitively intact). Interview with Resident #2's wife on 08/14/2023 at 8:47 a.m. revealed a pest problem existed at the facility with flies,gnats, cockroaches and June bugs. Observation on 08/14/2023 at 8:50 a.m. of Resident #2's room revealed the trash can overflowing with trash; the floor filthy with trash, food debris, and grime; spider webs with small black specks located in the crevices along both sides of the air condition unit; 2 dead brown bugs underneath the air condition unit on the floor; and flies and gnats flying around in the room. There was a dead cockroach on the bathroom floor in front of the toilet. Interview with Resident #2 on 08/14/2023 at 8:50 a.m. revealed he had seen cockroaches, gnats, flies and June bugs in his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-04-26 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to: 1. Maintain soiled linen in a sanitary manner; 2. Store clean linen in a sanitary manner; 3. Ensure staff were consistent with infection control practices for cleaning Residents' shower; and 4. Ensure staff changed gloves and performed hand hygiene after touching contaminated area during wound care for a resident who was diagnosed with MRSA (Methicillin-Resistant Staphylococcus Aureus) (#65). Findings: 1. Observation on 04/25/2023 at 9:50 a.m. revealed 18 soiled linen containers outside of the laundry area. Two of the soiled linen containers containing soiled linens were uncovered without lids attached. Interview and observation on 04/25/2023 at 10:20 a.m. with S1 Administrator outside of the laundry area revealed two soiled linen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-26 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure resident assessments accurately reflected the residents' status due to improper coding of hearing aid, toileting use, schizophrenia and chronic renal failure diagnosis for 3 (#30, #53, #84) of 31 sampled residents. Findings: Resident #30 Review of Resident #30's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis of Schizophrenia. Resident #30's clinical record revealed the Schizophrenia diagnosis resolved on 12/15/2022. Review of the S12 PSY (Psychiatrist), Nurse Practitioner's notes dated 12/07/2022 and 01/18/2023 indicated no documented evidence of Schizophrenia diagnosis. Review of the telephone order dated 12/07/2022 for Resident #30 revealed S12 PSY, Nurse Practitioner ordered to remove diagnosis of Schizophrenia. Review of Resident #30's Quarterly MDS (Minimum Data Set) with the ARD (assessment reference date) of 03/10/2023 revealed, in part: Section C, Bims (Brief Interview Mental Status), indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-26 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure 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 record review and interview, the Facility failed to ensure each Residents' medication regimen was free from unnecessary medications by failing to discontinue an antidepressant as ordered by the physician for 1 (#72) of 5 (#34, #72, #19, #65 and #71) Residents reviewed for unnecessary medications in a total sample size of 31. Findings: The Facility's Policy Titled Medications-Unnecessary Drugs-Without Adequate Indication for Use read in part . Policy Explanation and Compliance Guidelines: 2. Each Resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: (a) Dose (including duplicate therapy). (b) Duration of use (c) Indications and clinical need for medication (d) Adequate monitoring for efficacy and adverse consequences (e) Preventing, identifying and responding to adverse consequences (f) Any combination of the reasons stated above. Review of Resident #72's medical record revealed an admit date of 02/22/2022 with the following diagnoses: Brief Psychotic Disorder, Unspecified Dementia, Major Depressive Disorder and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-26 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the Facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Findings: Observation on 04/24/2023 at 9:00 a.m. of the walk in freezer revealed: 1. 2 boxes of hamburger patties open and undated. 2. 1 box of ground beef meat pies open to air and undated. 3. 2 boxes of garlic bread open to air and undated. Observation of the kitchen's microwave at this time revealed dried splattered food particles in the top and on the side. Review of the kitchen's cleaning schedule revealed no documentation of when the microwave was cleaned. Interview at the time of observation with S5 DM revealed the staff who opens a food item should label and date it and store it properly. S5 DM confirmed: The above listed items were not dated and they should have been; the above listed items were open to air and they should not have been; and the kitchen's microwave was splattered with dried food particles and it should not have been.
- Potential for harm · Ecited before2023-04-26 · tag F0814 — failed to dispose of garbage properly — patternDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the Facility failed to ensure garbage and refuse were disposed of properly. Findings: Observation on 04/24/2023 at 9:20 a.m. of the outside kitchen area accompanied by S5 DM revealed 3 trash cans without lids with black garbage bags inside each, contained soiled diapers, gloves, food, wash basin and other trash. Observation of the garbage disposal area revealed 3 blue dumpsters. Two of the dumpster's top lid was open and the middle dumpster had a side sliding door which was open. Dirty gloves and trash littered the ground surrounding the dumpsters. A wood fence surrounded the garbage disposal area was broken and leaning. Observation revealed two large trapping cages by the third dumpster. Observation and interview at 9:35 a.m. with S1 Administrator confirmed trash outside of the kitchen area in trash cans without lids. S1 Administrator stated the 10:00 p.m.-6:00 a.m. shift CNA's were supposed to put the trash in the big dumpsters at the end of their shift. S1 Administrator confirmed the dumpster doors were open and the ground surrounding the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-26 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the Facility failed to treat Residents with respect and dignity by failing to provide a cover for a drainage bag for 1 (#88) of 2 (#43, #88) sampled Residents with an indwelling catheter. The total sample size was 31. Findings: Review of Resident # 88's EHR revealed and admit date of 11/15/2022. Resident #88 had the following diagnoses including in part . Urinary Tract Infection, Major Depressive Disorder, Retention of Urine, Bacteremia, and Chronic Kidney Disease. Review of Resident #88's Quarterly MDS with ARD of 02/12/2023 revealed in part .Resident had a BIMS of 13 (Cognitively intact). Resident had an indwelling catheter, and required extensive assistance for toileting. Review of Resident #88's April 2023 MD orders revealed in part . 03/06/2023 Foley Catheter 16FR for urinary retention 03/06/2023 Foley Catheter care every shift and as needed 03/23/2023 Change Foley Catheter every month on the 23rd and as needed for leakage. Observation on 04/25/2023 at 8:20 a.m. revealed Resident #88 lying in bed. The Resident's catheter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-26 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the Facility failed to ensure their grievance policy and procedure was followed by failing to ensure prompt investigation of an allegation and to provide a written summary of the report for 1 (#13) of 31 sampled Residents. Findings: The Facility's Policy Titled Grievances/Complaints read in part . 4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations; and ensure that immediate action is taken if necessary to prevent further potential violations of any resident rights while the allegation is under investigation. 7. A written summary of the report will also be provided to the resident which includes date grievance was received, summary of the grievance, a statement of whether or not the grievance was confirmed, any corrective action to be taken by the facility and the date the decision was issued. The summaries will be maintained in the facility for a period of no less than 3 years from issuance of the decision. Review of Resident #13's medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure resident assessments accurately reflected the residents' status due to improper coding of hearing aid, toileting use, schizophrenia and chronic renal failure diagnosis for 3 (#30, #53, #84) of 31 sampled residents. Findings: Resident #30 Review of Resident #30's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis of Schizophrenia. Resident #30's clinical record revealed the Schizophrenia diagnosis resolved on 12/15/2022. Review of the S12 PSY (Psychiatrist), Nurse Practitioner's notes dated 12/07/2022 and 01/18/2023 indicated no documented evidence of Schizophrenia diagnosis. Review of the telephone order dated 12/07/2022 for Resident #30 revealed S12 PSY, Nurse Practitioner ordered to remove diagnosis of Schizophrenia. Review of Resident #30's Quarterly MDS (Minimum Data Set) with the ARD (assessment reference date) of 03/10/2023 revealed, in part: Section C, Bims (Brief Interview Mental Status), indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the Facility failed to ensure that Residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide hair and nail care to dependent Residents for 2 (Resident #11 and Resident #34) of 31 sampled Residents. Findings: Resident #11 A review of Resident #11's HER revealed she was admitted to the facility on [DATE] with diagnoses that included in part . Type 2 Diabetic Mellitus, Essential (primary) Hypertension, Primary open -angle glaucoma bilateral, and Dementia. Review of Resident #11's Quarterly MDS with an ARD of 03/24/2023 revealed Resident #11's BIMS was 99 and the Resident was coded for being severely impaired-never/rarely made decisions, blind and hard of hearing. Resident #11's functional status revealed she required one person physical assistance with transferring, shower/bathing, toileting and dressing. Review of Resident #11's Care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-04-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a Resident received adequate supervision to prevent accidents while smoking for 1 (# 2) of 1 Residents reviewed for smoking in a total sample of 31 Residents. Findings: Resident #2 was admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder, Hypertensive Heart disease, Chronic Obstructive Pulmonary Disease, Peripheral vascular disease, Essential Hypertension, and Anxiety disorder. A review of Resident#2's safe smoking assessment dated [DATE] revealed that Resident#2 can light and smoke cigarettes' using safe technique for putting out the match or lighter and disposing of the ash. Resident #2 is physically able to safely hold the cigarette while smoking, remains alert during smoking, demonstrated the she only smokes in designated areas in or around facility and avoids smoking with oxygen use or in the area. Upon random inspection Resident #2's clothing and bed linens were free of burn holes and has demonstrated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to RIGHTCARE HEALTH SERVICES — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 2 of 5 | 1.9 | +0.1 vs chain |
The other 12 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DAVIS, ERIC | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 13% | since 07/01/2019 |
| DOWDEN, CHRISTINE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 01/01/2024 |
| GATES, CYNTHIA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 5% | since 01/01/2024 |
| HERPIN, DANIEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 01/01/2024 |
| KIMBLE, SHANNON | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 01/01/2024 |
| LEBOUEF, STEPHANIE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 01/01/2024 |
| POSTON, ALBERT D | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 6% | since 08/29/2001 |
| POSTON, BRYAN A | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 09/30/2011 |
| POSTON, LARRY S | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 09/30/2011 |
| SANDERS, JACK | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | 11% | since 05/01/2024 |
| STEVENS, VIKKI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 13% | since 07/01/2019 |
| SULLIVAN, MARJORIE P | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 08/29/2001 |
| CA DAVIS ENTERPRISES LLC | Organization | DIRECT OWNERSHIP INTEREST | — | since 11/01/2023 |
| DAVIS, CRAIG | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 13% | since 04/16/2019 |
| RIGHTCARE HEALTH SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/11/2025 |
CMS files one row per role, so the 21 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% 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 $658K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in LA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195525. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-30, 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.