Oak Lane Wellness & Rehabilitative Center
1400 W Magnolia, Eunice, LA 70535 · For profit - Corporation · 130 certified beds · (337) 550-7200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $96,785 in federal fines (most recent 2025-04-02)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (58%) 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 | 14.7% | 17.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.6% | 5.2% | 5.4% | typical |
| 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 | 0.4% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 2.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.7% | 0.2% | 0.1% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.6% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 7.0% | 17.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.8% | 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 | 2.2% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 32.6% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.9% | 22.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 3.1% | 1.4% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 39.0% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.3% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.37 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.59 | 2.74 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
46.5% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.3% 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 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% 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
| 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 | 46.5%CMS range 33.9–58.2 | 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 | 12.3%CMS range 9.3–17.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 54.3% | 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 | 65.7% | 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 | 45.7% | 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 | 96.3% | 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 | 1.9% | 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 | 9.1%CMS range 4.9–15.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 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 130 beds and averages 74.7 residents a day — about 57% occupied, or roughly 55 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.94 hrs/resident/day on weekends vs 3.60 on weekdays — 19% thinner on weekends. RN hours go from 0.26 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · J2025-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility staff failed to recognize and properly respond to a resident who was demonstrating exit seeking behaviors or recognize the Wanderguard alarm to prevent elopement for 1 (Resident #1) of 5 residents investigated for elopement (Resident #1, #4, #5, #6 and #7). This deficient practice resulted in an Immediate Jeopardy on 03/22/2025 at 10:40 a.m. when Resident #1, a moderately cognitively impaired resident, eloped from the facility located in a residential area. On the morning of 03/22/2025, prior to his elopement, Resident #1 asked staff members for the code to the facility's door alarm and expressed that he wanted to go home before exiting the facility undetected by staff. Staff failed to recognize the residents exit seeking behavior and the sound of the wanderguard as he went out of the door. On 03/22/2025 at 10:50 a.m., the facility received a phone call from Resident #1's responsible party that Resident #1 was at his home. Resident #1 walked…
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.
- Actual harm · G2024-05-22 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 implement its antibiotic stewardship policy to timely evaluate culture and sensitivity results in order to determine appropriate antibiotic usage by failing to: 1. Obtain culture report and sensitivity data in a timely manner in order to initiate possible treatment for Residents #43 and #77 and; 2. Notify the physician of culture report and sensitivity data in order to ensure Resident #380 was prescribed the appropriate antibiotic, out of 6 (Residents #34, #43, #54, #65, #70, #77, and #380) residents reviewed for infection control tracking and trending during the Infection Control facility task. The facility's census was 77. This deficient practice resulted in actual harm when Resident #43's final urine culture and sensitivity final report dated 04/26/24 showed that the bacteria, Klebsiella pneumoniae, was present in the resident's urine. The facility failed to have the final culture and sensitivity report resulted on 4/26/2024 in the resident's 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 · Ecited before2026-03-25 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's plan of care was implemented as ordered through five consecutive months by failing to follow physician orders for completing wound care and monitor swelling for 1 (Resident #2) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.Findings:Review of Resident #2's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease and dementia.Review of Resident #2's November 2025 physician's order and TAR (Treatment Administration Order) revealed the following order dated 11/07/2025: Skin tear to R (right) forearm. Clean with NS (normal saline), apply TAO (triple antibiotic ointment), cover with a dry dressing daily until healed. The TAR failed to reveal evidence that treatment for the skin tear to the right forearm was administered for the resident for November 2025.Review of Resident #2's December 2025 physician's order and TAR…
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 before2025-06-25 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or physician's orders for 1 (Resident #38) out of 29 sampled residents. This deficient practice was evidenced when the facility failed to implement standing orders for constipation for Resident #38. Findings: Review of Resident #38's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's disease, Diabetes Mellitus and Cerebral Infarction. Review of Resident #38's Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C, revealed Resident #38's Brief Interview for Mental Status (BIMS) score was 12, indicating her cognition was moderately impaired. Further review of the assessment, under Section H revealed Resident #38's bowel continence was always incontinent. Review of Resident #38's Care Plan revealed in part, risk for inadequate bowel pattern. Interventions included in part, administer medication as…
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 before2025-06-25 · 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 observations and interviews, the facility failed to maintain professional standards for food service safety by failing to: 1. Discard food items that were past the used by date, 2. Label and date opened food items stored in the walk in cooler, 3. Label and date an opened food item in the area where food is prepared 4. Label and date an opened food item in the pantry, 5. Remove a dented can from the dry storage area, 6. Ensure kitchen staff wear proper hair restraints. The facility's census was 69. Findings: A review of the facility's policy titled Food Receiving and Storage with a last review date of 08/07/2024 read in part, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use bydate). A review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices with a last review date of 08/07/2024 read in part, Policy Statement: Food and nutrition services employees will follow appropriate…
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 · D2025-06-25 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (#59) out of 29 sampled residents. The facility failed to provide a diet according to Resident #59's food preferences. Findings: A review of Resident #59's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Cerebral Infarction, Dementia, and Vitamin Deficiency. A review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident has a BIMS (Brief Interview for Mental Status) score of 06, indicating the resident's cognition was severely impaired. On 06/23/2025 at 11:18 a.m., an observation was conducted of Resident #59 consuming lunch. He did not eat the mixed vegetables or beans that were on his lunch tray. An interview was conducted with Resident #59 at this time,…
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 before2025-06-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #66) out of 29 sampled residents. Findings: Review of Resident #66's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to unspecified combined systolic (congestive) and diastolic (congestive) heart failure. Further review revealed Resident #66 was discharged on 04/25/2025. Review of Resident #66's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a code of 2 in section A0310 - Type of Assessment, which indicated unplanned discharge. Review of Resident #66's care plan revealed a focus area initiated on 01/28/2025 for D/C (discharge) planning - active plans to return to the community. A review of progress notes revealed on 04/24/2025 at 10:59 a.m. S12LPN (Licensed practical Nurse) wrote: New order per (by) Dr. (doctor) .for patient to be discharged home with home…
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 · D2025-06-25 · 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 review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) receives services to maintain personal hygiene for 1 (#16) of 1 (#16) residents investigated for ADL care. The sample size was 29. Findings: Resident #16 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral infarction and unspecified dementia, unspecified severity and encounter for palliative care. Review of Resident #16's Significant Change Minimum Data Set (MDS) assessment revealed a code of 1 in section GG0115 A. Upper extremity, indicating the resident had impairment on one side. Further review revealed a code of 03 in section GG0130. Self-Care I. Personal hygiene indicating the following .Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Review of Resident #16's care plan revealed a focus area initiated on 01/24/2025 for mobility and self-care needs with an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to properly store respiratory equipment for 2 (Resident #16 and Resident #22) out of 3 residents (Resident #16, Resident #22 and Resident # 63) investigated for respiratory care. Findings: Resident #22: Review of Resident #22's electronic medical record revealed that she was admitted on [DATE] with a diagnosis of obstructive sleep apnea. Review of the resident's June 2025 physician orders revealed an order to change replacement cushion (mask) on CPAP machine every month on the 22nd. On 06/23/2025 at 09:15 a.m., an observation was made of Resident #22's CPAP mask in a plastic storage bag dated 05/13/2025. On 06/23/2025 at 2:35 p.m., an interview and observation was conducted with S2DON (Director of Nursing). S2DON stated the plastic storage bags for the CPAP mask should be changed once a month when they change the CPAP mask. She confirmed the plastic bag with the resident's CPAP mask was dated 05/13/2025. She stated that the plastic storage bag should have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-25 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 Resident #50 Review of Resident #50's electronic medical record revealed he was admitted to the facility on 09/12//2022 with the following diagnoses in part, but not limited to, Type 2 Diabetes mellitus, cerebral infarction and chronic obstructive pulmonary disease. On 06/23/2025 at 10:20 a.m., a medication administration observation was conducted with S15LPN (Licensed Practical Nurse). After S15LPN drew up Resident #50's insulin injection, she proceeded to the resident's room and administered his injection without donning gloves prior to giving the injection. On 06/23/2025 at 10:30 a.m., an interview was conducted with S15LPN. S15LPN confirmed she did not wear gloves when she administered Resident #50's injection. She stated that she should have worn gloves to give the injection. Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of…
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 · D2025-04-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 resident (#2) out of 7 (#1,#2, #3, #4, #5, #6, #7) sampled residents. Findings: Review of the facility's policy titled Prevention of Pressure Ulcer/Injuries, with a last reviewed date of August 2024, read in part: 1. Evaluate, report, and document potential changes in the skin with weekly skin assessments. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including; type 2 diabetes, pressure ulcer of sacral region, and unstageable pressure induced deep tissue damage of other site. Review of Resident #2's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed section M in part: Resident has a pressure ulcer/injury, at risk for developing pressure ulcers. Review of Resident #2's care plan initiated on 12/12/2024 revealed an intervention to conduct body audit per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-22 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on in record review and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility by failing to ensure dialysis communication forms were filled out completely for 1 (#66) resident sampled for dialysis. The deficient practice had the potential to affect 1 dialysis resident that resided in the facility. Findings: On 05/22/2024 at 2:27 p.m., a request was made for a facility policy for dialysis communication. No policy was provided by the time of survey completion and exit. A review of Resident #66's EMR (Electronic Medical Record) revealed an admission date of 01/11/2023 with diagnoses that included End Stage Renal Disease, Essential Hypertension, and Type 2 Diabetes Mellitus. A review of Resident #66's Physician's Orders from May 2024 revealed an order with a start date of 01/26/2024 that read; Hemodialysis at dialysis center on Tuesday, Thursday, Saturday. Send communication form on all visits. A review of Resident #66's dialysis communication forms revealed a total of 39 sheets with date ranges from 02/01/2024 through…
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 · E2024-05-22 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to ensure recipes for pureed, chopped, and bite sized meals were used during meal preparation. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for 1 (#26) resident who received pureed meals, 6 residents ( #16, #19, #29, #32, #49 and #65) who received mechanical chopped meals, and 13 residents (#2, #4, #5, #7, #23, #28, #30, #42, #46, #58, #68, #69, and #71) who received bite sized meals. Findings: On 05/20/2024, a review of the facility's policy and procedure titled, Therapeutic Diets, with a reviewed date of 08/02/2023 revealed in part: .7. Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet, unless approved by the Attending Physician in conjunction with the Clinical Dietitian . Review of the facility's dinner menu for pureed, mechanical chopped and bite sized meals on 05/20/2024 revealed hamburger steak with gravy. Review of the facility's week 3…
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 · D2024-05-22 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment for 1 (#50) out of 3 (#44, #48, and #50) residents investigated for environment out of a total sample of 55 residents. Findings: Resident #50 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hypertension, Heart Failure, and Hyperlipidemia. Review of Resident #50's Quarterly MDS (Minimum Data Set) dated 02/21/2024 revealed the Brief Interview for Mental Status (BIMS) of 15, suggesting his cognition was intact. Under Section GG: Functional Abilities and Goals revealed the resident utilized a wheelchair as his mobility device. On 05/20/2024 at 8:47 a.m., an observation was made of Resident #50's bathroom. There were multiple areas of paint scraped off of the wall on the left side of the toilet. Further observation revealed there were multiple areas of paint scraped off the wall near the shower. On 05/22/2024 at 8:43 a.m., a second observation was made of the resident's bathroom. 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 · D2024-05-22 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 interviews, the facility failed to complete a comprehensive assessment, including resident's dental status, within 14 days of admission for 1 (#131) of 1 (#131) resident reviewed for pain management from a sample of 55 residents. Findings: Record review of Resident #131's electronic record confirmed she was admitted on [DATE] with diagnoses of Vitamin Deficiency, Depression, Acute Embolism and thrombosis of deep veins, Long Term Use of Anticoagulants, Gastro Esophageal Reflux Disease, and Hypertension. On 05/20/2024 at 2:20 p.m., an observation of Resident #131's oral cavity revealed the residents' upper gums had missing and broken teeth at the gum level. Her bottom gums had approximately 6 teeth in the front that were broken and decayed. She stated she has pain continuously especially when she eats. Record review of Resident #131 Electronic MDS (Minimum Data Set) , with an Assessment Reference Date (ARD) of 5/7/2024 , Section L titled Oral/Dental Status under Dental…
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 · D2024-05-22 · 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 — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure resident assessments were opened, completed, and electronically transmitted in a timely manner for 1 (#74) out of 3 (#51, #66 and #74) residents investigated for Resident Assessment out of a finalized sample of 55 residents. This deficient practice had the potential to affect 77 residents that resided in the facility. Findings: A review of resident #74's EMR (Electronic Medical Record) revealed an admission date of 12/12/2023 with diagnoses that included Edema and Hypothyroidism. Further review of the EMR revealed a discharge date of 02/02/2024. Continued review of the resident's EMR revealed no documented evidence that a discharge assessment was opened, completed and/or transmitted in the last 120 days. On 05/22/2024 at 2:02 p.m., a concurrent record review and interview was conducted with S10LPN (Licensed Practical Nurse). S10LPN confirmed the residents discharge date of 02/02/2024. She then viewed Resident #74's EMR and confirmed a discharge assessment had not been opened, completed, or transmitted. S10LPN also…
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 · D2024-05-22 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASRR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#20) out of 2 (#3,#20) sampled residents investigated for PASRR. This had a potential to effect a census of 77. Findings: On 05/22/2024 a review of the facility's policy titled PASRR Level II Request for Resident Review Guidelines to Follow if a Resident Review/Level II is Needed (review date 08/02/2023) was conducted. The policy read in part, If any of the below exist, a Resident Review may be required - The resident has a new mental health diagnosis, which will not normally resolve itself once the condition stabilizes. Review of Resident #20's electronic medical record revealed she was admitted to the facility on [DATE] with a diagnosis that included in part, Bipolar Disorder, Unspecified (05/31/2022). Review of Resident #20's current physician orders…
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 before2024-05-22 · 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 staff interviews, observations and record review, the facility failed to follow the physician's orders for 1 (#8) resident as evidence by failing to check for residual before the nurse administered PEG (percutaneous endoscopic gastrostomy) tube water flush and bolus feeding as scheduled. The final sample size was 55. Findings: On 05/22/2024, a review of the facility's policy titled Restraints and Safety Devices with a last reviewed date of 08/02/2023 read in part, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .Steps in the Procedure . 20. Check gastric residual volume (GRV) to assess for tolerance of enteral feeding. 21. When correct tube placement and acceptable GRV has been verified, flush tubing . Review of Resident #8's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Gastro-Esophageal Reflux Disease, Gastrostomy Status, and Gastritis. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-22 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to effectively manage pain for 1 (#131) of 1 (#131) resident reviewed for pain management out of sample of 55 residents. Findings: On [DATE] at 2:00 p.m., review of the facility's policy dated [DATE] titled, Pain Assessment and Management, read in part, Purpose .to help the staff identify pain in the resident .that are consistent with the resident's goals and needs and that address the underlying causes of pain .Steps to . Recognizing pain .f. rubbing or favoring a particular part of the body. g. difficulty eating .Assess pain using a consistent approach and standardized pain assessment .Re-assess the residents pain and consequences of pain at least each shift for acute pain. Monitor the resident by performing a basic assessment ( .pain scales .) .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Record review of Resident #131's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-22 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 observations, interview and policy and procedure review, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to ensure opened containers in dry storage and foods stored in the facility's freezer were labeled and dated. Findings: On 05/20/2024, a review of the facility's policy and procedure titled, Food Receiving and Storage, with a last reviewed date of 08/02/2023 revealed in part: Foods shall be received and stored in a manner that complies with safe food handling practices . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On 05/20/2024 at 9:00 a.m., an initial tour of the facility's kitchen was conducted with S8DM (Dietary Manager). The facility's dry storage area revealed a one gallon bottle of vanilla extract that was opened and had been used. On a separate shelf of the dry storage area, there was one 16 ounce plastic container of grated parmesan that was opened and had been used. S8DM confirmed these two…
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 · D2024-05-14 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the responsible party for 1 (#1) of 3 (#1, #2, #3) residents sampled for an incident that involved suspected sexual abuse. Findings: A review of the facility's policy titled, Abuse: Definition: 3. Sexual Abuse: non-consensual sexual contact of any kind revised 06/01/2017 that read: Procedure - Patient grievances system for patient abuse: 1. anyone who receives or witnesses an incident of patient abuse or neglect must report the incident to the immediate supervisor who in turn reports to Social Services Director/Director of Nurses (SSD/DON) and administrator. This does not say anything about notifying the responsible party. Review of the facility Incident and Accident report dated 04/27/2024 at 3:40 p.m., read in part: Resident #1 was at the medication cart when the nurse was passing medications. When the nurse began to gather supplies to obtain blood sugar, Resident #1 wandered into Resident #2's room. The nurse went into Resident #2's room 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 · D2024-05-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, video review, and interview, the facility failed immediately implement safeguards to protect a resident without the capacity to consent to sexual activity from sexual abuse for 1 (#1) of 3 (#1, #2, #3) sampled residents when Resident #2 had non-consensual sexual contact with Resident #1. This deficient practice had the potential to affect 3 female residents who resided on the dementia care unit. Findings: Review of the facility's Policy and Procedure titled, Abuse read in part sexual abuse is nonconsensual sexual contact of any type with a resident. Sexual abuse includes, but is not limited to: A. unwanted intimate touching of any kind especially of breast or perineal area. B. all types of sexual assault or battery, such as rape, sodomy and coerced nudity. If you suspect any type of abuse, the Director of Nursing (DON) must be notified immediately or the administrator to determine next step. The facility will conduct an investigation and protect a resident from nonconsensual sexual…
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 · D2024-05-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure alleged violation of sexual abuse were reported immediately, but not later than 24 hours after the allegation was made to the State Survey Agency for 1 (#1) out of 3 (#1, #2, #3) sampled residents. This had the potential to effect a census of 78 residents. Findings: A review of the facility's policy titled Unusual Occurrence Reporting revised date 12/2007 read in part Policy Interpretation and Implementation: 1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect and misappropriation of resident property. H. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event…
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 before2023-08-22 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 review and interviews, the facility failed to ensure that staff wore the appropriate PPE (personal protective equipment) and performed hand hygiene when providing care to a resident on contact transmission based precautions (TBP) per the facility's policy for 1 (#4) of 4 (#4, #5, #R2, #R3) residents in the facility on TBP in a sample of 5 (#1-#5) residents. This deficient practice affected Resident #R1 and had the potential to affect 23 other residents on Hall A who were not on TBP. The facility's census was 74. Findings: Review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions revealed in part: Transmission-based precautions are initiated when a resident has a laboratory confirmed infection and is at risk of transmitting the infection to other residents .Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact 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 · Ecited before2023-05-24 · 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 observations and interviews, the facility failed to ensure the air conditioning ventilation system above where food was being prepared and served was sanitary. This had the potential to affect the 76 Residents that consumed food out of the kitchen. Finding: On 05/22/2023 at 11:38 a.m., an observation with S8Cook, confirmed that above the steam serving table was the housing for the roller window that was covered with a brown greasy lint like substance. The overhead air conditioning output vents and ceiling throughout the kitchen was covered with the same brown greasy lint like substance. The overhead air conditioners 2 intake vents at the exit was covered with the same brown greasy lint like substance. At this time, S8Cook stated that maintenance usually cleans all the air conditioning vents in the kitchen. On 05/23/2023 at 10:13 a.m., an observation with S9DM (Dietary Manager) confirmed the overhead air conditioning intake and output vents were still not cleaned. She stated maintenance was to clean the air conditioning vents and cleaning the air conditioning ventilation…
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 before2023-05-24 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident's PASARR (Preadmission Screening and Record Review) Level II was accurately coded on the MDS (Minimum Data Set) for the comprehensive assessment for 1 (Resident #4) out 1 (Resident #4) resident reviewed for PASARR. The facility had a census of 76 residents. Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses including Paranoid Schizophrenia, Other Schizophrenia, Schizoaffective Disorder and Bipolar Disorder. Resident #4's record revealed resident had a current Level II PASARR that was effective 05/28/2022 through 05/28/2023. Record review of resident #4's annual comprehensive MDS assessment dated [DATE], Section A1500 questioned; Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or related condition? The section was coded 0 for no. On 05/24/2023 at 1:13 p.m., an interview was conducted with S4MDS. S4MDS stated that she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to revise 1 (#4) residents care plan to include the level II PASARR invite 1 (#5) residents to care plan meeting for 2 (#4, #5) residents reviewed for Care Planning from a sample of 18 Residents. The facility had a census of 76 residents. Findings: Resident #4 Resident #4 was admitted to the facility on [DATE]. Records review revealed the resident had diagnoses including Paranoid Schizophrenia, Other Schizophrenia, Schizoaffective Disorder and Bipolar Disorder. Resident #4's record revealed resident had a current Level II PASARR (Preadmission Screening and Resident Review) that was effective 05/28/2022 through 05/28/2034. Records review of Resident #4's care plan revealed there were no entries regarding interventions to care for the above mentioned diagnoses addressed in the resident's Level II PASARR. An interview was conducted on 05/24/2023 at 1:34 PM with S5MDS. S5MDS confirmed that Resident #4 was not care planned for having a Level II PASARR.…
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 · D2023-05-24 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, record review and interviews, the facility failed to ensure a resident's medical record clearly reflected the resident's wishes for do not resuscitate for 1 (#60) of 2 (#60 and # 4) residents reviewed for Hospice care. The facility had a census of 76 residents. Findings: Review of the facility's Advance Directive policy revealed in part, 2. A do not resuscitate (DNR) order must be completed and signed by the attending physician and placed in the front of the residents chart. Review of Resident #60's medical record revealed an admit date of [DATE] with diagnoses that included dementia unspecified, anxiety disorder, diabetes type 2, and atherosclerosis heart disease of native artery. Resident #60 was admitted to hospice services on [DATE]. Review of Resident #60's electronic physician's orders revealed a code status for DNR dated [DATE] and an order for full code status that was discontinued. Review of resident #60's paper medical record binder revealed a full page physician's order in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to clean resident's CPAP (Continuous Positive Airway Pressure) machines' reservoir as required by the facilities policy and procedure for 1 (#5) of 4 (#5, #7. #12, #23) Residents reviewed for Respiratory Care from a sample of 18 Residents. Findings: Record review of the facilities policy titled CPAP Support, under General Guidelines for cleaning read in part, 4. Machine Cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. 5. Humidifier: a. Use clean distilled water only in the humidifier chamber., b. Clean humidifier weekly and air dry., c. to disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnosis of Congestive Heart Failure, Morbid-Severe-Obesity, Asthma, Congestive Obstructive Pulmonary Disease, Acute and Chronic Respiratory failure, Sleep Apnea, Hypoxia, 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.
“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
$96,785 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $65,458 — penalty dated 2025-04-02
- $31,327 — penalty dated 2024-05-14
- Medicare payment denial — starting 2024-06-21 for 7 days
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| LAFLEUR, CLARK DAVID | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 10% | since 05/01/2003 |
| LAFLEUR, ELLA MAE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 60% | since 04/15/2013 |
| LEGER, ANGELLA FAE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 10% | since 05/01/2003 |
| LEONARDS, LLOYD P | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | 10% | since 05/01/2003 |
| DUPLECHIN, OLIVIA | Individual | W-2 MANAGING EMPLOYEE | — | since 10/30/2013 |
CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
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.
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 195588. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-25, 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.