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Gueydan Memorial Guest Home

1201 Third St, Gueydan, LA 70542 · Government - Hospital district · 66 certified beds · (337) 536-6584 Medicare & Medicaid certified

Call the home — (337) 536-6584 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0567)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0567)
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
802 Manceaux Ave · (337) 643-3800 · Call to confirm hours
Pharmacy
200 Main St · (337) 536-9600 · Call to confirm hours
Grocery
909 1st St · (337) 536-9525 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 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 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.7%17.8%15.4%worse
Long-stay residents who lose too much weight4.1%5.2%5.4%better
Long-stay residents with a catheter left in their bladder1.1%1.2%0.9%worse
Long-stay residents with a urinary tract infection6.8%2.1%2.0%worse
Long-stay residents with depressive symptoms0.0%2.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.9%3.5%3.3%worse
Long-stay residents whose ability to walk worsened11.3%17.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication36.4%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine94.5%94.9%95.3%typical
Long-stay residents with pressure ulcers1.8%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control22.2%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table25.2%22.7%17.1%worse
Short-stay residents rehospitalized after admission14.9%28.0%22.6%better
Short-stay residents with an outpatient ER visit6.7%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.782.561.67typical
Long-stay outpatient ER visits per 1,000 resident days2.602.741.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

13.0%U.S. median 10.7%
Went back to hospital
0.21U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.0%CMS range 9.1–18.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.461.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.25
RN hours/ resident / day
0.87
LPN hours/ resident / day
2.01
Aide hours/ resident / day
3.13
Total nurse hours/ resident / day
0.17
RN hoursweekends
31.0%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 66 beds and averages 55.7 residents a day — about 84% occupied, or roughly 10 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.

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 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.55 hrs/resident/day on weekends vs 3.36 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.28 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-08-27)
11
at the previous standard inspection (2024-08-07)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Ecited before2025-08-27 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (#2, #13, and #42) residents out of 29 sampled residents. Findings: Resident #2 Review of Resident #2's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with a diagnoses which included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an assessment reference date of 07/01/2025 revealed Section N0415 (J) Hypoglycemic was coded no which indicated the resident did not receive a hypoglycemic in the 7 day look back period. Review of Resident #2's Medication Administration Record (MAR) revealed that Lantus and Novolog were administered 06/25/2025 through 07/01/2025. On 08/26/2025 at 4:02 p.m., an interview and review of Resident #2's MDS with an assessment date of 07/01/2025 was conducted with S4MDS. S4MDS confirmed that yes should have been coded for section…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 policy review, the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#5) out of 1 (#5) resident investigated for tube feeding.Findings:On 08/25/2025, a review of the facility's policy titled, Enteral Tube Feeding via Continuous Pump, with a last review date of August 2025, revealed in part.Purpose: The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.Initiate Feeding:.5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Review of Resident #5's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, muscle wasting and atrophy, dysphagia, and gastrostomy status. Review of Resident #5's August 2025 physician's orders revealed an order dated 07/30/2025 that read in part.Enteral Feed Order every shift.Osmolite 45 ml (milliters)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 1 (#18) out of 1 (#18) resident investigated for respiratory care.Findings:On 08/25/2025, a review of the facility's policy titled, Oxygen Administration, with a last review date of August 2025, revealed in part.Purpose: The purpose is to provide guidelines for safe oxygen administration. Oxygen shall only be administered by physician order.Steps in the Procedure.4. Turn on the oxygen. Start the flow of oxygen at the rate order by physician. Review of Resident #18's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease and pneumonia. Review of Resident #18's Annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 07/02/2025 revealed she had a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to ensure: 1. Resident #13 was assessed for the risk of entrapment from assist bars. 2. Informed consent was obtained from the resident or the resident's representative prior to installation of assist bars for Resident #13. The deficient practice occurred for 1 (Resident #13) of 29 sampled residents. Findings: A review of the facility's policy, Bed Safety and Bed Rails, with a last review date of August 2025, revealed in part: Use of Bed Rails, The resident assessment to determine risk of entrapment includes, but is not limited to : a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medications; e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. cognition, j. communication; k. mobility (in and out of bed); and i. risk of falling. 8. Before using bed rails for any reason, the staff shall…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including accurately documenting controlled medication reconciliation in 1 (Med (medication) Cart 1) of 2 (Med Cart 1 and Med Cart 2) med carts for Resident #43. Findings:A review of the facility's policy titled, Controlled Substances with a last review date of 08/2025, read in part, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medication. The policy also indicated general guidelines, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up.A review of Resident #43's electronic medical record revealed she was admitted to the facility on 0721/2022 with a diagnosis that included in part, Anxiety Disorder.A review of Resident #43's physician's orders revealed a start date of 08/16/2025: Lorazepam Oral Tablet 1 mg (milligram) *Controlled Drug* Give 1 tablet…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, observations, and record review the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles as evidenced by: 1. failing to discard an expired medication in 1 (Med (medication) Cart 1) of 2 (Med Cart 1 and Med Cart 2) med carts, 2. failing to discard 2 expired medications in 1 (Med Room) of 1 (Med Room), and 3. failing to ensure food was stored separately from medications. Findings:A review of the facility's policy titled, Storage of Medications with a last review date of 08/2025, read in part, The facility stores all drugs and biologicals in safe, secure, and orderly manner. The policy also indicated general guidelines, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Medications are stored separately from food. On 08/27/2025 at 9:03 a.m., observation was conducted of Med Cart 1 with S2LPN (Licensed Practical Nurse) which revealed the following: 1 Linzess 72 mcg (microgram) bottle with an expiration date of 06/05/2025.On 08/27/2025…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the designated interdisciplinary team member obtained the most recent hospice plan of care, and the physician recertification of the terminal illness for 1 (#9) of 1 (#9) resident investigated for hospice care.Findings:On 08/27/2025, a review of the facility's policy titled Hospice Program, read in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation.11.Our facility has designated S1DON (Director of Nursing) to coordinate care provided to the resident by our facility staff and the hospice staff.she is responsible for the following.d. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident.3. Physician certification and recertification of the terminal illness specific to each resident.Resident #9 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to atherosclerotic…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-07 · tag F0567 — failed to protect residents' money held by the home — widespread
    Honor the resident's right to manage his or her financial affairs.
    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 residents' personal funds were available during non-banking hours. This failed practice had the potential to affect 51 residents who deposited funds in the residents' trust fund. The facility's total census was 51 with a census of 49 residents physicially in the nursing home at the time of the survey. Findings: During a resident council meeting conducted with 4 (#8, #11, #24, #37) residents and S9ACT (Activities Director) on 08/05/2024 at 2:05 p.m., the residents were asked about personal funds and petty cash. Resident #24 stated they could not get petty cash on the weekend, and the other residents agreed. Resident #24 reported the only time residents could get cash was when the business office was open during weekdays not weekends. The residents present in the meeting all agreed, they were not aware they should have petty cash available to them at any time, including weekends. On 08/07/2024 at 8:37 a.m., an interview was conducted with S3SSD (Social Services Director), she reported she was responsible for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-07 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 49 residents residing in the facility. Findings: On 08/05/2024 at 2:05 p.m., during a resident council meeting, Residents #11, #24 and #37 each stated they do not receive their unopened mail on Saturdays. Residents #11 and #24 stated they only get their mail when the office is open Monday through Friday. On 08/07/2024 at 10:52 a.m., an interview was conducted with S4SEC (Secretary/Transportation Supervisor/Medical Record). She reported there was no one in the business office on Saturdays to deliver mail to residents. S4SEC stated the Saturday mail was delivered to residents first thing on Monday morning. S4SEC confirmed mail was not delivered to residents on Saturdays.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-07 · tag F0585 — failed to handle grievances — widespread
    Honor 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 record reviews and interviews, the facility failed to ensure that their grievance policy and procedure was followed. The facility failed to ensure the residents and staff were aware of the procedure for filing grievances. The deficient practice had the potential to effect a census of 49 residents. Findings: Review of the facility's policy and procedure titled, Resident Care Grievance Policy, with a revision date of April 2017 and a review date of April 2023, revealed in part: Policy statement: all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Policy interpretation and implementation: 2. upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations .5. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. 6. The resident grievance/complaint investigation report form will be filed with the administrator within 5 working days of the incident. 7. The resident, or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Fcited before2024-08-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of the facilty's policy and procedures,the facility failed to maintain a clean and sanitary kitchen. This deficient practice had the potential to affect the 44 residents who consumed food from the kitchen. The facility's census was 49. Findings: On 08/05/2024, a review of the facility's policy titled, Fryer with no date of implementation or revision, read in part: After each use, fryer must be drained and thoroughly cleaned. The procedure to use is as follows: 1. Drain grease into thick container after cooled and dispose of . On 08/05/2024, a review of the facility's policy titled, Conventional Oven with no date of implementation or revision, read in part: Wipe oven doors, outside surface and racks with clean damp cloth . The porcelain interior can easily be cleaned with oven cleaners . On 08/05/2024, a review of the facility's policy titled, Pantry with no date of implementation or revision, read in part: . 2. dented can and spoiled foods should be disposed of promptly to prevent contamination of other foods . On 08/05/2024, a 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-07 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviews and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 3 (#14, #28, #102) residents records reviewed out of a finalized sample of 23 residents as evidenced by: 1. failing to ensure Resident #14's MDS (Minimum Data Set) assessment reflected dialysis; 2. incorrectly identifying physical restraint use on Resident #28's MDS assessment; and 3. failing to ensure Resident #102's MDS assessment reflected oxygen use. Findings: 1. Resident # 14 A review of Resident #14's EMR (Electronic Medical Record) revealed an admission date of 11/21/2022 with diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #14's Physician's Orders, revealed and order dated 11/21/2022, that read in part, Dialysis on Monday, Wednesday and Fridays. A review of Resident #14's Quarterly MDS assessment dated [DATE], under Section O-Special Treatments, Procedures, and Programs; dialysis was not…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure residents who smoked were free from potential accidents and hazards, by failing to implement the facility's policy that required unsafe smokers to be provided a smoking apron for 3 (#36, #41 and #43) of 3 (#36, #41 and #43) residents who were care planned as unsafe smokers. The final sample size was 23 residents. Findings: On 08/07/2024, a review of the facility's smoking policy titled, Smoking Policy for Residents, with no documented revision date, read in part .Purpose: To assure that a resident desiring to smoke is allowed to do so in a manner and area which will not compromise his/her safety or that of others in this facility .Resident found to be unsafe smoker will be provided smoking apron and will be supervised by staff member while in smoke room . Resident #36 Review of Resident #36's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-07 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 provide the resident and the resident's representative a written notice that specified the duration of the bed-hold policy for 1 (#102) of 1 (#102) residents investigated for hospitalizations in a final sample of 23 residents. This deficient practice had the potential to effect a census of 49. Findings: Review of the facility's policy titled, Bed-Holds and Returns, with a revision date of 04/2024, revealed in part: Policy statement: Resident and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy interpretation and implementation: 1. all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 2 (#2, #102) out of 2 (#2, #102) residents investigated for respiratory care in a final sample of 23 residents. Findings: Resident #2 A review of Resident #2's EMR (Electronic Medical Record) revealed an admission date of 11/18/2020 with diagnoses that included Pneumonia, Sepsis, and Dementia. A Review of Resident #2's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 06/18/2024 revealed she had a BIMS (Brief Interview for Mental Status) score of 03, indicating severely impaired cognition. Further review of Resident #2's August 2024 physician's orders revealed in part . Oxygen at 2L (Liters) per nasal cannula continuously with an order start date of 12/26/2023. On 08/05/2024 at 11:16 a.m., an observation was made of Resident #2 in the dining room with oxygen on and in place per nasal cannula. The oxygen setting was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-07 · tag F0727 — failed to provide required RN coverage — isolated
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    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 an RN (Registered Nurse) was on duty for 8 consecutive hours per day 7 days per week. This deficient practice had the potential to affect all 49 residents residing in the facility. Findings: Review of Time Card Reports for RN hours from January 2024 through March 2024 revealed an RN did not work a total of 8 consecutive hours for the following dates in February 2024: 02/19/2024 S2DON/IP (Director of Nursing/Infection Preventionist) had a clock-in time of 11:50 a.m. and clock-out time of 5:42 p.m. with 5.5 hours worked. No other RN had time on the time card reports. 02/26/2024 S11RN had a clock-in of 5:29 a.m. and clock-out time 12:00 p.m., with 6.35 hours worked. S2DON/IP had a clock-in time of 6:57 a.m. and clock-out time 1:18 p.m. The facility's RN coverage totaled 7 hours and 48 minutes. Further review of time cards for March 2024 revealed no RN for had time documented on the time card report for March 10, 2024. On 08/07/2024 at 11:00 a.m., an interview was conducted with S2DON/IP as she reviewed the time card…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-07 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 a mechanically altered diet as ordered by the physician for 1 (#35) out of 6 (#2, #34, #35, #43, #44, and #102) residents reviewed for dining. Findings: Review of Resident #35's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Non-infective Gastroenteritis and Colitis and Dysphagia. Review of Resident #35's most recent admission Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating her cognition was intact. Section K: Swallowing/Nutritional Status was checked for mechanically altered diet. Review of Resident #35's physician's orders revealed an order dated 06/24/2024 that read, NAS (No Added Salt) diet, Finely Chopped texture, Regular Consistency. On 08/05/2024 at 11:55 a.m. an observation was made of Resident #35's meal ticket and meal tray. Resident #35's meal ticket read in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to maintain an effective infection control and prevention program by failing to conduct yearly review of the infection program policies and procedures. Findings: On 08/06/2024, a review of the facility's policy titled, Infection Prevention and Control Program read in part: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to prove a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Further review revealed the policy was last updated on 10/2018. On 08/06/2024 at 9:56 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Preventionist). S2DON/IP stated that she was responsible for oversight of the infection control program. S2DON/IP failed to provide documentation when requested regarding when the facility's IPCP policies and procedures were last reviewed. S2DON/IP stated she was unaware that IPCP policies and procedures were to be reviewed annually.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-16 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the provider failed to post the nurse staffing data at the beginning of each shift, which would reflect current daily totals of the number of hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care. Findings: On 08/16/2023 at 10:35 a.m., an observation of the facility walls was conducted for posting of the facility's current daily totals of number of hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care. There were no postings observed. On 08/16/2023 at 10:40 a.m., an interview was conducted with S9WC (Ward Clerk), she stated she had the facility's current daily totals of nursing hours lying on the desk at the nurses' station. She reported she is responsible for filling out the daily staff nursing hours. She stated the information for today is not recorded on the form until tomorrow, as they don't know who will call in, so they can't get the actual hours for today. On 08/16/2023 at 1:22 p.m., an interview was conducted 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to maintain a safe, sanitary environment evidenced by: 1. Failure to ensure cookware was stored in a sanitary manner. 2. Failure to verify dishwasher temperature and chemical concentration every shift. The deficient practice had the potential to affect a total of 43 out of 43 residents that were served a meal tray from the kitchen. Findings: 1. A walk through observation of the kitchen on 08/14/2023 at 8:20 a.m., revealed 2 large pot lids and 1 oven rack on the floor. An immediate interview on 08/14/2023 at 8:20 a.m., with S2DM (Dietary Manager) who confirmed the pot lids and oven rack were on the floor and should not have been. 2. Further observation of the kitchen on 08/14/2023 revealed an log titled, Dishwasher Temperature/Chemical Record .Month: August 2023. The Lunch temperature and chemical readings were missing 11 days out of 13 days. The Dinner temperature and chemical readings were missing for 9 days out of 9 days. An immediate interview was conducted with S2DM who confirmed the temperature and chemical readings 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-16 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to ensure Agency CNA's (Certified Nursing Assistant's) completed annual in-service training including Dementia, Resident Rights, HIPPA (Health Insurance Portability and Accountability Act), Infection Control, and Abuse/Neglect Prevention for 3 (S5CNA, S6CNA, S7CNA) out of 3 (S5CNA, S6CNA, S7CNA) sampled Agency CNA's personnel files reviewed. Findings: Review of S5CNA's personnel file revealed no start date. Further review of personnel file revealed S5CNA had not completed Abuse/neglect or HIPAA training since on 09/20/2016. Further review revealed no education verification provided for Dementia training, infection control or resident rights. Review of S6CNA's personnel file revealed no start date. Further review of personnel file revealed no education verification provided for Dementia training, infection control or resident rights. Review of S7CNA's personnel file revealed no start date. Further review of personnel file revealed S5CNA had not completed HIPAA training since 05/28/2010. Further review revealed no education…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-16 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status by failing to ensure a resident's discharge status was accurately coded for 1 (#46) resident of 23 sampled residents. Findings: Resident #46 was admitted to the facility on [DATE] with diagnoses including in part: Iron deficiency Anemia, Urinary Tract Infection, and Age Related Osteoporosis. A review of Section A2100 of Resident #46's Discharge MDS (Minimum Data Set) dated 06/27/2023 revealed that the resident was discharged to acute hospital. A review of Resident #46's June 2023 Physician's Orders revealed an order written on 06/27/2023 that read: Ok to D/C (discharge) to . nursing home. A review of Resident #46's Discharge summary dated [DATE] revealed that she was discharged to a nursing facility. On 08/16/2023 at 9:41 a.m., an interview and record review was conducted with S3MDS. S3MDS confirmed that resident #46 was discharged to a different nursing facility. A review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-16 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to refer all residents with a newly evident or serious mental disorder, intellectual disability, or a related condition for level II resident review for 1(#10) out of 1 (#10) resident reviewed for Pre-admission Screening and Resident Review (PASARR). The deficient practice had the potential to affect a total census of 43 residents. Findings: Resident #10 was admitted to the facility on [DATE] with diagnosis in part: Bipolar Disorder, Diabetes Mellitus II, Major Depressive Disorder, Peripheral Vascular Disease, Panic Disorder and Anxiety Disorder. A review of Resident #10's Level I Pre-admission Screening and Resident Review dated 06/05/2019 revealed the resident had no mental illness, mental disorder that may lead to chronic disability. Further review of Resident #10's OBH (Office of Behavioral Health)-PASARR Level II evaluation summary and determination notice dated 06/17/2019 revealed the individual does not have a serious mental illness and a level II…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 interviews and record reviews, the facility failed to ensure that 1 resident (#37) was invited to participate in careplan meetings out of a total sample of 23 residents. Findings: A review of the facility's policy titled, Care Planning - Interdisciplinary Team read in part: The interdisciplinary team is responsible for the development of resident care plans .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. Resident #37 was admitted to the facility on [DATE] with diagnoses including: Muscle Wasting and Atrophy, Weakness, Major Depressive Disorder, and Generalized Edema. A review of a signature list for a care planning meeting conducted by the facility's care team for Resident #37 on…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure hospice agencies communicated with facility staff, and maintained and updated the residents' medical record that reflected the services provided for 1 (#20) of 1 (#20) resident that were provided Hospice Services. This deficient practice had the potential to affect the 2 hospice residents who resided in the facility. Findings: Record review of the Hospice and Nursing Facility Residential Agreement between the facility and Hospice dated [DATE], read in part, III. Services/ Responsibility to be provide by Hospice: 3.1 (a) .Hospice shall perform an assessment of such resident and shall notify the nursing facility . Hospice shall maintain adequate records of each authorization of Hospice admission. 3.2 Design and Maintenance of Plan of Care: (a) in accordance with applicable Federal and state laws and regulations, Hospice shall coordinate with the nursing facility to develop a Plan of Care for each new residential hospice patient.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-16 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident received services consistent with accepted professional standards by failing to document that a resident's dialysis shunt was assessed daily prior to and after dialysis treatments for 1 (#17) out of 2 residents (#17, #28) investigated for dialysis. Findings: Review of the facility's policy titled Arteriovenous Fistula Post Dialysis Care of Internal Access- General Care read in part .Check the fistula for a bruit .or a thrill .Assess for bleeding every day and especially when the resident returns from dialysis. Documentation: Document .thrill or bruit, circulation check of extremity, assessment of site (intact, bleeding, redness, etc.) and any other particular signs/symptoms you note. Resident #17 was admitted to the facility on [DATE] with diagnoses including but not limited to: End Stage Renal Disease, Type 2 Diabetes, and Essential Hypertension. Review of Resident #17's August 2023 Physician's Orders revealed an order that read…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
VERMILION PARISH HOSPITAL SERVICE DIST. #3Organization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/03/1991
HAIR, TREVORIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 01/16/2014

CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.3M
Net patient revenuemost recent cost report
-10.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 65%Medicare 6%Other / private 29%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$279per resident / day
operating cost
$8,494per month
≈ monthly operating cost
$253per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in LA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.

Typical monthly cost in Louisiana
$7,604/mo
Nursing home (semi-private)
$8,076/mo
Nursing home (private)
$5,163/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195458. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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