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The Columns Rehabilitation and Healthcare Center

3025 Fourth Street, Jonesville, LA 71343 · For profit - Limited Liability company · 140 certified beds · (318) 339-4344 Medicare & Medicaid certified

Call the home — (318) 339-4344 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 2025
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • 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) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Urgent care / clinic
800 Audubon Dr · (318) 261-8326 · Call to confirm hours
Pharmacy
1806 4th St · (318) 339-8532 · Call to confirm hours
Grocery
612 Fourth St · (318) 339-9841 · Call to confirm hours
Park
Front St · Typically dawn to dusk
Place of worship
603 Dorothy Dr

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 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased8.5%17.8%15.4%better
Long-stay residents who lose too much weight0.0%5.2%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.0%1.2%0.9%better
Long-stay residents with a urinary tract infection0.3%2.1%2.0%better
Long-stay residents with depressive symptoms0.3%2.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.8%3.5%3.3%worse
Long-stay residents whose ability to walk worsened7.5%17.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication25.1%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine95.5%94.9%95.3%typical
Long-stay residents with pressure ulcers4.8%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control10.2%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table23.6%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.1%3.1%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine72.1%76.3%79.4%typical
Short-stay residents rehospitalized after admission28.2%28.0%22.6%worse
Short-stay residents with an outpatient ER visit17.0%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.832.561.67typical
Long-stay outpatient ER visits per 1,000 resident days3.492.741.80worse

* 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.

45.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.8%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
42.0%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 42.0% 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 50 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 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.8%CMS range 35.3–60.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.7–14.810.7%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 discharge42.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge42.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay2.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 3.4–14.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.881.02Oct 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

0.29
RN hours/ resident / day
0.91
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.42
Total nurse hours/ resident / day
0.12
RN hoursweekends
50.0%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 140 beds and averages 91.5 residents a day — about 65% occupied, or roughly 48 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 3.42 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.29 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 2.80 hrs/resident/day on weekends vs 3.67 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.36 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

5
deficiencies at the latest standard inspection (2026-04-22)
11
at the previous standard inspection (2025-05-14)

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 before2026-04-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 93. Findings: Review of an undated facility policy on 04/21/2026 at 8:46 a.m. titled, Sanitation Inspection revealed the following in part.It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Review of an undated facility policy on 04/20/2026 at 2:50 p.m. titled, Date Marking for Food Safety revealed the following part .The facility adheres to a date marking system to ensure the safety of ready -to-eat, time/temperature control for safety of food. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-22 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interview, the facility failed to ensure residents receiving a psychotropic medications had a Gradual Dose Reduction (GDR) completed for 1 resident (Resident #26) of 5 (#8, #13, #26, #40, #87) residents reviewed for unnecessary medications.Findings:Review of the facility's undated policy titled, Gradual Dose Reduction of Psychotropic Drugs, revealed in part, Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs. Review of Resident #26's medical records revealed an admit date of 06/16/2025 with the following diagnoses, including in part: Parkinson's Disease With Dyskinesia, With Fluctuations, Chronic Obstructive Pulmonary Disease, Unspecified, Alzheimer's Disease, Delusional Disorders, Depression, and Anxiety Disorder. Review of Resident #26's Physician's Orders revealed in part the following orders:Haloperidol Oral Tablet 5 MG (milligrams), Give 1 tablet by mouth at bedtime related to Alzheimer's Disease…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    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 notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #96) of 1 resident reviewed for transfer/discharge. The total sample size was 30.Findings:Review of the facility's undated policy titled, Transfer and Discharge (Including AMA) read in part. Policy Explanation and Compliance Guidelines: 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and a manner in which they can understand. The notice will include all of the following at the time it is provided: h. the name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.Review of Resident #96's medical record revealed an admission date of 02/04/2026 and a discharge date of 03/04/2026. Resident #96 had diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. Review of Resident #96's Discharge-Return…

    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 · D2026-04-22 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 provide care and services that meet professional standards of quality, by failing to accurately assess 1 resident (Resident #87). The total sample size was 30 residents.Findings:Review of Resident #87's medical record revealed an admission date of 08/22/2025 with diagnoses that included in part. Alzheimer's Disease with Late Onset, Atrial Fibrillation, and Cognitive Communication Deficit. Review of Resident #87's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/22/2026 revealed in part a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. Review of Resident #87's physician orders revealed in part.Eliquis (an anticoagulant or blood thinner) Oral Tablet 2.5 MG (milligrams) Give 1 tablet by mouth every morning and at bedtime related to Unspecified Atrial Fibrillation with a start date of 08/22/2025.Monitor side effects of anticoagulant therapy.0 - .6 - Abnormal bruising, with a start date of 08/22/2025.An additional order for Weekly Skin…

    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 · D2026-04-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. The sample size was 30. The facility failed to ensure: Enhance Barrier Precautions (EBP) were implemented and utilized for Resident #10; andProper hand hygiene and gloving were performed throughout Resident #10's wound care treatment.Findings: Review of an undated facility policy on 04/21/2026 at 4:22 p.m. titled, Clean Dressing Change revealed the following in part .It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify the type of dressing and frequency of changes. 9. Loosen the tape and remove the exiting dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered. Pat dry with gauze. 14. Wash…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-03 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    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 an effective Quality Assurance and Performance Improvement (QAPI) program was developed, implemented, and/or maintained in an effective and comprehensive manner for falls. The facility failed to provide documentation of evidence of its ongoing facility QAPI program. This deficient practice had the potential to affect 85 residents residing in the facility. Findings:A facility policy titled Quality Assurance and Performance Improvement (QAPI), with a revision date of 04/28/2025 revealed in part.It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.Definitions: Quality Assurances and Performance Improvement (QAPI) refers to the coordinated application of two mutually reinforcing aspects of a quality management system: (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive,…

    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 · E2025-05-14 · tag F0761 — failed to label and store drugs safely — pattern
    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 observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Nursing carts were free of loose pills for 1 (Cart A) of 2 (Cart A and Cart B) carts reviewed, and 2. Nursing carts were free of expired supplies for 1 (Cart B) of 2 (Cart A and Cart B) carts reviewed. Findings: Review of the facility's policy entitled Storage of Medication Requiring Refrigeration revised on 09/01/2024 revealed, in part .the facility must provide safe and effective storage of all drugs and biologicals consistent with professional standards of practice. Staff should remove any expired medications from active stock and discard according to facility policy. Interview with S19 CQI on 05/14/2025 at 12:23 p.m. confirmed the facility's policy entitled Storage of Medication Requiring Refrigeration was used for all medications in the facility, not just refrigerated medications. Observation of Cart A on 05/13/2025 at 1:45 p.m., with oversight from S9 LPN, revealed 2 unidentified…

    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 · D2025-05-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 1 (Resident #51) of 26 sampled residents. Findings: On 05/14/2025, review of facility policy titled, Answering Call Lights, with effective date of 06/01/2023 and revision Date of 9/28/2025, revealed in part . Purpose: Call lights are to serve as notice to the staff that the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident . Process: Place call light within reach of the resident before leaving the room and anticipate other needs of the resident . Resident #51 Review of Resident #51's electronic medical record revealed an admit date of 02/16/2024 with diagnosis that included: Neurocognitive Disorder with Lewy Bodies, Major Depressive Disorder, Altered Mental Status, Generalized Anxiety Disorder, Aphasia, Cognitive Communication Deficit, Hallucinations, unspecified, unsteadiness on feet, and history of repeated falls. Review…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to inform each resident of the charges for services for which the residents may be responsible for paying for 2 (#45 and #70) of 2 (#45 and #70) sampled residents who received Advanced Beneficiary Notices of Non-Coverage (ABN). Findings: Review of the ABN notices (Form CMS-10055) signed by Resident #45 on 02/17/2025 and Resident #70 on 03/19/2025 revealed the estimated cost for continuing daily skilled nursing care was not completed but left blank. In an interview on 05/14/2025 at 12:10 p.m., S5 Accounts Manager confirmed she was responsible for completing the ABN forms and having them signed by the resident or representative. During a review of the Form CMS-10055 for Residents #45 and #70 at that time, S5 Accounts Manager confirmed the estimate of the cost of services amount per day was not completed. S5 Accounts Manager stated she would have to get that information from the Corporate Office and only does so if the resident or resident representative specifically requests it. S5 Accounts Manager confirmed she did not obtain…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 the physician documented a clinical rationale for a denial of a dose reduction for 2 (#37 and #51) of 5 (#24, #37, #45, #50, and #51) residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction. Findings: Review of the facility policy on 05/13/2025 at 11:29 a.m., titled Gradual Dose Reduction of Psychotropic Drugs with a revision date of 09/01/2024 revealed in part .Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 6. For any individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: The physician has documented the clinical rationale…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-05-14 · 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 record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #45) of 26 sampled residents. Findings: Review of Resident #45's medical record revealed an admission date of 10/07/2022 with diagnoses including, in part .Muscle Wasting and Atrophy, Unspecified Protein-Calorie Malnutrition, and Dementia. Review of Resident #45's Quarterly MDS with an ARD of 02/17/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #45 required supervision or touching assistance while eating. Resident #45 had significant weight loss and was not on a prescribed weight-loss regimen. Review of Resident #45's current comprehensive care plan revealed a history of unplanned/unexpected weight loss related to recent illness and hospitalization, initiated on 03/16/2023 and revised on 08/27/2023 and 11/21/2024. Interventions included, in part .monitor and record my food intake at each meal. Review of Resident #45's Nutrition - Meal Intake of Food & Drink task for 02/2025, 03/2025, 04/2025, and 05/01/2025 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · 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

    Based on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan was revised after a quarterly assessment for 1 (Resident #45) of 26 sampled residents. Findings: Review of Resident #45's medical record revealed an admission date of 10/07/2022 with diagnoses including, in part .Muscle Wasting and Atrophy, Difficulty in Walking, Unsteadiness on Feet, Muscle Weakness, and Dementia. Review of Resident #45's Quarterly MDS with an ARD of 02/17/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #45 used a manual wheelchair and had limited range of motion to his lower extremities. He was dependent for ambulation. Review of Resident #45's current care plan revealed the resident had limited physical mobility related to generalized weakness, initiated on 10/07/2022. Interventions included, in part .the resident walks independently, initiated on 10/07/2022 and revised on 02/17/2023. Interview with S2 DON on 05/14/2025 at 11:50 a.m. revealed Resident #45 could not walk independently. S2 DON confirmed Resident…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (Resident #24) of 26 sampled residents. Findings: Review of the facility's policy entitled, Nail Care dated 06/01/2023 revealed in part .nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath. Review of Resident #24's medical record revealed an admission date of 05/06/2024 with diagnoses which included in part Diabetes Mellitus and Morbid Obesity. Review of Resident #24's Annual MDS with ARD of 04/16/2025 revealed in part .a BIMS score of 15, which indicated intact cognition. Resident #24 was dependent for bathing and required substantial/maximal assistance with personal hygiene. Review of Resident #24's current physician's orders revealed, in part .RN was to trim toe nails every month, dated 05/06/2024. Review of Resident #24's care plan revealed in part .the resident was dependent for meeting his physical needs…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide foot care and treatment in accordance with professional standards of practice for a resident with Diabetes. The facility failed to schedule and complete podiatry appointments for toenail care and trimming for 1 (Resident #24) of 3 (Resident #17, Resident #24, and Resident #78) residents sampled for Activities of Daily Living (ADLs). Findings: Review of the facility's policy entitled, Nail Care dated 06/01/2023 revealed in part .refer residents whose toenails are too thick or difficult to cut to a Podiatrist. It is recommended a Podiatrist provides foot care for residents with Diabetes. Review of Resident #24's medical record revealed an admission date of 05/06/2024 with diagnoses which included in part Diabetes Mellitus. Review of Resident #24's Annual MDS with ARD of 04/16/2025 revealed in part .a BIMS score of 15, which indicated intact cognition. Resident #24 was dependent for bathing and required substantial/maximal assistance with personal hygiene. Review of Resident #24's current physician'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F692 Based on interview and record review the Facility failed to ensure that a Resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable weight range for 1 (#69 ) of 3 (#39, #45, #69) sampled Residents reviewed for nutrition. Total sample size 26. The facility failed to ensure Resident #69 received ordered nutritional supplements with meals, assistance or encouragement with eating, and accurate documentation of meal intake. Findings: Review of Resident #69's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Aphasia, Alzheimer's disease, Depressive Disorder, Cognitive Communication Deficit, Vitamin B12 Deficiency, and Dementia. Review of Resident #69's Quarterly MDS, with ARD of 04/02/2025, revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #69 was independent with eating. Review of Resident #69's current care plan, revealed in part .Resident #69 has a potential for 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 · D2025-05-14 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regard to portion size to ensure the nutritional adequacy of the meal for all 10 residents who received a puree diet. Findings: In an interview during the initial kitchen tour at 8:50 a.m. on 05/12/2025, S3 Dietary Manager stated the facility had 10 residents being served a puree diet. In an observation on 05/12/2025 at 10:30 a.m., S4 [NAME] used a 2 ounce ladle and put 6 scoops of lima beans into the blender to puree. S4 [NAME] then added 2 scoops of liquid from the lima beans to the blender. S4 [NAME] blended them together and placed them in a pan for the steam table. Review of the recipe for lima beans provided by S3 Dietary Manager revealed for 10 servings, 1 and ¼ quart (40 ounces) of beans should have been pureed. In an interview on 05/12/2025 at 11:00 a.m., S4 [NAME] confirmed she put 6 scoops of lima beans into the blender with a 2 ounce ladle. In an interview 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-14 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was not open to air while stored in the pantry; and 2. Food serving scoop was not left inside sugar bin in direct contact with resident food items. This deficient practice had the potential to affect 84 residents who received meals served from the kitchen. Findings: An observation on 05/12/2025 at 9:00 a.m. revealed the serving scoop was inside the bulk storage container of sugar lying on top of and in direct contact with the sugar. In an interview at that time, S3 Dietary Manager confirmed the scoop should not be in the sugar bin touching the sugar. An observation on 05/12/2025 at 9:05 a.m. revealed a package of fish breading in the pantry that was open to air. In an interview at that time, S3 Dietary Manager confirmed the fish breading in the pantry was open to air and should not be.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse for 3 (#2, #3, and #4) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to 1. Ensure Resident #2 was not physically abused by Resident #3; 2. Ensure Resident #3 was not physically abused by Resident #4; and 3. Ensure Resident #4 was not physically abused by Resident #3. Findings: Review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 07/26/2023, revealed in part .The facility's policy strictly prohibits abuse and neglect. This policy is against abuse, neglect, exploitation and misappropriation of resident property including abuse by any other person, including, but not limited to other residents. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for the treatment of a skin tear was followed for 1 (#3) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 90. Findings: Review of the Facility policy titled: Skin Tears, with an effective date of 04/04/2024 revealed in part . Process: 2 (b). Tropical treatments in accordance with current standards of practice will be provided for residents who have a skin tear. 4. Monitoring b. Licensed nurses will participate in the management of skin tears and medical conditions by following physician orders. Assessment of residents, and reporting changes in condition to the resident's physicians. Review of Resident #3's clinical record revealed an admit date [DATE] with diagnoses which included in part . Alzheimer's Disease with Late Onset, Impulse Disorder Unspecified, Generalized Anxiety, History of Falling and Dementia. Review of Resident #3's Quarterly MDS with an ARD 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 · Dcited before2024-08-07 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5) sampled residents. Findings: Review of the facility policy titled Abuse, Neglect, Misappropriation of Resident property, Suspicious Injuries of Unknown Source, Exploitation, with a revision date of 04/25/2024, revealed in part .This policy is against abuse, neglect, exploitation and misappropriation of resident property including abuse by any other person, including, but not limited to: other residents. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. A cognitively impaired resident that hits another resident, may be considered abusive. Physical Abuse: Physical abuse includes, hitting, slapping, pinching, and kicking. Resident #4 Review of the clinical record revealed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-08 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#46) out of a total of 23 sampled Residents, by failing to ensure she was free of facial hair. Findings: Review of Resident #46's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included in part .Schizoaffective Disorder Unspecified, Dementia, Aphasia, Cognitive Communication deficit, Major Depressive Disorder, Chronic Atrial Fibrillation Unspecified and Transient Ischemic Attack. Review of Resident #46's Annual MDS with an ARD of 01/10/2024 revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #46 required partial/moderate assistance with personal hygiene, and substantial/maximal assistance with bathing. Review of Resident #46's care plan with a target date of 04/21/2024 read in part .I…

    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 · D2024-03-08 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure a resident (Resident #53) personal furniture was maintained in good sanitary condition. The sample resident size was 23. Findings: Observation on 02/26/2024 at 10:55 a.m. revealed Resident #53 lying in bed with an oversized brown message type recliner position next to his bed. The recliner was noted to have a dried brown sticky substance on the left side near the head, brown substance scattered in the bottom cushion, and a small amount of sand type substance inside the right/left enclosed foot rest. Observation on 02/27/2024 at 10:00 a.m. revealed an oversized brown message like recliner position next to his bed. The recliner was still noted to have a dried brown sticky substance on the left side near the head, brown substance scattered in the bottom cushion, and a small amount of sand type substance inside the right/left enclosed foot rest. Interview on 02/27/2024 at 10:10 a.m. with S18 LPN revealed the recliner is used by Resident #53 to sit up…

    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 · D2024-03-08 · tag F0585 — failed to handle grievances — isolated
    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 interview and record review the Facility failed to ensure their grievance policy and procedure was followed by failing to complete a grievance for 1 (#62) of 23 sampled residents. Findings: The Facility'sv undated Policy Titled Grievance Program reviewed on 02/26/2024 read in part .when there is a grievance it will be: Process: a. Documented on the facility's Grievance Report. b. Routed to the Grievance officer. e. Investigated accordingly. Review of Resident #62's medical record revealed an admit date of 12/01/2023 with diagnoses which included in part .Paroxysmal Atrial Fibrillation, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, Major Depressive Disorder and Generalized Anxiety Disorder. Review of Resident #62's admission MDS with an ARD 12/07/2023 revealed she had a BIMS score of 15 (indicating intact cognition), and required supervision or touching assistance with personal hygiene, toileting hygiene and lower body dressing; independent with eating and partial/moderate assistance with shower/bath. Interview on 02/26/2024 at 11:05 a.m. Resident #62 revealed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · 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 interview and record review, the facility failed to implement a person-centered care plan for recurrent Urinary Tract Infections (UTI) for 1 (#25) of 1 (#25) residents reviewed for UTIs. Findings: Interview with Resident #25 on 02/26/24 at 1:54 p.m. revealed she had a recurrent UTI every 6-8 weeks since admission and had been placed on antibiotics each time. Interview with S11 LPN on 02/27/2024 at 10:35 a.m. revealed Resident #25 may have had a UTI when she first came in, but doesn't remember her having recurrent UTIs. Review of the Nurses' Notes: 12/02/203 at 1:49 p.m. revealed Resident #25 was sent to the emergency room due to a fall and returned that same day with a new diagnosis of UTI and new order for Macrobid 100 mg BID X 7 days. 01/31/2024 at 2:45 p.m. revealed the Nurse Practitioner made rounds and placed Resident #25 on Levaquin 500 mg one QD X 7 days for UTI. Review of the care plan revealed no history of or current history of Resident #25 having a UTI. Interview with S7 RN/CCN on 02/27/2024 at 3:30 p.m. revealed that he had not care planned Resident #25 for her…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 Residents (Resident #10 and Resident #21) of 23 sampled residents. Findings: Review of the facility policy titled: Activities of Daily Living (ADLs) Maintain Abilities revealed in part: 1. Based on the resident's comprehensive assessment and consistent with the resident's need and choices, the facility will provide the necessary care and services. 3. The facility will provide care and services for the following activities of daily living: a. Hygiene- bathing, dressing, grooming, and oral care. Policy Explanation and Compliance Guidelines: 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #10 Review of Resident #10's EHR revealed he 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-08 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure that food was properly stored in accordance with professional standards for food service safety. The facility failed to ensure that expired/outdated items were not available for resident consumption. Findings: Review of the facility's Policy and Procedure titled, Storage of Canned and Dry Food read in part . Policy: The facility ensures the quality and safety of canned and dry food through accepted storage practices. Procedure #5. Canned goods and dry foods are dated when received. The first in, first out method is used: Products with the earliest date are stored in front of products with a later date. On initial tour of the kitchen on 02/26/2024 at 9:20 a.m. accompanied by S6 Dietary Manager in the dry food storage room revealed the following items on the shelf available for use: 1. One 2.12 ounce grinder bottle of sea salt with an expiration date of 03/2023. 2. One open box of 48 - 4 ounce thickened orange juice containers with an expiration date of 02/22/2024. The opened box dated 02/15/2024 was missing 6…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to VENZA CARE MANAGEMENT — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.4+0.6 vs chain
Staffing 2 of 52.9-0.9 vs chain
Quality measures 2 of 52.8-0.8 vs chain
The other 24 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Decatur Health & Rehab CenterDecatur, AL 1 of 5Falkville Rehabilitation And Healthcare CenterFalkville, AL 1 of 5Holston Rehabilitation And Care CenterKingsport, TN 1 of 5Regency House Of AlexandriaAlexandria, LA 1 of 5Rocket City Rehabilitation And Healthcare CenterHuntsville, AL 1 of 5Smithfield Manor Rehabilitation and Healthcare CenSmithfield, NC 1 of 5Snow Hill Rehabilitation & Healthcare CenterSnow Hill, MD 2 of 5Canterbury Health Care FacilityPhenix City, AL 2 of 5Cullman Health Care CenterCullman, AL 2 of 5Delaware Bay Rehabilitation And Healthcare CenterGeorgetown, DE 2 of 5Essex Rehabilitation and Healthcare CenterLouisville, KY 2 of 5Five Oaks Rehabilitation and Care CenterConcord, NC 2 of 5Lynwood Rehabilitation And Healthcare CenterMobile, AL 2 of 5Oak Haven Rehabilitation and Healthcare CenterCenter Point, LA 2 of 5Tri Cities Rehabilitation and Healthcare CenterCumberland, KY 3 of 5Aiken Rehabilitation and Care CenterAiken, SC 3 of 5Brookshire Healthcare CenterHuntsville, AL 3 of 5Forest Manor Health And RehabNorthport, AL 3 of 5Northside Health CareGadsden, AL 3 of 5Rivers Edge Rehabilitation and Healthcare CenterProspect, KY 4 of 5Folsom Rehabilitation And Healthcare CenterCullman, AL 4 of 5Woodland Village Rehabilitation And Healthcare CenCullman, AL 5 of 5Adams Rehabilitation And Healthcare CenterAlexander City, AL 5 of 5Haleyville Health Care CenterHaleyville, AL

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
LA2 SNF OPERATIONS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/28/2023
CH LA2 HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST22%since 12/28/2023
CW LA2 HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST22%since 12/28/2023
MS LA2 HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST25%since 12/28/2023
SS LA2 HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST25%since 12/28/2023
SE SNF ASSOCIATES LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/25/2026
SE SNF ASSOCIATES TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 03/25/2026
SE SNF HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 03/25/2026
SE SNF HOLDINGS TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 03/25/2026
GOODMAN, MENUCHAIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2025
LA2 OPCO MANAGER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 12/28/2023
MELB OPCO MANAGER LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2025
VERTEX FINANCIAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
CLARK, CHEYANNEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/09/2025
SMITH, ROGERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/28/2023
HERZKA, YISROELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/15/2026
STRAUSS, SUSANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; TRUSTEE OF THE SNFsince 02/13/2026

CMS files one row per role, so the 24 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$4.3M
Net patient revenuemost recent cost report
+5.7%
Operating marginrevenue minus expenses
$634K
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 7%Other / private 19%

About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $634K paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$258per resident / day
operating cost
$7,849per month
≈ monthly operating cost
$274per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in LA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195478. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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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