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Kaplan Healthcare Center

1300 W. Eighth Street, Kaplan, LA 70548 · For profit - Corporation · 113 certified beds · (337) 270-6131 Medicare & Medicaid certified

Call the home — (337) 270-6131 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 20242 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$34,508 in federal fines
Insights

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

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $34,508 in federal fines (most recent 2024-11-06)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (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.

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
707 N Montgomery Ave · (337) 643-6219 · Call to confirm hours
Pharmacy
100 S Cushing Ave · (337) 643-8611 · Call to confirm hours
Grocery
1313 W Veterans Meml Dr · (337) 643-6492 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
503 N Trahan Ave · (337) 643-3313

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 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 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased22.0%17.8%15.4%worse
Long-stay residents who lose too much weight2.9%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.6%1.2%0.9%better
Long-stay residents with a urinary tract infection0.0%2.1%2.0%better
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 injury3.1%3.5%3.3%typical
Long-stay residents whose ability to walk worsened17.7%17.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication30.5%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine93.8%94.9%95.3%typical
Long-stay residents with pressure ulcers2.7%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control17.2%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.4%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 vaccine92.2%76.3%79.4%better
Short-stay residents rehospitalized after admission25.4%28.0%22.6%worse
Short-stay residents with an outpatient ER visit17.8%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.462.561.67worse
Long-stay outpatient ER visits per 1,000 resident days3.502.741.80worse

* 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.

41.8% 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 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.8%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
43.3%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 43.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNF41.8%CMS range 29.9–56.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 7.6–15.910.7%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 discharge43.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge36.7%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 discharge40.0%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 identified34.1%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 setting96.2%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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 hospitalization6.5%CMS range 3.3–14.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 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

0.27
RN hours/ resident / day
1.19
LPN hours/ resident / day
1.82
Aide hours/ resident / day
3.28
Total nurse hours/ resident / day
0.16
RN hoursweekends
47.7%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 113 beds and averages 72.5 residents a day — about 64% occupied, or roughly 40 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 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 2.87 hrs/resident/day on weekends vs 3.44 on weekdays — 17% thinner on weekends. RN hours go from 0.31 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% is about the same as 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

10
deficiencies at the latest standard inspection (2025-12-03)
7
at the previous standard inspection (2024-11-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · K2024-11-06 · tag F0658 — failed to meet professional standards of care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to ensure the resident was provided nursing services and care that adhered to accepted standards of quality. Nursing staff failed to reconcile and administer the resident's prescribed anticoagulant medication for 39 days which jeopardized the resident's health and safety for 1 (#37) of 1 residents investigated for nursing services in a final sample of 31 residents. This deficient practice resulted in an Immediate Jeopardy for Resident #37 on 07/29/2024 when S3LPN (Licensed Practical Nurse) failed to resume the resident's anticoagulant Eliquis 5 mg (milligrams) twice daily after undergoing a same-day scheduled procedure at HC1 (Hospital Center) to remove an inferior vena cava (IVC) filter. On 09/06/2024, the nurse observed Resident #37 confused and lethargic with swelling to the left lower extremity. Resident #37 was transferred via ambulance to Hospital A's emergency room (ER) for evaluation on 09/06/2024 at 3:52 p.m. Upon admit to the ER,…

    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 · Past Non-Compliance
  • Immediate jeopardy · Kcited before2024-11-06 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation and record review, the facility failed to ensure care and services were provided according to professional standards of practice resulting in harm for 1 (Resident #37) resident out of 31 final sampled residents. This deficient practice resulted in an Immediate Jeopardy for Resident #37 on 07/29/2024 when the facility's process for medication reconciliation failed as evidenced by: 1.S3LPN (Licensed Practical Nurse) failed to reconcile Resident #37's medications when the resident was readmitted to the facility following discharge from HC1 (Hospital Center) to remove an inferior vena cava (IVC) filter on 07/29/2024. The resident's discharge orders from HC1 included administration of the anticoagulant Eliquis 5 mg (milligrams) twice daily. -S6ADON and S11LPN further failed to follow the facility's standard of practice to conduct an additional review of Resident #37's medications reconciled by S3LPN. The resident's order for Eliquis 5 mg (milligrams) twice daily had not been resumed…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · F2025-12-03 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. The facility's census was 71.Findings:On 12/02/2025 at 9:05 a.m., an observation and interview was conducted with S2DON (Director of Nursing). S2DON stated the survey results were pinned on the bulletin board in a packet outside of social service's office door only. S2DON confirmed the last survey results from 10/01/2025 were not in the packet and should have been posted in a place readily accessible to residents, family members, or legal representatives.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-03 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 71.Findings:On 12/02/2025 at 9:00 a.m., an observation and interview was conducted with S2DON (Director of Nursing). S2DON confirmed that the nurse staffing data was posted on a whiteboard upon entry into the facility at the nurse's station. S2DON stated the nurse staffing data was from 12/01/2025. S2DON confirmed the nurse staffing data should have been updated daily and was not.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-03 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation, and record reviews, the facility failed to develop a comprehensive person-centered care plan for 3 (Resident #2, Resident #27, Resident #31) out of 35 sampled residents. Resident #27 Review of Resident #27's EMR (Electronic Medical Record) revealed she was admitted to the facility on [DATE] with a diagnosis that included but not limited to polyosteoarthritis, neuropathy, vertebrogenic low back pain, muscle spasm of back, and cutaneous abscess of left lower limb. Further review of Resident #27's medical diagnosis did not reveal a diagnosis for left drop foot. Review of Resident #27 quarterly (Minimum Data Set) dated 10/08/2025 revealed BIMS (Brief Interview for Mental Status) of 14 which indicated Resident #27 was cognitively intact. Review of Resident #27's Medical Progress Note dated 05/14/2025 revealed a diagnosis of left foot drop.An interview was conducted on 12/01/2025 at 10:15 a.m. with Resident #27. Resident #27 stated she had left drop foot and had a brace to help 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 · Ecited before2025-12-03 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure coordination of care between the physical therapy department and nursing services for a resident who had leg prosthetic devices that no longer fit for 1 (#4) out of 35 sampled residents reviewed for quality of care.Findings:Review of Resident #4's EMR (Electronic Medical Record) revealed, in part, Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included complete traumatic amputation at level between knee and ankle, left lower leg and right lower leg, and type 2 diabetes mellitus. Review of the quarterly MDS (Minimum Data Set) dated of 10/18/2025 revealed a BIMS (Brief Interview for Mental Status) of 14 which indicated the resident was cognitively intact. Functional Abilities and Goals (GG) revealed ADL (activities of daily living) as self care deficit and lower extremity impairment on both sides.Review of Resident #4's care plan revealed bilateral (both sides) BKA (below knee amputation), with the following…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-03 · 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 clean and sanitary kitchen, as evidenced by: 1. Equipment: A. Build-up of debris and brown substance inside the ice machine. B. Build-up of debris and food particles inside the microwave.2. Food storage: A. Walk-in Refrigerator 1. [NAME] and fuzzy patches on the inside and outside of a honey mustard container. 2. A container of lemon juice with an expiration date of 09/28/2025. B. Stand-up Refrigerator 1. A bag of bread not labeled with the date it was opened. 2. A piece of pie not labeled with the date it was prepared. C. Dry Storage 1. A bag of rice bag opened with an expiration date of 04/23/2025. This deficient practice had the potential to affect 68 residents who ate out of the kitchen.Findings:A review of the facility's policy titled, Food Receiving and Storage with a last review date of 06/23/2025, reads in part, All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).A review of the facility's policy titled, Sanitization with a last review date of 08/2025, reads…

    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 before2025-12-03 · 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 accurately code a resident's MDS (Minimum Data Set) assessment for 1 (Resident #14) out of 1 (Resident #14) investigated for resident assessments.Review of Resident #14's EHR (electronic health record) revealed she was admitted to the facility 07/14/2022 with diagnoses which included unspecified dementia, bipolar disorder, major depressive disorder and anxiety disorder.Review of Resident #14's most recent MDS (significant change) dated 09/11/2025 revealed under Section A1500 Preadmission Screening and Resident Review (PASRR) was coded as no to the question Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?Review of Resident #14's PASRR Level II Evaluation dated 09/16/2024 under the determination results section revealed Serous Mental Illness present. On 12/02/2025 2:30 p.m., an interview with S6MDS/LPN. During the interview, she reviewed 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 · Dcited before2025-12-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This was evidenced by 1 (Resident #62) having untrimmed and unclean fingernails out of 2 Residents #61 and #62) investigated for ADLs. Findings:Review of Resident #62's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, chronic obstructive pulmonary disease; dementia in other diseases classified elsewhere; and unspecified osteoarthritis. Review of Resident #62's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/15/2025 revealed in Section GG that the resident required partial/moderate assistance with personal hygiene.Review of Resident #62's care plan revealed in part, the resident has an ADL self-care performance deficit, with an intervention 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
  • Potential for harm · D2025-12-03 · 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 observations, record reviews, and interviews, the facility failed to follow professional standards of practice and the comprehensive person-centered care plan to remove the AV (arteriovenous) shunt pressure dressing for 1 (Resident #28 ) out of 1 (Resident #28 ) resident reviewed for dialysis.Findings:Resident #28 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction due to thrombosis of right middle cerebral artery, end stage renal disease and dependence on renal dialysis.Review of Resident #28's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/21/2025 revealed in Section C that the resident had a brief interview for mental status (BIMS) score of 15, indicating the resident had normal thinking and memory.Review of Resident #28's December 2025 physician's orders revealed an order written on 12/15/2023 which read in part, dialysis M-W-F (Monday-Wednesday-Friday).Review of Resident #28's care plan revealed an…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-03 · 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 (#21) out of 5 (#1, #21, #31, #56, #67) residents reviewed for dining.Findings: Review of Resident #21'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, dysphagia and gastro-esophageal reflux disease. Review of Resident #21's December 2025 physician's orders revealed an order dated 04/02/2025 that read, NAS (No Added Salt) diet, Chopped Meat Texture, Thin Consistency, Bite sized Meats. On 12/02/2025 at 11:41 a.m., an observation was made of Resident #21's meal tray. Resident #21's meal tray revealed a piece of rotisserie chicken leg. The meat item was not chopped or bite sized. On 12/03/2025 at 8:08 a.m., an observation was made of Resident #21's meal ticket and meal tray. Resident #21's meal ticket read in part, Chopped Meat. Meal tray…

    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 · D2025-12-03 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to maintain accurate documentation across the resident's record that the resident was discharged from hospice services for 1 (#6) out of 35 sampled residents. Findings: Review of Resident #6's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis, and cachexia. Review of Resident #6's December 2025 physician's orders revealed an order dated 09/10/2025 that read, Admit to contracted hospice provider related to CVA (cerebrovascular accident) dx (diagnosis. Further review of physician's orders revealed an order dated 09/11/2025 that read, Accucheck (blood sugar check) daily. Notify contracted hospice provider nurse if greater than 200. Review of Resident #6's October 2025 progress notes revealed a nurses note dated 10/16/2025 that read in part.resident seen by facility's medical director today post hospice D/C (discharge). 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
Show the remaining 16 citations
  • Potential for harm · D2025-10-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure CNAs (Certified Nurse Aides) and Shower Aides provided showers and baths for 2 (Resident #5, Resident #R1) of 2 (Resident #1, Resident #R1) sampled residents investigated for ADLs (Activities of Daily Living). Findings:On 10/1/2025, a review of the facility's policy titled, Bath, Shower/ Tub with a revision date of 2/2018 read in part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident.Resident #5Review of Resident #5's electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Major Depressive Disorder, Anxiety Disorder, and Legal Blindness, as defined in the USA (United States of America). Record review of Resident #5's care plan revised on 09/11/2025 revealed a focus area which stated, ADL self-care performance deficit, and interventions which included substantial maximal assistance to shower/ bathe. Record…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-01 · 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 observations, interviews, and policy and procedure reviews, the facility failed to maintain clean and sanitary kitchen equipment to prevent cross contamination and the likelihood of foodborne illnesses by failing to clean a Dumbwaiter Cart.Findings:Review of the facility's policy, Sanitization, with a last revised date of August 2025, revealed the following in part: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 13. Dumbwaiters may be used to transport food to dining areas and soiled dishes back to the dietary department provided that the compartment is sanitized between the transportation of soiled dishes and food. On 09/29/2025 at 12:07 p.m., an interview and observation was conducted with S14DM (Dietary Manager) of an empty dumbwaiter cart outside of the kitchen door. The cart was observed to have multiple dried clumps of yellow, brown, food matter; and dried thin layers of yellow food matter on multiple shelves. S14DM confirmed that the cart was used to deliver the lunch trays today.…

    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 before2025-10-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and policy and procedure review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to:1. ensure staff wore proper PPE (Personal Protective Equipment) while providing care for 2 (#1 and #2) of 2 (#1 and #2) residents who were on Enhanced Barrier Precautions in a final sample of 6 (#1, #2, #3, #4, #5, #6) residents investigated for infection control practices; and2. ensure the shower facilities and shower equipment were cleaned and disinfected between residents for 1 (Shower room A) out of 4 shower rooms (Shower room A, Shower room B, Shower room C, Shower room D) observed.Findings:1.Review of facility policy and procedure titled, Enhanced Barrier Precautions (EBP) with a review date of 06/30/2025, read in part . Enhanced Barrier Precautions refers…

    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 · D2024-11-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to notify the physician and/or NP (Nurse Practitioner) of a resident's invasive procdure for IVC (Inferior Vena Cava) filter removal for 1 (Resident #37) out of 1 (Resident #37) residents reviewed for notification of change in a final sample of 31 residents. Review of Resident #37's medical record revealed the following diagnoses, in part: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side, Acute Embolism and Thrombosis of Left Femoral Vein and Dysphagia following Cerebral Infarction. Review of progress note per S6ADON (Assistant Director of Nursing) on 07/29/2024 read in part: Resident left in stable condition via facility vehicle to HC1 (Hospital Center) for procedure. Review of the resident's Interventional Radiology Brief Post-procedure note revealed the date of service as 07/29/2024 at 1:54 p.m. Description of procedure: IVC filter removed without issue. On 11/05/2024 at 09:35 a.m., a phone interview was conducted with S4NP. She stated she was not made aware that Resident #37 had…

    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 · D2024-11-06 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to report an alleged violation of its failure to provide care to a resident necessary to avoid physical harm to designated state agency for 1 (Resident #37) out of 31 residents reviewed in the sample. On 11/04/2024 at 10:12 a.m., a request was made to the facility for all incidents that had been reported to the state agency in the past 120 days. There were no reports recieved for Resident #37. A request was also made for a policy regarding reportable incidents, but no policy was received prior to survey exit. Review of Resident #37's medical record revealed an admission date of 02/23/2024 with the following diagnoses, in part: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Acute Embolism and Thrombosis of Left Femoral Vein and Paroxysmal Atrial Fibrillation. On 11/04/2024 at 1:56 p.m., a phone interview was conducted with Resident #37's Responsible Party (RP) who stated the resident had her IVC (Inferior Vena Cava) filter removed on 07/29/2024, and upon her return to the facility,…

    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 before2024-11-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) for antipsychotic use for 1 (Resident #42) out of 2 (Resident #42 and #53) residents reviewed for resident assessment discrepancy for antipsychotics. The final sample was 31 residents. Findings: Review of Resident #42's electronic revealed she was admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE], Section N - Medications revealed the box for taking Antipsychotics was selected. Review of Resident #42's September 2024 physician orders failed to reveal an order for an antipsychotic. On 11/06/2024 at 9:50 a.m., an interview was conducted with S7RMDS (Regional Minimum Data Set). She confirmed that the resident had not received any antipsychotic medication. She stated she made an error in coding therefore the assessessment was inaccurate.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-06 · 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 and interviews the facility failed to provide appropriate pharmaceutical services, by not properly disposing of a contaminated sharp, observed during medication administration. Findings: On 11/05/2024, a review of the facility's policy titled, Sharps Disposal, with a last revision date of January 2012, revealed in part: Policy Statement: This facility shall discard contaminated sharps into designated containers .1. Whoever uses contaminated sharps will discard them immediately, or as soon as feasible into designated containers . On 11/05/2024 at 11:01 a.m., an observation was made of S9LPN (Licensed Practical Nurse) perform a blood glucose test of a resident. After she performed the blood glucose test, she placed the used lancet in the palm of her gloved hand, and then removed her gloves. S9LPN returned to the medication cart, and placed her soiled gloves with the lancet inside into the trash receptacle of the medication cart. On 11/05/2024 at 11:09 a.m., an interview was conducted with S9LPN. S9LPN confirmed that she placed the used lancet inside her gloves…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-06 · 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 observations and interviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff performed hand hygiene when indicated according to accepted standards of practice during medication administration pass. Findings: On 11/05/2024, a review of the facility's policy titled Handwashing-Hand Hygiene Policy and Procedure, with a last reviewed date of 01/24/2024, revealed in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .i. After contact with a resident's intact skin .l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. On 11/05/2024 at 11:06 a.m., an observation was made of S9LPN (Licensed Practical Nurse) administering insulin to a resident. After…

    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 · F2023-11-15 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to maintain an effective antibiotic stewardship program to monitor antibiotic use by failing to obtain culture reports, sensitivity data, and review antibiotic usage. The facility's census was 63. A review of the facility's policy titled, Infection Prevention and Control Program read in part: 8. Antibiotic Stewardship a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities .Infection Preventionist Policy Statement: The Infection Preventionist is responsible for coordinating the implementation, assessment, developing, monitoring and management of the program .Monitoring Compliance with Infection Control Policy Statement: Routine monitoring and surveillance of the workplace are conducted .Policy Interpretation and Implementation 6. The infection preventionist .provides reports .that reflect c. Adherence to the facility's antibiotic stewardship program . A review of the facility's monthly infection control logs revealed: 14 residents with infections were prescribed antibiotics…

    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 · Ecited before2023-11-15 · 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, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure compromised cans in the dry storage room were disposed of 2. Follow the 3-step process for manually washing and sanitizing dishware correctly per the manufacturer's instructions and food safety requirements. This deficient practice had the potential to affect the 62 residents who consumed food from the kitchen. The facility's census was 63. Findings: Review of the facility's policy titled, Dry Storage read in part, 6. All dented cans must be removed from the storeroom, or marked do not use until it is picked up. Review of the facility's policy titled, Sanitization read in part, 9. Manual washing and sanitizing will employ a three step process for washing, rinsing and sanitizing: a. Scrape food particles and wash using hot water and detergent; b. rinse with hot water to remove soap and residue, and c. sanitize with hot water or chemical…

    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 before2023-11-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to maintain an effective infection control and prevention program by: 1. Failing to ensure that contract staff wore gloves while changing a dirty mop pad and; 2. Failing to ensure staff sanitize hands during meal tray distribution for Residents #29, #48, #57, and #367. This deficient practice had the potential to affect the 63 residents residing in the facility. Findings: 1. A review of a policy titled, Healthcare Services Group, Inc. and its Subsidiaries Infection Control Policy read in part .1. Standard Precautions .Standard precautions for environmental and dining service employees include but are not limited to .Proper use of PPE (e.g., gloves .) .Also, equipment or items in the resident environment likely to have been contaminated .must be handled in a manner so as to prevent transmission of infectious agents, (e.g., wear gloves for handling soiled equipment .). On 11/14/2023 at 9:11 a.m., an observation was made of S10HSK (Housekeeper) mopping the dining room floor without wearing gloves. S10HSK removed the dirty…

    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 · D2023-11-15 · 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 observation, record review, and interview, the facility failed to ensure that each resident with urinary catheters had a privacy bag or covering over thier urine collection bag for dignity for 2 (#36 and #41) of 2 (#36 and #41) sampled residents reviewed for urinary catheters. Findings: Resident #41 Review of Resident #41's record revealed he was admitted to the facility on [DATE] with diagnoses in part .Chronic Kidney Disease Stage 4, Neuromuscular Dysfunction of Bladder, Displaced Bicondylar Fracture of Right Tibia. Review of Resident #41's November 2023 physician's orders revealed an order dated 09/09/2023 that read: Privacy bag or covering over urine collection bag for dignity every shift. Review of Resident #41's current care plan revealed in part .The resident had a urinary catheter with an intervention for privacy bag or covering over urine collection bag for dignity. On 11/13/2023 at 10:35 a.m., an observation was made of Resident #41 as he entered the facility from an appointment. The 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-15 · 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 — the official record, unedited, may be distressing

    Based on interviews and observations, the facility failed to maintain a homelike environment for 1 (#22) out of 3 (#22, #36, and #39) residents investigated for a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all the residents residing in the facility. The facility's census was 63. Findings: An observation on 11/13/2023 at 10:34 a.m., revealed a visible hole in the wall of Resident #22's room. She stated it happened a couple of weeks ago when someone was pushing the bed towards the wall and created a hole. A follow up observation on 11/14/2023 at 1:54 p.m., was conducted of Resident #22's room and the hole in the wall was still present. On 11/14/2023 at 2:13 p.m., an interview was conducted with S6MTN (Maintenance). He stated he was aware of Resident #22's hole in her wall. He was notified somewhere between the dates of 10/23/23 to 10/26/23. S6MTN stated he was the only maintenance worker and had not been able to get to it. He stated the hole in Resident #22's wall should have been repaired.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure 1 (#37) out of 2 (#32 and #37) residents were administered their tube feeding in a timely manner as ordered by the physician from a total sample size of 36 Residents. Findings: Review of the facility's policy, Enteral Nutrition revealed, the following, in part, Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered .Policy Interpretation and Implementation: . 10. Enteral feedings are scheduled to try to optimize resident independence whenever possible (at night or during hours that do not interfere with resident's ability to participate in facility activities) . Resident #37: Review of Resident #37's record revealed that he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Gastro-Esophageal Reflux Disease Without Esophagitis, Dysphagia Following Cerebral Infarction, Unspecified Protein-Calorie Malnutrition, and Gastrostomy Status. 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 · D2023-11-15 · 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, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (#57) of 2 (#2 and #57) sampled residents reviewed for respiratory care by failing to ensure that respiratory equipment was properly stored when not in use. Findings: Review of facility's policy, titled, Administering Medications through a Small Volume (Handheld) Nebulizer, read in part .Purpose: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the Procedure 28. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Review of Resident #57's record revealed he was admitted to the facility on [DATE] with diagnoses including Lobar Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Dysphagia, Muscle Wasting and Atrophy, and COVID 19. Review of Resident #57's November 2023 physician's orders revealed an order dated 04/18/2023 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-13 · 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, record review, and interview, the facility failed to ensure that a resident who was unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain personal hygiene for 2 (#4, R1) of 6 (#1-5, and R1) sampled residents, of a total census of 68 residents. Findings: A review of Resident #4's record revealed diagnoses that included Hemiplegia, Hemiparesis, and history of a Stroke (Cerebral Vascular Accident). A review of Resident #4's quarterly Minimum Data Set assessment dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating that she was cognitively intact. The assessment revealed that Resident #4 was able to understand, make herself understood, and that she had not rejected care. The assessment revealed 4/3 for toileting, indicating that she was totally dependent on 2 persons for toileting. Further review of the MDS assessment revealed that Resident #4 was always incontinent of bowel and bladder. A review of Resident #4'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

“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

$34,508 in federal fines across 2 penalties.

  • $17,254 — penalty dated 2024-11-06
  • $17,254 — penalty dated 2024-11-06

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

Part of a chain

This home belongs to NEXION HEALTH — 51 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 2 of 52.2-0.2 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 2 of 52.8-0.8 vs chain
Quality measures 2 of 52.6-0.6 vs chain
The other 50 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Bay Ridge Healthcare CenterLa Porte, TX 1 of 5Claiborne Healthcare CenterShreveport, LA 1 of 5Cornerstone Rehabilitation And Healthcare CenterCorinth, MS 1 of 5Crystal Rehabilitation And Healthcare CenterGreenwood, MS 1 of 5Duncanville Healthcare and Rehabilitation CenterDuncanville, TX 1 of 5Flatonia Healthcare CenterFlatonia, TX 1 of 5Gonzales Healthcare CenterGonzales, LA 1 of 5Green Valley Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Grenada Rehabilitation And Healthcare CenterGrenada, MS 1 of 5Holly Springs Rehabilitation And Healthcare CenterHolly Springs, MS 1 of 5Indianola Rehabilitation And Healthcare CenterIndianola, MS 1 of 5Lily Springs Rehabilitation and Healthcare CenterLampasas, TX 1 of 5Meadowview Health & Rehab CenterMinden, LA 1 of 5New Iberia Manor SouthNew Iberia, LA 1 of 5Patterson Healthcare CenterPatterson, LA 1 of 5Picayune Rehabilitation And Healthcare CenterPicayune, MS 1 of 5Pierremont Healthcare CenterShreveport, LA 1 of 5Prairie Meadows Rehabilitation and Healthcare CentFloresville, TX 1 of 5The Bluffs Rehabilitation And Healthcare CenterVicksburg, MS 1 of 5Village Creek Rehabilitation and Nursing CenterLumberton, TX 1 of 5Willow Park Rehabilitation Health Care CenterClifton, TX 1 of 5Woodlands Rehabilitation And Healthcare CenterClinton, MS 1 of 5Yazoo City Rehabilitation And Healthcare CenterYazoo City, MS 2 of 5Great Oaks Rehabilitation And Healthcare CenterByhalia, MS 2 of 5Many Healthcare and Rehabilitation CenterMany, LA 2 of 5New Iberia Manor NorthNew Iberia, LA 2 of 5North Star Ranch Rehabilitation and Healthcare CenBonham, TX 2 of 5Willow Park Rehabilitation And Care CenterWillow Park, TX 3 of 5Barton Valley Rehabilitation and Healthcare CenterAustin, TX 3 of 5Cedar Ridge Rehabilitation and Healthcare CenterPilot Point, TX 3 of 5Columbia Rehabilitation And Healthcare CenterColumbia, MS 3 of 5Cross Timbers Rehabilitation and Healthcare CenterFlower Mound, TX 3 of 5Delta Rehabilitation And Healthcare CenterCleveland, MS 3 of 5Golden Creek Healthcare And Rehabilitation CenterNavasota, TX 3 of 5Lakeview Rehabilitation and Healthcare CenterWinnsboro, TX 3 of 5Lone Star Ranch Rehabilitation and Healthcare CentKingsville, TX 3 of 5Midwestern Healthcare CenterWichita Falls, TX 3 of 5Natchez Rehabilitation And Healthcare CenterNatchez, MS 3 of 5Ridgecrest Healthcare And Rehabilitation CenterForney, TX 4 of 5Arbor Hills Rehabilitation And Healthcare CenterEagle Lake, TX

Showing 40 of 50; lowest-rated first.

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
NEXION HEALTH OF OHI INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/14/2005
NEXION HEALTH LEASING, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/15/2002
NEXION HEALTH, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/15/2002
BOLT, BRETTONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/15/2002
KIRLEY, FRANCISIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICERNO PERCENTAGE PROVIDEDsince 01/15/2002
LEMAIRE, TANIAIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 03/09/2009
HERDRICH, WILLIAMIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2012
LEE, BRIANIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/15/2002
REID, JOHNIndividualCORPORATE DIRECTORsince 12/03/2018
RINER, MEERAIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2012

CMS files one row per role, so the 20 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$6.9M
Net patient revenuemost recent cost report
-4.4%
Operating marginrevenue minus expenses
$431K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 7%Other / private 19%

About 73% 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 $431K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$300per resident / day
operating cost
$9,121per month
≈ monthly operating cost
$287per 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 195315. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, 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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