Amelia Manor Nursing Home
903 Center Street, Lafayette, LA 70501 · For profit - Corporation · 151 certified beds · (337) 234-7331 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- 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
- it has a citation for mishandling residents’ money or property (F0568)
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (59%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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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 | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.6% | 17.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.9% | 5.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 2.1% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.0% | 2.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 15.0% | 17.9% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 28.1% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 14.0% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.1% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.0% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 86.8% | 76.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 42.6% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.9% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.01 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.93 | 2.74 | 1.80 | better |
* 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.
45.9% 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 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.7% 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 24 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 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 45.9%CMS range 31.1–59.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 6.9–17.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 41.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 41.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 93.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 2.4–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 151 beds and averages 82.5 residents a day — about 55% occupied, or roughly 68 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 4.28 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.74 is at or above 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 3.58 hrs/resident/day on weekends vs 4.56 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.33 to 0.10 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 59% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2026-04-08 · tag F0628 — isolatedProvide 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 ensure the State Ombudsman Office was notified of a resident discharge for 1 (#87) out of 1 discharge record reviewed. Findings: Review of Resident #87's electronic health record revealed he was admitted to the facility on [DATE] for short term respite care. His diagnoses included, but were not limited to: hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, spastic hemiplegia affecting right dominant side, bipolar disorder, major depressive disorder, recurrent moderate, and anxiety disorder.Review of the facility's Notice of Transfer or Discharge form revealed Resident #87 was discharged from the facility on 02/23/2026. There was no evidence the State Ombudsman Office was notified of a resident's discharge.On 04/07/2026 at 3:55 p.m., an interview with S6SSD was conducted. She stated only residents who were emergency transfers are listed on the Emergency Transfer Log. She stated for the non-emergent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-08 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interview, the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#2) out of 1 (#2) sampled residents reviewed for tube feeding.Findings: Review of the facility's policy titled, Enteral Tube Feeding via Continuous Pump, with a last review date of January 2026, revealed under the heading Initiate Feeding read, in part.5. On the formula label document initials, date and time the formula was hung/administered. Review of Resident #2's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dysphagia, severe protein calorie malnutrition, and encounter for attention to gastrostomy. Review of Resident #2's April 2026 physician's orders revealed an order dated 02/26/2025 that read in part.Enteral Feed Order every night shift.Change feeding administration set daily, label the formula container, syringe and administration set with resident's name, date, time and nurse's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record and policy review, the facility failed to provide respiratory care consistent with professional standards of practice, by failing to label a nebulizer tubing and mask with a date, and store the mask in a bag when not in use for 1(#5) of 1 residents investigated for respiratory care.Findings:On 04/08/2026, a review of the facility's policy titled, The Facility Oxygen Administration which was last reviewed on 01/2026, read in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Steps in the Procedure .19. When not in use oxygen tubing will be stored in a plastic bag with date. 20. Change oxygen tubing weekly and label with date. 21. When not in use, store nasal cannula or mask in bag.Review of Resident #5's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, primary lateral sclerosis, atherosclerotic heart disease of native coronary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the nurse maintained infection control practices while administering wound care treatments for 1 resident (#40) out of 2 residents reviewed for wound care in a sample of 32 residents. Findings: Review of the facility's policy titled, Handwashing/Hand Hygiene, with a revision date of December 2025, read in part: Hand hygiene is indicated: d. before moving from work on a soiled body site to a clean body site on the same resident;.h. after glove removal. Review of Resident #40's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral infarction and pressure ulcer of sacral region stage 4. Review of Resident #40's current physician's orders revealed the following orders: -Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to sacrococcygeal topically every day shift for pressure wound. Cleanse, apply collagen, calcium…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure a resident's plan of care was implemented for 1 (Resident #51) out of 32 sampled residents. The facility failed to ensure Resident #51's splint was applied on her left hand. Findings: A review of Resident #51's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, cerebral infarction. A review of Resident #51's Order Summary Report revealed a physician's order, dated 02/06/2025 that read, left hand splint to be worn during the day, take off at night and for showers. A review of Resident #51's Care Plan Report revealed a care plan intervention initiated on 02/07/2025 that read, left hand splint to be worn during the day, take off at night and for showers. On 03/18/2025 at 9:27 AM, an observation was made of Resident #51 in her room. No splint was observed on her left hand. On 03/18/2025 at 10:07 AM, a second observation was made of Resident #51 in her room. No splint was observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-10 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the facility's policy and procedure, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the state survey agency for 1 (#1) of 4 (#1, #2, #3 and #R1) residents sampled with facility reported incidents. Findings: On 09/10/2024, a review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with a last reviewed date of 03/11/2024 read in part: Policy Statement: All reports of resident abuse (including injuries of unknown origin) . are reported to local, state and federal agencies (as required by current regulations) . 1. If resident . injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-04 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #2) out of 3 (Resident #1, #2, and #3) sampled residents by failing to ensure that Resident #2 was coded correctly for the use of a wander guard. Findings: Resident #2 Review of Resident #2's health record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease, Peripheral Vascular Disease, and Hypertension. Review of Resident #2's most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 99, indicating the resident was unable to cooperate. Further Review of Resident #2's most recent MDS dated [DATE] Section P - Restraints and Alarms, P0200 Alarms, E. Wander/elopement Alarm, revealed it was coded as 0. Not used. Review of the Wandering Risk Scale dated 03/16/2024 revealed in Section E. History of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infections as evidence by S3CNA failing to: 1. utilize the proper PPE (Personal Protective Equipment) while providing care to Resident #2 who was on Contact Precautions. 2. perform hand hygiene before entering and exiting Resident #2's room. 3. disinfect the vital sign machine and blood pressure cuff after use. The facility had a census of 88. Findings: On 06/04/2024, a review of the facility's policy, Isolation - Categories of Transmission-Based Precautions, with a last reviewed date of 03/08/2024, revealed in part, the following, . Contact Precautions: . 2. Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of 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.
- Potential for harm · F2024-03-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of policy and procedure and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. One opened package of bread on the counter not labeled with the date. 2. Food residue noted on the deep fryer and layer of oil and debris noted on the floor underneath the deep fryer. 3. Food storage: A. Walk-in cooler: 1. A container of onion mix not labeled with the date it had been prepared. 2. Two bags of ham opened and placed in a zip log bag not labeled with the date. 3. One bag of lettuce opened and not labeled with the date. 4. Four cucumbers with texture changes indicated the items were spoiled. 4. Failure to distribute food under sanitary conditions for Resident #61. The total amount of residents that ate out of the kitchen was 89 residents. Findings: Review of the facility's policy, Sanitization, last reviewed on 03/2024, revealed in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-13 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a comprehensive patient-centered care plan for 2 residents (Resident # 6 and Resident # 84) out of a total sample of 30 residents. Findings: On 03/13/2024, a review of the policy dated 03/2024 titled Care Plans, Comprehensive Person-Centered read in part, Policy Statement, A comprehensive, person-centered care plan that includes measureable objectives and timetable to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. Resident #6 Review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Lobar Pneumonia. Review of Resident #6's physician's orders revealed an order dated 01/15/2024 that read: O2 (oxygen) at 2L/MIN (liters per minute) continuously/titrate as needed. Review of Resident #6's Comprehensive Care Plan failed to reveal a care plan had been developed for oxygen use.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · E2024-03-13 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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, interview, and policy and procedures review, the facility failed to ensure menus met the nutritional needs of the residents and were followed as evidenced by: 1. No menu posted in resident areas, in a position and in print large enough for resident to read them. 2. The kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 14 residents who consumed pureed diets. Findings: Review of the facility's policy, Menu, last reviewed on 03/2024, revealed in part, the following: Policy Statement: Menus are developed and prepared to meet resident choices including religious, culture and ethnic needs while following established national guidelines for nutritional adequacy. On 03/11/2024 at 9:57 a.m., an observation was made of S5DC (Dietary Cook) preparing pureed lunch meals. S5DC prepared an unmeasured amount of chicken by blending pieces of chicken into the blender and added…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-13 · tag F0838 — failed to assess facility resources and resident needs — patternConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
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, policy review and interview, the facility failed to complete an accurate facility-wide assessment that reflected the resident population. This was evidenced by failure to address or include Mexican ethnic or cultural factors for 1(#48) out of a total sample of 30 residents. The facility's census was 92 residents. Findings: On 03/12/2024 at 2:05 p.m., a record review was conducted of __________Facility Assessment March 2024 with a review date of 03/08/2024. The facility assessment revealed in part: Ethnic, cultural, or religious factors . Further review of the facility's assessment failed to include ethnic or cultural factors that reflected the Mexican resident population. On 03/13/2024 at 12:21 p.m., a review of the facility's Facility Assessment Policy which was reviewed per annual policy and procedure review in March 2024 revealed: Policy Statement. A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-13 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's 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 interviews and record reviews, the facility failed to ensure consent was obtained from the Resident's Representative prior to purchasing a burial policy for a resident who did not have the mental capacity to consent for 1 (#51) out of 1 sampled residents in a final sample of 30 residents. Findings: Review of Resident #51's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease, Schizoaffective Disorder, Manic Episode Severe with Psychotic Symptoms, Anxiety Disorder, Peripheral Vascular Disease, and Hypertension. Review of Resident #51's Annual MDS (Minimum Data Set) admission assessment with an ARD (Assessment Reference Date) of 12/2022 revealed a BIMS (Brief Interview for Mental Status) score of 06, which indicated severe cognitive impairment. Review of Resident #51's facesheet revealed the resident had a Resident Representative. Review of Personal Funds Statement dated 1/01/2023-3/12/2023 revealed a charge withdrawn…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to properly label respiratory equipment for 1 resident (#6) out of 1 (#6) resident investigated for respiratory care. Findings: Review of Resident #6's medical record revealed that she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Lobar Pneumonia. Review of Resident #6's physician's orders revealed an order dated 01/15/2024 that read: O2 (oxygen) at 2L/MIN (liters per minute) continuously/titrate as needed. On 03/11/2024 at 9:47 a.m., an observation was made of the Resident in her room using oxygen via nasal cannula. The oxygen tubing was not labeled with a date. On 03/11/2024 at 9:52 a.m., an interview was conducted with S7LPN (Licensed Practical Nurse). S7LPN was unsure of the date that the tubing was changed. She confirmed the Resident's oxygen tubing did not have a label on it and it should have.
- Potential for harm · D2024-03-13 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 record review and interview the facility failed to ensure appropriate care and services had been provided for 1 (Resident #21) of 1 resident investigated for dialysis. The facility failed to ensure Resident #21 was accurately assessed and monitored for the care of his dialysis access site following dialysis. Findings: Review of the facility's policies on 3/13/2024 revealed policy dated 3/2024, titled Hemodialysis read in part, Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. Review of Resident #21's electronic medical record revealed he was admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure medications were stored according to professional standards of practice as evidenced by loose pills found in the bottom of medication cart drawers for 1 (Cart B) of 2 medication carts (Cart B, Cart C ) reviewed. Findings: Review of the facility's policy titled Medication Labeling and Storage dated 03/08/2024 and reviewed on 03/13/2024 read in part .Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 03/13/2024 at 9:40 a.m., an observation was made of Medication Cart B with S6LPN (Licensed Practical Nurse). Observation of the second drawer of the medication cart revealed 6 loose pills at the bottom of the drawer. The pills included the following: 1 red oblong tablet, 2 large white round tablets, 1 small white round tablet, 1 blue round tablet, and 1 orange round tablet. S6LPN could not identify the loose pills. S6LPN also stated that the nurses were responsible for ensuring the medication carts were free from loose…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-13 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, and interview the facility failed to provide quarterly statements for resident personal funds for 1 (#1) resident out of 1 resident (#1) reviewed for personal funds. Findings: Resident #1 MDS (Minimum Data Set) dated 06/13/2023 revealed that a Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment. Review of the facility's policy titled Resident Trust Fund revealed, in part: Policy Interpretation and Implementation: 4. Quarterly statements reflecting the interest earned and balance of the account are to be mailed to all residents and or responsible party. Review of Resident #1's Medical Chart revealed her daughter as the Responsible Party (RP). During a phone interview on 09/11/2023 at 1:00 p.m., Resident #1's daughter stated that she and her sister who is the responsible party, were not aware of how much the resident pays monthly for services. She stated that when she asked S3BA (Business Assistant) about the resident's bank statement, she was told she couldn't receive that information. During 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.
- Potential for harm · D2023-09-13 · tag F0571 — isolatedLimit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
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 ensure that charges were not imposed against the personal funds of a resident for personal liability for 1 (#1) out of 5 sampled residents. Findings: Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Aphasia, Schizoaffective disorder, Bipolar type, Manic episode, Severe with psychotic symptoms, and Cognitive communication deficit. Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 04, indicating severe cognitive impairment. Reviewed a document titled Provider Decision Letter dated 03/03/2023 which read in part: You must pay part of the cost for your nursing facility/waiver services each month.01/01/2023 - 02/28/2023 monthly amount $1,650.00. Further review revealed payment as of 03/03/2023 - continuing was $1,501.00. Review of a document titled Trust Transaction…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility's staff failed to notify the resident's representative and/or the resident's physician of a change in the resident's condition for 1 (#1) of 5 (#1 - #5) sampled residents. Findings: Review of the facility's policy, Change in a Resident's Condition or Status revealed in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .The nurse will notify the resident's attending physician on call when there has been a(an): accident or incident involving the resident; discovery of injuries of an unknown source; .need to transfer the resident to a hospital/treatment center; .specific instruction to notify the physician of changes in the resident's condition .a nurse will notify the resident's representative when: the resident is involved in any accident or incident that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 2 (#2, #4) of 5 (#1- #5) residents reviewed for ADLs. The facility failed to provide baths/showers for Resident #2, and #4. Findings: Review of a facility document titled Bath, Shower/Tub read in part: Documentation: 1. Date and time the shower/tub bath was performed 2. Name and title of the individual(s) who assisted the resident. 5. If the resident refused, the reason why and intervention taken. Reporting: 1. Notify the supervisor if resident refuses the shower/tub bath. Review of Resident #2's clinical record revealed he was admitted on [DATE] and had diagnoses of Blindness of the right eye, Diabetes Mellitus, Chronic kidney disease, stage 3, Atherosclerotic heart disease, and Dementia. Review of Resident's care plan dated 12/15/2022 read in part, ADL self-care performance deficit related…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-13 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure appropriate nursing competencies to assure resident safety and maintain the highest practicable physical well-being for one (#1) of 5 (#1- #5) sampled residents. Findings: Review of a facility document titled Prevention of Pressure injuries read in part: Skin Assessment - 3. Inspect the skin on a daily basis when performing or assisting with personal care or Activities of Daily Living (ADL's). a. identify any signs of developing pressure injuries (i.e non blanchable skin). Monitoring: 1. Evaluate, report and document potential changes in the skin. Review of Resident #1's medical record revealed he was admitted on [DATE] with diagnoses including Alzheimer's disease, Aphasia, Schizoaffective disorder, Bipolar type, Manic episode, Severe with psychotic symptoms, Peripheral vascular disease, and Cognitive communication deficit. Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-15 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility's staff failed to notify the resident's representative and/or the resident's physician of a change in the resident's condition for 4 (#1, #2, #4, #R1) of 6 (#1-#5, #R1) residents in a final sample of 6 residents by failing to: 1. Immediately inform the resident's (#1) representative of a fall with injury which resulted in the resident having to be transferred to the hospital for evaluation; 2. Immediately inform the resident's (#4) representative that the resident was transferred to the hospital and admitted inpatient to the hospital for abnormal labs; 3. Immediately inform the resident's (#R1) representative of abnormal lab results and of a new medication order; and 4. Immediately inform the resident's (#2) physician when the CNA (Certified Nurse Assistant) reported to the nurse on 07/07/2023 a bruise of unknown origin and the resident's complaint of pain to her left arm. This deficient practice has the potential to affect all the residents residing in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-15 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 assess, document and report the resident's condition which resulted in a delay in the resident's transfer to the hospital for treatment of an injury of unknown source for 1 (#2) of 6 (#1-#5, #R1) sampled residents. Findings: Review of the facility's policy, Acute Condition Changes - Clinical Protocol revealed in part: The nurse shall assess and document/report the following baseline information: .current level of pain, and any recent changes in pain level; onset, duration, severity; .and all current medications. Direct care staff including nursing assistants will be trained in recognizing subtle but significant changes in the resident for example .changes in skin color or condition and how to communicate these changes to the nurse. The nursing staff will contact the physician based on the urgency of the situation. Staff will monitor and document the resident's progress and responses to treatment and the physician will adjust accordingly. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to implement care plan interventions for 1 (#2) of 4 (#1, #2, #3, #5) residents investigated for falls in a sample of 6 (#1, #2, #3, #4, #5, #R1) residents. Findings: Review of Resident #2's record revealed she was admitted to the facility on [DATE]. The resident had diagnoses including Amnesia, Systemic Lupus Erythematosus, Anxiety disorder, age related Osteoporosis, overactive bladder, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side, and a fracture of the upper end of left humerus on 07/11/2023. The resident also had impaired visual function related to blindness. Review of the resident's significant change MDS (Minimum Data Set) dated 7/18/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 7, indicating her cognition was severely impaired. The resident had impairment on one side of her upper and lower extremities. She required limited one person assistance for bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-15 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident was administered pain medication as ordered for 1 (#2) of 6 (#1-#5, #R1) sampled residents. Findings: Review of Resident #2's record revealed she was admitted to the facility on [DATE]. The resident had diagnoses including Amnesia, Systemic Lupus Erythematosus, Anxiety disorder, age related Osteoporosis, overactive bladder, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominate side. She also had impaired visual function related to blindness. The resident was diagnosed with a fracture of the upper end of left humerus on 07/11/2023. Review of the resident's physician orders revealed an order dated 02/06/2023 assess and document resident's pain level q (every) shift. Review of the facility's Standing Orders revealed in part, Pain: Acetaminophen 325 mg (milligrams) take 2 tabs by mouth every 6 hours PRN (as needed) for mild pain . Review of Resident #2's MAR (Medication Administration Record) for July 2023…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AMELIA MANOR, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/10/2022 |
| DON G SARVER ESTATTES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 02/10/2022 |
| FOREMAN, LINDA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2013 |
| LYONS, ALBERTA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/14/2015 |
| PETRY, GWEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2013 |
| SARVER, DANNY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2013 |
| SARVER, WILLIE BELLE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2013 |
| SARVER, GREGORY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/1998 |
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $655K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in LA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195469. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-08, 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 →
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