Grand Cove Nursing & Rehabilitation Center
1525 W McNeese St., Lake Charles, LA 70605 · For profit - Corporation · 109 certified beds · (337) 474-6000 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2023
- 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $29,042 in federal fines (most recent 2023-11-08)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 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.
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 | 18.1% | 17.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.8% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.6% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.1% | 2.1% | 2.0% | worse |
| 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 | 28.1% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 20.5% | 23.2% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.1% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.2% | 15.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.1% | 22.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 3.1% | 1.4% | better than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 91.3% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 39.3% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 18.6% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.47 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 4.32 | 2.74 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
44.9% 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 84 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.9% 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 70 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% 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 | 44.9%CMS range 33.9–54.0 | 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 | 10.0%CMS range 7.0–13.7 | 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 | 42.9% | 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 | 41.4% | 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 | 50.0% | 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 | 94.4% | 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 | 95.2% | 100.0% | Oct 2024–Sep 2025 | CMS 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 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 | 0.0% | 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 | 3.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.1%CMS range 5.7–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.27 | 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 109 beds and averages 85.6 residents a day — about 79% occupied, or roughly 23 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.80 hrs/resident/day on weekends vs 3.88 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.55 to 0.19 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.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · J2023-11-08 · 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 interviews and record reviews, the facility failed to ensure nursing staff effectively notified the physician of a resident's injury for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident's whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. On Monday, 10/16/2023 at 7:11 a.m. S3LPN observed the injury, notified the doctor by phone and sent the resident to the hospital for evaluation and treatment where she was diagnosed with a fracture of the right arm. The facility implemented corrective actions and was in substantial compliance on 10/16/2023 prior to the State Agency's investigation 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.
- Immediate jeopardy · J2023-11-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 reviews and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#1) of 3 (#1, #2 and #3) sampled residents. The facility failed to ensure nursing staff: 1. effectively communicated a change in Resident #1's condition to a physician and 2. intervene by following up with the physician after the identified a change in condition for Resident #1 when she continued to display signs of injury and pain. This deficient practice resulted in an immediate jeopardy for Resident #1 on Friday, 10/13/2023 at 7:30 p.m., when S5LPN noted Resident #1's right arm tucked behind her back. She observed the resident whimpering and her right arm was swollen and puffy. S5LPN notified S9MD's office via fax at approximately 10:30 p.m. that same evening when the physician's office was closed and would have remained closed and not staffed for the weekend. Nursing staff verbalized 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 before2026-03-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
Based on record review and staff interviews, the facility failed to ensure medical records were complete and accurately documented for 1 (#R1) of 4 residents reviewed for medical record accuracy. This deficient practice had the potential to affect a census of 87.Findings: Review of the facility policy titled Medical Records, with a revision date of 09/2025 and an annual review date of 01/2026, revealed in part: This community maintains a separate electronic clinical record on each resident in accordance with regulations and accepted professional standards of practice that are complete, accurate, readily accessible, and systematically organized. The resident clinical medical record shall contain sufficient information to identify the resident, a record of the resident's assessments, the comprehensive plan of care and services provided, and the results of any preadmission screenings, progress notes, and any lab, radiology, and other diagnostic services. Review of Resident #R1's electronic medical record (EMR) revealed an admission date of 03/29/2021 with diagnoses that included…
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 before2025-11-24 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 interview, and record review, the facility failed to ensure medical records were accurately documented and maintained in accordance with professional standards of practice for 2 (#1 and #9) residents out of 6 (#1, #2, #3, #4, #6, #9) sampled residents investigated for wound care in a total sample of 9 residents. Findings: Resident #1Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of left ankle with unspecified severity.Review of Resident #1's physician's orders revealed an order dated 10/16/2025 that read: clean diabetic ulcer to left lateral malleolus with normal saline; apply moist hydrofera blue; cover with border gauze dressing. Replace prevalon off-loading boot every Tuesday, Thursday and Saturday until healed.Review of Resident #1's October and November 2025 TAR (Treatment Administration Record) revealed the following: clean diabetic ulcer to left lateral malleolus with normal saline; apply moist…
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 before2025-10-01 · 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 record reviews and interviews, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or physician's orders for (#2) out of 11 (#1, #2, #3, #4, and #R1-#R7) sampled resident as evidenced by failing to identify and implement interventions for refusal of care for Resident #2.Findings: Review of Resident #2's EHR revealed she was admitted to the facility on [DATE] with diagnoses that included in part, schizoaffective disorder, unspecified, unspecified dementia, moderate, with other behavioral[MC1] , anxiety disorder and major depressive disorder.Review of Resident #2's complex alert documentation report from 07/01/2025 to 09/08/2025 revealed resident refused hygiene care every day in July 2025, and on 08/13/2025, 08/15/2025, 08/25/2025, 09/01/2025 and 09/02/2025.Review of Resident #2's hospice records revealed aide visit notes from 07/14/2025 to 08/29/2025 unable to document: patient refused nail care, nurse notified. Review of Resident #2's care plan revealed no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-10-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to revise a comprehensive person-centered plan of care for 1 (#1) out of 11 (#1, #2, #3, #4, and #R1-#R7) sampled resident as evidenced by failing to revise a care plan with changes in ADL (activities of daily living) care. Findings: Review of Resident #1's EHR (electronic health record) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, congestive heart failure, anxiety and depression.Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating her cognition was intact. Further review of the MDS revealed resident was independent with eating, oral hygiene, toileting, dressing, transfers; and supervision or touch assistance for shower/bathe.Review of Resident #1's care plan date initiated: 06/23/2025 revision on: 08/19/2025 revealed resident needs partial/moderate assist with bathing/showering. 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.
- Potential for harm · D2025-10-01 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observations, interviews and record reviews, the facility failed to provide services to meet professional standards in accordance with the resident's written plan of care by failing to administer daily medication on time as ordered for 3 (#1, #R1 and #R2) out of 11 (#1- #4 and #R1 - #R7) sampled residents. The deficient practice had the potential to effect a census of 87.Findings: Review of the facility's policy titled, Administration of Medication with last revision date 03/2025, read in part, purpose: to administer medications in accordance with best practice.Procedure: 3. Drugs and biologicals are administered no more than one hour before or no more than one hour after the dosage time is ordered.Resident #1Review of Resident #1's EHR (electronic health record) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, congestive heart failure, anxiety and depression.Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed 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 · D2025-06-11 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure that the resident's quarterly MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center for Medicare and Medicaid Services) in a timely manner for 1 (#44) of 5 (#29, #41, #44, #46, #56) residents investigated for resident assessments in a final sample of 30 residents. Findings: Review of Resident #44's electronic medical record revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/06/2025. Review of the MDS assessment signature page revealed the assessment had been completed and signed on 06/05/2025. On 06/11/2025 at 3:30 p.m., an interview was conducted with S7MDS who stated she was responsible for Resident #44's MDS assessments. S7MDS reviewed Resident #44's quarterly MDS with an ARD of 05/06/2025 and confirmed the assessment had not been completed in the CMS required timeframe of 14 days.
- Potential for harm · Dcited before2025-06-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for use of antiplatelet medication for 1 (#56) out of 30 sampled residents. Findings: Review of Resident #56's Quarterly MDS with an ARD (Assessment Reference Date) of 02/12/2025 revealed, in part: Section N- Medications High Risk Drug Classes E. Anticoagulant, Is taking- checked Yes .I. Antiplatelet, Is taking- checked No. Review of Resident #56's electronic medication administration record (EMAR) for February 2025 revealed he had taken Plavix, an antiplatelet medication. On 06/11/2025 at 12:45 p.m., an interview and record review was conducted with S7MDS. She verified that Resident #56 was administered Plavix, an antiplatelet medication during the lookback period for his Quarterly MDS with an ARD of 02/12/2025. S7MDS confirmed that Resident #56's Quarterly MDS was coded incorrectly as him taking an anticoagulant instead of an antiplatelet medication.
- Potential for harm · Dcited before2025-06-11 · 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 record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (#9, #41) out of a final sample of 30 residents. The deficient practice had the potential to affect a total census of 84 residents. Findings: Resident #9 Review of Resident #9's EMR (Electronic Medical Record) revealed an admission date of 03/24/2025 and diagnoses that include Hemiplegia following Cerebral Infarction affecting right dominant side, Type 2 Diabetes Mellitus, and Morbid Obesity. Review of Resident #9's Quarterly MDS (Minimum Data Set) dated 03/28/2025 indicated Resident #9 was dependent on staff for personal hygiene. On 06/09/2025 at 10:30 a.m., an observation was made of Resident #9 unshaven with long unkempt facial hair and fingernails that were long, curling under with brown debris under them. On 06/11/2025 at 8:37 a.m., an interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN confirmed the resident had unkempt facial hair and fingernails. She stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observation, interview, and record review, the facility failed to provide pharmaceutical services that ensured accurate administration of medication to meet the needs of 1 (#72) of 6 residents observed during medication administration. The deficient practice had the potential to effect the facility census of 84 residents. Findings: On 06/11/2025 at 9:40 a.m., S10LPN (Licensed Practical Nurse) was observed during medication pass. During her preparation for medication administration for Resident #72, S10LPN stated that the prescribed Carbidopa-Levodopa ER Tablet 25-100 mg (milligrams) orders on her computer indicated Resident #72 was to take 1 tablet PO (by mouth) TID (three times per day) but that the instructions on the medication blister pack read to take 2 tablets PO TID. In that moment, S10LPN reviewed Resident #72's physician's orders on her computer and read from the prescribed Carbidopa-Levodopa order, take 1 tablet PO TID. S10LPN returned to the Carbidopa-Levodopa blister pack and read, take 2 tabs PO TID. S10LPN then removed a round, bright orange sticker from 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 · Dcited before2025-06-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure: 1. dietary staff with facial hair utilized a hair restraint to prevent hair from contacting food; 2. dietary staff utilized gloves when handling and preparing food; and, 3. dietary staff utilized proper sanitary procedures when serving ice with a ice scoop. These deficiencies had the potential to affect the entire census of 80 residents who consumed food and beverages prepared in the kitchen. Findings: A review of the facility's policy titled Employee Work Practice, with a revised date of 05/2018 and annual policy review date of 01/30/2025, read in part: Policy: Food service employees shall follow sanitary practices to prevent the spread of food borne illness. Procedure: 2. Proper Work Attire a.maintain their hair and skin to prevent the transfer of pathogens to food and food equipment .c. ii. Wears a clean hat or other hair restraint (hair net, hat, surgical cap and/or beard restraint) in the food production area.…
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 11 citations
- Potential for harm · D2024-06-05 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a reentry MDS (Minimum Data Set) assessment was completed timely for 1 (Resident #14 ) out of 25 sampled residents. The deficient practice had a potential to affect a total census of 73. Findings: A review of Resident #14's electronic medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Urinary Tract Infection and Vascular Dementia. A review of Resident #14's electronic medical record revealed the resident was admitted to the hospital on [DATE] and returned on 05/30/2024. Further review of Resident #14's MDS assessments failed to reveal a reentry MDS assessment had been initiated indicating the resident had readmitted from the hospital. On 06/05/24 at 9:51 a.m., an interview and record review was conducted with S7RN (Registered Nurse). S7RN confirmed Resident #14 had a recent hospital stay with a readmission date of 05/30/2024. She reviewed the Resident #14's assessments and confirmed a reentry…
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 before2024-06-05 · 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 reviews and interview, the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 1 (#68) out of 3 (#38, #3, #68) residents' records reviewed in a final sample of 25 residents. The deficiency had the potential to affect a census of 73. Findings: Review of Resident #68's EMR (Electronic Medical Record) revealed an admit date of 10/03/2023 with diagnosis not limited to Schizophrenia and Bipolar Disorder. Further review of Resident #68's EMR had a PASRR (Pre-admission Screening and Resident Review) Level II determination date 01/17/2024 indicating the individual had a serious mental illness and was recommended nursing home admission. Lesser services were commended and specialized services were recommended. Review of Resident #68's Significant Change (SC) MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) 01/17/2024 revealed resident evaluated by PASRR - No. On 06/04/2024 at 12:30 p.m., an interview was conducted with S4MDS. S4MDS…
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 · D2024-06-05 · 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 policy review, observation, and interview, the facility failed to ensure medication was stored securely and discarded upon expiration and was not available for improper resident use as evidenced by an expired medication being left in an unlocked refrigerator designated for resident food storage. The facility had a census of 73. Findings: On 06/04/2024 at 12:05 p.m., a review of a policy titled Medication Storage ,with a last revision date of 11/2017, read in part: There shall be storage areas provided that assure . security for medications within the facility, including .a lock and key system with suitable protection against access by unauthorized personnel. This locked system shall be secured when not in use by authorized personnel. A separate and secure area shall be provided for the storage of medications that are discontinued, expired, or otherwise unusable. On 06/04/2024 at 9:20 a.m., an observation of an unlocked refrigerator labeled Resident Refrigerator centrally located on Hall A was conducted with S3ADON (Assistant Director of Nursing). She confirmed 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 · D2024-06-05 · 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 record review, observation, and interviews, the facility failed to maintain an effective infection control and prevention program as evidenced by staff failing to put on the appropriate Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) and perform hand hygiene and glove changes when indicated during a nephrostomy tube dressing change for 1 (#280) of 2 (#61, #208) residents who were investigated for catheters in a final sample of 25 residents. Findings: On 06/04/2024, a review of the facility's policy titled, Enhanced Barrier Precautions with the latest review date of 03/2024 revealed in part . Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities. Enhanced Barrier Precautions are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organism). On 06/04/2024, a 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 before2023-11-21 · 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 reviews and interviews, the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 1 (#1) out of 3 (#1, #2, #3) residents' records reviewed. The deficiency had the potential to affect a census of 84. Findings: Review of Resident #1's EHR (electronic health record) revealed the resident was admitted to the facility on [DATE] with diagnoses in part, but not limited to Gastroenteritis, Colitis, Chronic Kidney Disease, Acute Kidney Disease, Congestive Heart Failure, Schizoaffective Disorder, Bipolar Disorder, Major Depression and Anxiety. A review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/18/2023 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating resident was cognitively intact. Also, resident was dependent for rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair bed-to-chair transfer, toilet transfer and wheelchair…
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 before2023-11-21 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 review and interview, the facility failed to maintain a complete medical record on each resident for 1 (#1) out of 3 (#1, #2, #3) sampled residents. This was evidenced by failing to ensure medications were documented as administered on the MAR (medication administration record) after administering to the resident. This deficient practice had the potential to affect a census of 84 residents. Findings: Review of the facility's policy titled, Administration of Medications, read in part: Oral Medication Administration Procedure . 2. Ensure that an appropriate physician's order is in place. 3. Verify the physicians order, comparing the medication label to the MAR to verify the following: a. right medication, b. right dose, c. right route, d. right time, e. right resident. Review of Resident #1's EHR revealed the resident was admitted to the facility on [DATE] with diagnoses in part, but not limited to Gastroenteritis, Colitis, Chronic Kidney Disease, Acute Kidney Disease, Congestive Heart Failure,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-10 · 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 records reviewed and interviews, the facility failed to implement the person centered care plan by not following physician orders for 4 (#1, #15, #46, #57 and #58) residents out of a total of 32 sampled residents as evidenced by failing to: 1. obtain a monthly weights as per facility policy and procedure for Resident #1 and, 2. document dietary intake amount for each meal as ordered for Residents #1, #15, #57 and # 58, and, 3. obtain laboratory testing as ordered for Resident #46 This deficient practice had the potential to affect the 79 residents who resided in the facility. Findings: Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses including: End Stage Renal Disease, Diabetes Mellitus, Dysphagia, Dementia, Malnutrition and Depression. Review of Resident #1's physician orders revealed in part: order entry dated 03/20/2023 Pureed/thin liquids, renal diet, and order entry dated 05/09/2023 Tube Feeding formula, Nepro at 40ml/hr (milliliters per hour) via PEG (percutaneous…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to protect the residents' right to be free from physical abuse by other residents for 1 (#27) out of 32 sampled residents. The facility failed to protect Resident #27 from physical abuse when Resident #32 shoved Resident #27 in the left shoulder on 2/28/2023. The facility had a census of 79. Findings: Review of the facility's incident, investigation, and reporting policy revealed .Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitations, misappropriation of resident property .Relevant terms: Abuse: Abuse is the willful infliction of injury .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #27 Review of Resident #27's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-10 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 2 (#31, #48) of 5 residents (13, 31, 46, 48, 58) investigated for PASARR in a final sample of 32 residents. Findings: Review of Resident #31's diagnosis list revealed on 11/22/2022 she was diagnosed with Bipolar Disorder in full remission, most recent episode manic. Review of Resident #31's records revealed no evidence of a Level II PASARR had been submitted to the appropriate state-designated authority. Review of Resident #48's diagnosis list revealed on 05/25/2021 she was diagnosed with Bipolar Disorder. Review of Resident #48's records revealed no evidence of a Level II PASARR had been submitted to the appropriate state-designated authority. On 05/09/2023 at 11:45 a.m., an interview was conducted with S4SSD. She confirmed Resident #31 had a new diagnosis of Bipolar…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure that acceptable parameters of nutritional status was maintained for 2 (Resident #1, Resident #58) out of 4 (#1, #15, #57, #58) residents reviewed for nutrition. The facility failed to: 1. obtain a weight monthly for Resident #1, and 2. identify significant weight loss for Resident #58. This deficient practice had the potential to affect a census of 79. Findings: Review of Policy and Procedures titled Weights, revealed in part: A. Weight/Height policy guidelines . 2. All residents will be routinely weighed monthly, unless otherwise specified by the physician's orders or care plan . 10. All weight deviations plus or minus 5% or more per month, or 10% of body weight over a six month period, require a Weight Evaluation form , physician notification, notification of resident representative and facility intervention, if appropriate, with physician supervision. Resident #1 Resident #1 was admitted to the facility on [DATE] with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-10 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, review, and interview, the facility failed to ensure food products were discarded on or before the expiration date and discard canned goods with compromised seals in the dry storage room. This deficient practice has the potential to effect the 79 residents that eat meals in the facility. Findings: Review of the facility's policy and procedure for Food Storage Labeling.foods store in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturers use-by date or expiration date. On 05/08/2023 at 8:42 a.m., an interview and observation with S3DM of the food stored on the shelves in the dry storage room revealed: one compromised dented can of lemon pudding, and one cheesecake mix that was expired on 9/13/22. S3DM confirmed the cheesecake mix was expired and remained on the shelf for use. S3DM confirmed the lemon pudding can was dented and remained on the shelf for use.
“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
$29,042 in federal fines across 2 penalties.
- $14,521 — penalty dated 2023-11-08
- $14,521 — penalty dated 2023-11-08
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BEEBE, TRACY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 100% | since 12/02/2022 |
| PARKINSON, TONI | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2010 |
| ACCOUNT MANAGEMENT SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2015 |
| ADMINISTRATIVE SYSTEMS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2015 |
| PATHWAY MANAGEMENT OF LOUISIANA LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2015 |
| PROVIDER PROFESSIONAL SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2010 |
| TRISTAR REHAB INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2024 |
| BEEBE, BOBBY | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2013 |
| COMEAUX, ALECISA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/26/2016 |
| GARRIS, KYLIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/05/2019 |
| HEBERT, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2015 |
| LANGHOFER, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2017 |
| ARIA CARE MANAGEMENT LLC | Organization | ADP OF THE SNF | — | since 08/01/2022 |
| ELTON G BEEBE FAMILY MORTAGE TRUST | Organization | ADP OF THE SNF | — | since 01/01/2025 |
| FOUR GENERATIONS HOLDINGS LLC | Organization | ADP OF THE SNF | — | since 12/18/2025 |
| LAKE CHARLES PROPERTIES LLC | Organization | ADP OF THE SNF | — | since 12/18/2025 |
| LTC HIM CONSULTING INC | Organization | ADP OF THE SNF | — | since 04/01/2007 |
| VERDIN ENTERPRISES, LLC | Organization | ADP OF THE SNF | — | since 11/01/2021 |
CMS files one row per role, so the 30 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.
11 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.
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 195376. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-11, 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.