Savoy Care Center
906 Cherry Street, Mamou, LA 70554 · For profit - Corporation · 119 certified beds · (337) 468-0347 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)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — 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 (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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 | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 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 | 20.0% | 17.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.7% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.5% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.0% | 2.3% | 6.5% | worse than state‡ — see note marked double-dagger 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 | 3.7% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.2% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 31.8% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.1% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.8% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 29.6% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 42.4% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 5.4% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 60.9% | 76.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 35.9% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 16.0% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.61 | 2.56 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 4.10 | 2.74 | 1.80 | worse |
‡ 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.
29.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 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 0.21 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 29.6%CMS range 19.5–43.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.4%CMS range 7.8–16.4 | 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 | 60.0% | 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 | 48.0% | 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 | 44.0% | 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 | 97.4% | 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 | 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 | 2.6% | 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 | 5.3% | 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 5.2–13.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.47 | 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 119 beds and averages 80.1 residents a day — about 67% occupied, or roughly 39 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.11 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 2.94 hrs/resident/day on weekends vs 3.80 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.11 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · E2026-03-26 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 an ongoing activities program to support residents in their choice of activities based on comprehensive assessments, care plans and preferences for 3 (Resident #15, Resident #43, and Resident #70) of 33 sampled residents. This deficient practice has the potential to affect all 83 residents currently residing in the facility. Findings:Review of the facility's undated policy titled, Activities , read in part . The facility will provide an ongoing program of actives that support the interest and enhances the quality of life of each resident. Activities will be individualized based in resident assessments, preferences, and functional abilities. Procedure: 3. Implementations:Activities will be scheduled daily, including afternoon and weekendsPrograms will include group and individual activitiesResidents will be encouraged but not forced to participate Review of the facility's March 2026 activities calendar revealed the following scheduled activities in part . 03/23/2026 - 9:00 a.m. Coffee &…
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 · E2026-03-26 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard 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 interviews and record review, the facility failed to ensure a resident's medical record was complete and accurate by failing to ensure administration of narcotics were properly documented on the narcotic record for 2 (Cart A & Cart B) of 2 medication carts reviewed during the medication storage facility task. Findings:Review of the Controlled Substances facility policy dated 01/15/2026 revealed the following in part: Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances. 7. The charge nurse who administers the prescribed narcotic will immediately document it on the medication administration record and the controlled drug administration record.Medication Carts A and B were observed and narcotics were counted and compared to narcotic records for both carts with S5 LPN present on 03/25/2026 at 2:15 p.m. The following discrepancies were found:Record Review revealed Medication Administration Record (MAR) for March 2026 for 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 · D2026-03-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #59 & Resident #60) of 33 sampled residents, by failing to:1. Promote resident dignity by providing a bedpan per the resident request for Resident #60.2. Promote resident dignity by providing disposable dishware for Resident #59 in the dining room. Findings: Resident #60 Record review of facility policy Resident Rights reads in part . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. On 03/25/2026 at 8:59 a.m. observation revealed Resident #60 lying in bed requesting bed pan. Surveyor assisted resident with pressing call light, per resident request. S6 CNA entered room shortly and stated resident has on a diaper and is not able to get up at this time due to left side weakness due to stroke; S6 CNA said she can go in her diaper. 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 · Dcited before2026-03-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident received a reasonable accommodation of their needs by failing to ensure the call light was accessible to a resident for 1 (Resident #3) of 33 sampled residents.Review of a facility policy dated 01/16/2026, titled Answering the Call Light revealed in part. The purpose of this procedure is to respond to the residents needs and request. 5. When the resident is in bed or confined to a chair be sure the call light is within easy each of the resident.Review of Resident #3's medical record revealed an admission date of 12/07/2023, with diagnoses that included, in part, Moneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease. Review of Resident #3's Quarterly MDS with an ARD 03/03/2026 revealed Resident #3 had a BIMS of 6, indicating severe cognitive impairment. Resident required set up assistance with eating, dependent for toileting hygiene and personal hygiene, and required substantial/maximal assistance to roll left to right.An observation on 03/24/2026 at 10:12 a.m. revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · 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
Based on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 1 (Resident #84) of 33 sampled residents. Findings:Review of Resident #84's electronic health record revealed an admission date of 10/06/2023 with diagnoses which included: Dementia, Depressive Disorder, Anxiety, Polyneuropathy, Peripheral Vascular Disease, Repeated Falls, and Mild Cognitive Impairment. Review of Resident #84's Quarterly MDS with an ARD of 12/25/2025 revealed a BIMS score of 6, indicating moderate cognitive impairment. Resident #84 required substantial to maximal assistance with transfers. Review of a task in Resident #84's electronic medical record, initiated on 02/15/2026, revealed Resident #84 required transfer using a Hoyer lift with two-person assist. Review of Resident #84's comprehensive care plan dated 02/04/2026 revealed Resident #84 required transfer using a Hoyer lift with two-person assist. On 03/23/2026 at 1:35 p.m., observation of S12CNA and S13CNA revealed staff exited Resident #84's room without a Hoyer lift. Interview with S12CNA…
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 · D2026-03-26 · 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
Based on observation, interview and record review, the facility failed to ensure the comprehensive plan of care was reviewed and revised to include nursing interventions implemented for a client with behaviors that required increased supervision and monitoring of behaviors for 1 resident (Resident #61) of 33 sampled residents. Findings:Review of the facility's revised policy dated March 2022 titled, Care Plans, Comprehensive Person-Centered read in part. Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of Resident #61's medical record revealed an admission date of 01/15/2025 with diagnoses that include Unspecified Dementia, Unspecified Severity with other Behavioral Disturbances, Insomnia, Depression, Alcohol Abuse, 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 · D2026-03-26 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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 obtain laboratory services as ordered by a physician to meet the needs of its residents for 1 (#2) of 5 (#1, #2, #7,#10, and #11 ) residents reviewed for unnecessary medications.Findings: Review of the Facility's undated policy titled Lab and Diagnostic Test Results- Clinical Protocol read in part.1. Thy physician will identify and order diagnostic and lab testing based on the residents diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for the test. Review of Resident #2's medical record revealed an admission to the facility on [DATE] with the following Diagnoses: Cerebral infarction, Dysarthria, Type 2 Diabetes, Congestive Heart Failure, Hypothyroidism, Hypertensive Heart Disease, and Cirrhosis of Liver. Review of Resident #2's medical record revealed a TSH lab completed 01/22/2026 with a hand written order at the bottom of the page that read in part . repeat TSH in 4 weeks. Review of Resident #'2 03/2026…
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 · D2026-03-26 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record, the facility failed to ensure that the mattress was compatible with the bedframe for 1 (Resident #3) of 33 sampled residents.Review of Resident #3's medical record revealed an admission date of 12/07/2023, with diagnoses that included, in part, Myoneural Disorder, Paraplegia, Epilepsy, and Peripheral Vascular Disease.Review of Resident #3's Quarterly MDS with ARD 03/03/2026 revealed Resident #3 had a BIMS of 6, indicating severe cognitive impairment.On 03/23/2026 at 11:39 a.m., observation revealed Resident #3 lying in bed with his feet hanging off of his mattress. Resident #3's mattress appeared to be too small for the bed frame.On 03/24/2026 at 10:12 a.m., an observation revealed Resident #3 lying in bed, positioned on his back with his head elevated. The resident's air mattress was observed not to fit the bed frame properly. There was approximately a 1-foot gap between the top of the bedframe and the head of Resident #3's mattress. Resident #3's head was partially above the mattress.On 03/24/2026 at 12:48 p.m., S4CNA was present at…
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 before2025-07-30 · 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 record review, observation, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure:1. A fall mat was in place as ordered and care planned for Resident #1, and2. Physician's orders for increasing water flush for Resident #3, who received feeding and hydration via PEG (Percutaneous Endoscopic Gastrostomy), was followed. Findings:Resident #1Review of Resident #1's electronic medical record revealed an admit date of 06/06/2025 with diagnoses that included in part: Encephalopathy, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Generalized Anxiety Disorder, Alcohol Abuse Uncomplicated, and Major Depressive Disorder Recurrent with Psychotic Symptoms. Review of Resident #1's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/18/2025 revealed Resident #1 had a 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 · Dcited before2025-06-11 · 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
Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice by failing to ensure a resident's Medical Director was notified of Registered Dietician recommendation in a timely manner for 1 (#2) of 6 (#1, #2,#3, #4,#5, and #6) sampled residents. Findings: Review of the facility's undated policy titled Weights read in part The Registered Dietician will complete the dietician recommendations and or/dietician noted at her discretion. The notes will be given to the DON for nursing staff to send to the physician for review and follow-up. Review of Resident #2's medical record revealed an admit date of 02/06/2025 with diagnoses that included in part .Supraventricular Tachycardia, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Cardiac Pacemaker, Aphasia following Cerebrovascular Disease and Chronic Atrial Fibrillation. Review of Resident #2's 03/2025 Physician Orders read in part . 02/06/2025 -Isosource hn at 50cc/hr per pump with water flushes at 30 cc/hr per feeding pump. Review of Registered…
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 17 citations
- Potential for harm · E2025-03-28 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure residents' rights to be free from verbal abuse and psychosocial harm by staff (Resident #15), resident to resident physical abuse (Resident #51 and #6); and protect a resident's right to be free from neglect (Resident #68), for 4 (Residents #6, #15, #51, and #68) of 4 residents (#6, #15, #51, and #68) reviewed for abuse and neglect. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m.,…
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 · E2025-03-28 · tag F0609 — failed to report abuse allegations — patternTimely 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 interview and record review the facility failed to ensure that all alleged violations involving verbal, sexual, physical,and/or mental abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse, or not later than 24 hours if the events that cause the allegation do not involve abuse in accordance with State law through established procedures, for 3 (#6, # 15, and #51) of 3 (#6, # 15, #51) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/16/2025, when S4 CNA yelled and cursed Resident #15, and made her go to bed; on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies; and on 03/08/2025 at approximately 4:20 p.m., when Resident #25 pulled Resident #6's hair. The facility failed to report the above staff to resident verbal abuse, and resident to resident abuse, to the State Agency. The deficient practice has 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 · E2025-03-28 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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 allegations of verbal, physical, and/or mental abuse, were thoroughly investigated for 3 (Resident #6, Resident # 15, and Resident #51) of 3 (Resident #6, Resident # 15, and Resident #51) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation for Resident #15 on 02/16/2025, when S4 CNA yelled at Resident #15 You stupid piece of sh*t. You're going to do what I say, and you're going to get in bed! Resident #15, who is cognitively intact, stated the incident hurt her feelings, made her cry, and she was fearful of S4 CNA. The Immediate Jeopardy continued on 02/21/2025 at approximately 3:28 p.m., when Resident #25 hit Resident #51 in the face with a box of cookies. Resident #51 stated this made her mad. The Immediate Jeopardy continued on 03/08/2025 at approximately 4:20 p.m., when Resident #25 (who exhibited aggressive and angry behavior on day of incident), pulled Resident #6's hair. S1 Administrator was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-28 · tag F0807 — failed to offer suitable drinks — patternEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to provide drinks consistent with resident preferences. The facility failed to ensure staff, in Hall X dining room, provided water to 10 residents with their meal during lunchtime. Findings: Observation on 03/24/2025 at 11:11 a.m. revealed staff serving resident lunch trays in Hall X dining room with only juice observed on the lunch tray. No water was observed on the lunch trays or offered to the 10 residents prior to receiving their lunch trays. Interview on 03/24/2025 at 11:12 a.m. with S5 CNA Supervisor revealed that the residents were given juice and milk with their lunch tray, but were not served/offered water with their meal. Observation on 03/25/2025 11:30 a.m. in Hall X dining room revealed the 10 residents were served only milk and juice with their lunch tray and were not offered or provided water. Interview on 03/25/2025 at 2:32 p.m. S5 CNA Supervisor revealed the kitchen does not send water on resident's meal trays and only send juice and Kool-Aid. S5 CNA Supervisor stated only if a resident were to request water…
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 · E2025-03-28 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 (Resident #6, Resident # 15, Resident #25, Resident #51, and Resident #68) of 34 Sampled Residents. The facility failed to: 1. Protect and ensure Resident #15 was free from verbal abuse and psychosocial harm by S4 CNA; 2. Ensure Resident #51 and Resident #6 were free from resident to resident physical abuse by Resident #25; 3. Ensure Resident #68 was free from neglect by S6 CNA; 4. Have an effective system in place to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made for Resident #6, Resident # 15, and Resident #51; and 5. Have an effective system in place to ensure allegations of abuse and neglect were thoroughly investigated for Resident #6, Resident # 15, Resident #51, and Resident #68. This deficient practice resulted in an Immediate…
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 · D2025-03-28 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records consistently reflected the resident's wishes to be a DNR (Do Not Resuscitate) code status. Findings: Review of the facility's policy dated 01/15/2025 titled, Advance Directives read in part . Policy statement: Advance Directives will be respected in accordance with state law and facility policy. 8. The plan of care for each resident will be consistent with his or her documented treatment preference and/or advance directives. Review of Resident #68's medical record revealed an admit date of 12/02/2024 with diagnoses that included: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's electronic record dashboard/orders revealed the resident was a Full Code status. Review of 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 · D2025-03-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review) Level I and/or Level II for 1(#23) resident of 2(#23 and #26) residents reviewed for PASARR screening. Findings: Review of the facility's undated policy titled, PASARR Policy read in part .If during the residents stay, their condition warrants having an inpatient psychiatric hospitalization or becomes diagnosed with a serious mental illness, a Level 2 screening should be done. Review of Resident #23's medical record revealed an admit date of 02/18/2022 with diagnoses read in part Benign Neoplasm of Stomach , Chronic Kidney Disease, and Bipolar Disorder, Current Episode Severe with Psychotic Features (01/19/2023). Review of Resident #23's medical record revealed a Level 1 pre-screening was provided for Resident #23 prior to admission on [DATE], which indicated a Level 2 screening is not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-28 · 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
Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan to meet the needs of 3 ( #34, #36, and #37) residents of 34 sampled residents. The facility failed to ensure Resident #34's and Resident #36's fall interventions were implemented, and failed to ensure 2 person physical assistance was used for bed mobility and toileting for Resident #37. Findings: Review of an undated facility policy titled, Care Plans Comprehensive read the following part .1. The interdisciplinary team will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, dietary and psychosocial needs and maximize the resident's highest level of functioning. Resident #34 Review of Resident #34's medical record revealed an admission date of 06/17/2024, with diagnoses that included in part .Chronic Kidney Disease, Stage 4 (Severe), Atrial Fibrillation, Pulmonary Fibrosis, and History of Falling. Review of Resident #34's admission MDS (Minimum Data Set) with an ARD…
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 · D2025-03-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (#68) of 1 resident reviewed for pressure ulcers. The facility failed to ensure: 1. gloves used during wound care were not contaminated by the bedside table; and 2. gloves were removed and hands were sanitized after cleaning Resident #68's wound. Findings: Review of the facility's undated policy titled Wound Treatment Management read in part .Policy: To promote wound healing of various types of wounds . to provide evidence based treatments in accordance with current standards of practice and physicians orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Review of Resident #68's medical records revealed an admit date of 12/02/2024 with diagnoses that include: Pressure Ulcer of Sacral Region, Stage 3, Cerebrovascular…
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 · D2025-03-28 · 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
Based on record review, observation, and interviews, the facility failed to administer a resident's enteral flush per the physician orders for 1(Resident #68) of 1 residents investigated for enteral feedings. Findings: Review of the facility's policy titled, Enteral Nutritional Therapy dated 04/05/2012, read in part Purpose: to provide hydration through a tube inserted into the stomach. If a feeding pump had been ordered .d. Adjust flow rate as prescribed. Review of Resident #68 medical records revealed an admit date of 12/02/2024 with diagnoses that include: Cerebrovascular Disease, Dysphagia following Cerebral Infarction, Generalized Anxiety Disorder, Bipolar Disorder, and Chronic Systolic Heart Failure. Review of Resident #68's 03/2025 physician orders revealed an order was started on 02/18/2025 for Glucerna 1.5 cal at 60cc/hour with 35cc/hour H2O flushes, per pump. Review of Resident #68's care plan with the next review date of 06/02/2025 read in part I require tube feeding related to Dysphagia secondary to Cerebrovascular Accident. Interventions: Glucerna 1.5 cal at…
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 · D2025-03-28 · 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
Based on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (#47) of 1 residents reviewed for respiratory care. Findings: Review of the facility's undated policy titled, Oxygen Concentrator revealed the following in part .Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Policy Explanation and Compliance Guidelines: 2. Oxygen is administered under orders of the attending physician, except in the case of an emergency. 4. Use of Concentrator: a. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.). Review of Resident #47's medical record revealed an admission date of 02/14/2024 with diagnoses that included in part, Cerebrovascular Disease; Shortness of Breath; Anxiety Disorder; Aphagia; Anorexia; and Dysphagia. Review of 03/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-28 · 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 assure the accurate administering of all drugs to meet the needs of each resident by failing to maintain accurate and complete documentation of controlled substances. Findings: Review of an undated facility policy on 03/27/2025 at 7:05 p.m. titled Drug Administration: Nursing Department Procedures read in part . b. Charting of medications shall be kept current and shall be completed as soon as administration is completed. Observation on 03/25/2025 at 8:48 a.m. of Cart B on Hall Y with S11 LPN revealed she had just completed morning medication pass for all resident's on Hall Y. Observation revealed narcotics were stored within a separate compartment of the cart and had a separate lock with key held by nurse. There was a narcotic log binder stored within the bottom drawer of cart. Record Review of the narcotic record log at time of the above observation for Resident # 37's Gabapentin 300mg capsules revealed a total of 18 capsules documented, with a last entry date 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 before2024-06-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of needs for 1 (#3) of 2 (#2 and #3) sampled residents reviewed for call bell placement. The facility failed to ensure Resident #3 had a call bell in reach in order to call for assistance. Findings: A review of Facility's undated policy on 06/11/2024 titled Call Bell/Light Policy, read in part . 2. The call bell must be within reach of the resident. If the resident constantly moves the call bell out of reach, it will be care planned. Review of Resident #3's medical record revealed an admit date of 03/27/2023, with diagnoses that included Cerebral Infarction due to thrombosis of right vertebral artery, CVA, Seizure Disorder, and HTN. Review of Resident #3's Minimum Data Set (MDS) with an ARD of 05/08/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 8, indicating cognitive impairment. The MDS revealed Resident #3 was dependent on staff for oral hygiene, showering, bathing, and dressing. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent incidents and accidents. The facility failed to ensure a resident wore a smoker's apron to prevent accidents while smoking for 1 (Resident #17) of 1 residents reviewed for smoking. Findings: Review of the facility's policy titled Safe Smoking Assessment read in part .The purpose of the Safe Smoking Assessment is to determine the individual's ability and willingness to comply with facility rules and regulations governing smoking. Appropriate care planning should be developed following the assessment. Review of Resident #17's medical record revealed she was admitted to facility on 08/03/2023 and had diagnoses that included in part Anxiety Disorder, Cerebral Infarction, Epilepsy, Parkinson's Disease, Major Depressive Disorder, and Type 2 Diabetes Mellitus. Record review of Resident #17's Quarterly MDS with ARD of 11/01/2023 reveled Resident #17 had a BIMS of 12. Record review of Resident #17's Safe Smoking Evaluation dated…
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 · D2023-11-30 · 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
Based on interview and record review the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments for 1 (#3) of 7 (#1, 2, 3, 4, 5, 6, and 7) sampled residents. The facility failed to ensure Resident #3 who had an iodine allergy was not served and consumed a meal tray that contained shellfish. Findings: Review of the facility policy titled: Meal Supervision and Assistance revealed in part . The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: Identifying hazards and risk Evaluating and analyzing hazards and risk Review of Resident #3's clinical record revealed an admit date of 08/03/2023 with diagnosis that included: Anxiety Disorder, Epilepsy, Bradycardia, Macular Degeneration, Essential Hypertension, Parkinson's Disease, and Type II Diabetes Mellitus. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · 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 observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to ensure staff changed gloves and performed hand hygiene after touching contaminated areas during wound care for 1 (#6) of 1 residents observed for wound care. Findings: Review of the Facility's Wound care policy read in part . Purpose: The Purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: 4. Put on exam glove. Loosen tape and remove old dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. Review of Resident #6's 11/2023 Physician Orders read in part: 11/03/2023 -Stage 2 Pressure injury to right buttocks. Cleanse with wound cleanser, pat…
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 · D2023-09-20 · 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
Based on record review, and interview the facility failed to ensure a residents received treatment and care in accordance with professional standards of practice, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to: 1. Ensure that medication was prescribed by a physician prior to being administered; and 2. Ensure Resident #1 received medications as ordered by the physician. Findings: Review of Resident #1's EHR revealed an admit date of 08/14/2017 with a readmission date of 05/05/2023, with diagnoses which included: Sepsis, unspecified organism, Pneumonia, unspecified organism, Acute Kidney Failure, unspecified, Other neuromuscular dysfunction of bladder, and Muscle wasting and atrophy. Review of Resident #1's Physician's Orders revealed the following: Apply Silvadene cream to burn areas on right chest area and right upper back area every day bid until resolved. (08/24/2023). Hydrocodone 10 mg -Acetaminophen 325 mg tablet by mouth prn q 4 hrs. prn pain (08/28/2023. Probiotic 15 billion cell capsule by mouth 3x/day for 7 days…
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.
Part of a chain
This home belongs to PARAMOUNT HEALTHCARE CONSULTANTS — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.4 | -0.4 vs chain |
| Health inspection | 3 of 5 | 2.9 | +0.1 vs chain |
| Staffing | 3 of 5 | 2.3 | +0.7 vs chain |
| Quality measures | 1 of 5 | 2.0 | -1.0 vs chain |
The other 13 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SMITH, DAWNE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2022 |
| TOWN OF MAMOU | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 01/01/2008 |
| VIDRINE, HEIDI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2023 |
| PARAMOUNT HEALTHCARE CONSULTANTS, LLC | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| STEPHEN DUCK, CPA PC | Organization | ADP OF THE SNF | — | since 01/01/2022 |
| ARDOIN, BRENT | Individual | ADP OF THE SNF | — | since 01/01/2022 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $325K 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 195619. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, 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.