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Many Healthcare and Rehabilitation Center

120 Natchitoches Hwy 6 East, Many, LA 71449 · For profit - Corporation · 162 certified beds · (318) 256-9233 Medicare & Medicaid certified

Call the home — (318) 256-9233 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 20242 actual-harm citations1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$129,108 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (28% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • inspectors recorded 1 serious finding 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 (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $129,108 in federal fines (most recent 2025-07-09)
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
395 S Capitol St · (318) 256-2000 · Call to confirm hours
Pharmacy
Walmart0.3 mi
25800 Highway 171 · (318) 256-6378 · Call to confirm hours
Grocery
175 E San Antonio Ave · (318) 256-9256 · Call to confirm hours
Park
Fort Jesup State Historic Site · Typically dawn to dusk
Place of worship
920 W Alabama St · (318) 256-5257

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.6%17.8%15.4%typical
Long-stay residents who lose too much weight8.3%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.1%1.2%0.9%worse
Long-stay residents with a urinary tract infection0.3%2.1%2.0%better
Long-stay residents with depressive symptoms0.8%2.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.8%3.5%3.3%worse
Long-stay residents whose ability to walk worsened13.6%17.9%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.6%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine98.6%94.9%95.3%typical
Long-stay residents with pressure ulcers7.1%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control14.4%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table11.5%22.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.1%3.1%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine93.5%76.3%79.4%better
Short-stay residents rehospitalized after admission21.1%28.0%22.6%typical
Short-stay residents with an outpatient ER visit6.9%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.532.561.67better
Long-stay outpatient ER visits per 1,000 resident days1.602.741.80better

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.

44.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.7%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
43.3%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 43.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.7%CMS range 28.1–58.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 6.3–18.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge43.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge46.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge40.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified63.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 2.6–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.24
RN hours/ resident / day
1.26
LPN hours/ resident / day
2.20
Aide hours/ resident / day
3.70
Total nurse hours/ resident / day
0.12
RN hoursweekends
28.4%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 162 beds and averages 75.4 residents a day — about 47% occupied, or roughly 87 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 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 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 3.14 hrs/resident/day on weekends vs 3.92 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.28 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 28% is below 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

7
deficiencies at the latest standard inspection (2026-03-11)
10
at the previous standard inspection (2025-01-14)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

35 citations, most serious first. The 13 most serious are shown; the remaining 22 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-04-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 record review, observation, and interview, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for accidents. The facility failed to properly secure Resident #3's wheelchair prior to transporting the resident in 1 of the facility's 2 vans. This deficient practice resulted in an immediate jeopardy situation on 03/20/2024 at 9:50 a.m., when Resident #3 was placed in the facility's van, and her wheelchair was anchored/secured in the facility's van with only three of the four anchors required. While the van was in motion, Resident #3's wheelchair fell backwards, and Resident #3 hit the back of her head on the lift. Resident #3 sustained an abrasion with bleeding noted to the back of her head. The Administrator stated the weekly safety inspections on the transportation van had not been completed by the van driver prior to the accident, as directed by the facility's policy. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2024-01-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's right to be free from physical and sexual abuse, and psychosocial harm by another resident, for (#1) of 3 (#1, #2, and #3) residents investigated for abuse. This failed practice resulted in an actual harm situation on 12/27/2023 at 3:40 p.m., when Resident #2 put his hands under Resident #1's shirt, and on her breast. On 11/19/2023, Resident #2 tried to throw a coffee cup at Resident #1; however, staff intervened. On 12/26/2023, Resident #2 lurched towards Resident #1 when staff tried to take Resident #1 to provide care, and a CNA had to step between the residents. On 12/27/2023, Resident #2 put his hand under Resident #1's shirt and on her breast, became angry when he was redirected, and grabbed and pinched Resident #1 on her back, and through her clothes, leaving a reddened area on her back. On 12/29/2023, Resident #2 grabbed Resident #1's hand squeezing it, and she yelled out Ouch! with a facial grimace. A reasonable person 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to use a two-person transfer, as determined necessary by the resident's person centered plan of care, during a transfer from bed to wheelchair for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Resident #2 fell to the ground, and sustained an Acute Left Femur Fracture. This failed practice resulted in an actual harm situation for Resident #2 on 09/06/2023 at 9:00 a.m., when S4 CNA transferred the resident from the bed to a wheelchair without assistance of another staff, as indicated on Resident #2's plan of care. During the transfer, Resident #2 fell to the ground. Resident #2 complained of left knee pain with swelling noted, and an x-ray was obtained which revealed an Acute Left Femur Fracture. Resident #2 was sent to the emergency room on [DATE], and had a Retrograde Nailing of the Left Distal Femur performed. Findings: Review of the facility's Fall Prevention Program revealed in part . All residents will be screened…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-27 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews the facility failed to maintain a safe, functional, and comfortable environment for 4 (Resident #1, Resident #3, R1, and R2) residents of 6 sampled residents reviewed for physical environment. The facility failed to provide transportation for residents to their appointments with a fully functional air conditioning system during the warm/hot weather climates.Findings: Review of a facility policy on 05/26/2026 at 3:10 p.m. titled, State of Resident Rights with an revision date of 12/13/2023 revealed the following in part .The resident does not give up any right when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. The resident has a right to: 1. all care necessary for you to have the highest possible level of health; 2. Safe, decent and clean conditions. Review of a facility vehicle maintenance inspection report on 05/27/2026 at 1:54 p.m. with a date of 11/2025-05/2026 revealed in part .Inspect air conditioning front and rear…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record view, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R3) resident of 6 sampled residents reviewed for quality of care. The facility failed to transport R3 to a nephrologist appointment in a timely manner as ordered. Findings:Review of R3's medical record revealed an admission date of 02/07/2025 with diagnoses which included in part . Chronic Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity, Bilateral, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Peripheral Vascular Disease, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Review of R3's current physician orders revealed in part . - Nephrology follow up appointment with Nurse Practitioner ______ at _______ on 06/11/2026 @ 9:00 a.m. one time only. (This is the rescheduled appointment- for reference.)Review of R3's 05/2026 monthly physician appointment calendar revealed in part .On 05/22/2026, R3 had an appointment at 8:20 a.m. with the Nephrologist. Further review…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (Resident #1) resident of 6 sampled residents. The facility failed to ensure nursing staff accurately documented Resident #1's medication/treatment administrations.Findings: Review of facility policy on 05/27/2026 at 1:54 p.m., titled, Medication Administration with a revision date of 03/05/2026 revealed the following in part .Purpose: To ensure medications were prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice. Review of Resident #1's medical record revealed an admission date of 12/04/2025 with diagnosis which included in part .End Stage Renal Disease, Type 2 Diabetes Mellitus with Hyperglycemia, Chronic Obstructive Pulmonary Disease, and Essential Primary Hypertension.Review of Resident #1's 03/2026 EMAR/ETAR (electronic medication administration record/electronic treatment administration record) revealed the following dates with 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-11 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the pureed meals for 13 Residents who receive pureed meals prepared by the facility kitchen.Findings: Review of the facility's policy titled: Food and Nutrition Services read in part . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Review of the facility's Pureed lunch Menu revealed.Turkey Breast Thigh- 1/4 cup, Cornbread Dressing f/Mix- 1/2 cup, [NAME] Bean Casserole w/Cut Freeze & Soup- 1/3 cup, Unfrosted Red Velvet f/Choc Mix-1/4 cup. Review of the Pureed Recipe menu revealed preparation steps and resident serving sizes to prepare each individual food item for residents' pureed meals according to the number of residents on pureed diets. Observation on 03/10/2026 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-11 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to store, prepare, distribute and serve food under sanitary conditions by: Failing to ensure safe food was served on the food line; and Failing to store clean dishes appropriately This failed practice had the potential to affect all 73 residents who receive food prepared from the facility's kitchen. Findings:Review of the facility's policy dated 03/05/2026 titled Food Preparation and Service revealed in part.Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Service/Distribution. 2. The temperatures of foods held in steam tables are monitored throughout the meal by food and nutrition services staff. Observation of temperature logs for steam tables for 03/2026 on 03/09/2026 at 9:15 a.m. revealed temperatures of prepared steam table foods were not completed for the following days and meals:March 3-breakfast and lunchMarch 5-breakfast, lunch, and dinnerMarch 6-breakfast, lunch, and dinnerMarch 7-breakfast, lunch, and dinnerMarch 8-breakfast, lunch, and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-11 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 2 (Resident #2 and Resident #81) of 2 residents reviewed for transfer/discharge. The total sample size was 33. Review of a facility policy on 03/11/2026 at 2:51 p.m. titled, Transfer or Discharge Notices with a revision date of 03/2025 revealed in part .Residents (or Resident Representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. Notice of Transfer or Discharge (Anticipated) 2. Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge: b. The resident's health improves sufficiently to allow a more immediate transfer or discharge, c. An immediate transfer or discharge is required by the resident's urgent medical needs. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a person-centered plan of care was developed for 1 (Resident #6) of 33 sampled residents to reflect a diagnosis of Dementia. The facility had a total census of 73. Findings: Review of Resident #6's medical record revealed an admit date [DATE] with diagnoses which included: Unspecified Dementia, Major Depressive Disorder, Psychotic Disorder with Delusions due to known physiological condition and Age-Related Cognitive Decline. Review of Resident #6's Quarterly MDS with an ARD of 12/29/2025 revealed a BIMS score of 99 (indicating severe impaired cognition), and required partial/moderate assistance with oral hygiene, bathing and toilet use. Resident #6's MDS revealed he was coded for a diagnosis of Non-Alzheimer's Dementia. Review of Resident #6's most recent care plan revealed no documented evidence of a care plan related to his diagnosis of Dementia. Interview on 03/11/2026 at 11:43 a.m. with S3 LPN/MDS confirmed Resident #6 did not have 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to asses a Central Venous Catheter for 1 (Resident #59) of 33 sampled residents. Findings:Review of a facility policy titled, Dialysis Management and AV Access Policy with a review date of 02/26/2026 read in part.Purpose: To establish standardized procedures for safe management of residents receiving hemodialysis, ensuring preservation of vascular access integrity, continuity of care, regulatory compliance, and effective interdisciplinary coordination.Policy Statement: The facility shall ensure all residents receiving dialysis services are monitored, assessed, and managed in accordance with physician orders, accepted standards of nursing practice, and regulatory requirements. Review of Resident #59's medical record revealed an admit date of 08/04/2021 with diagnoses that included in part.End Stage Renal Disease, Hypertensive Chronic Kidney Disease, Protein-Calorie Malnutrition, Human Immunodeficiency Disease, and Acute on Chronic…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 (Resident #4) of 33 sampled residents.Findings: Review of the facility's policy titled Oxygen Administration and Oxygen Safety, with a review date of 03/03/2026, revealed the following in part, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration and oxygen safety guidelines. Preparation: 1. Review the physician's orders or facility protocol for oxygen administration. Review of Resident #4's medical record revealed an admission date of 02/13/2025 with diagnoses that included in part, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Chronic Respiratory Failure, Type 2 Diabetes Mellitus with Hyperglycemia, and Functional Quadriplegia. Review of Resident #4's 03/2026 Physician Orders for revealed O2 (oxygen) at 2 liters per…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-11 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by failing to ensure medical equipment was cleaned in between uses with multiple residents. This had to potential to affect 73 residents. Findings: Review of the facility's policy dated 03/03/2026 on Infection Prevention and Control Program revealed in part Policy Statement-An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent and development and transmission of communicable diseases and infections. Observation of medication administration on 03/10/2026 at 9:20 a.m., revealed S9 LPN used an unclean, wrist blood pressure medical equipment in between uses with multiple residents. In an interview on 03/10/2026 at 10:05 a.m., S9 LPN revealed she did not clean wrist blood pressure medical equipment in between uses with multiple residents, but should have.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · Ecited before2025-01-14 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (Resident #46) of 29 sampled residents. The facility failed to ensure medications were administered safely and timely by leaving Resident #46's medications at her bedside. Findings: Review of the facility's policy titled Medication Administration dated 07/08/2024 revealed in part .Medications are administered in a safe and timely manner, and as prescribed. Review of Resident #46's medical record revealed an admit date of 07/19/2021 with diagnoses that included in part .Bilateral Primary Osteoarthritis, Morbid (severe) Obesity, Bipolar Disorder, Obstructive Sleep Apnea, Unspecified Myalgia, Repeated Falls, Chest Pain and Edema. Review of Resident #46's Quarterly MDS with an ARD of 10/22/2024 revealed a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #46 required supervision for: Bed mobility, Transfer, Eating and Toilet use. Review of Resident #46's care plan with a target date of 04/09/2025 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-14 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 4 (S11 CNA, S12 CNA, S13 CNA, and S14 CNA) of 5 (S11 CNA, S12 CNA, S13 CNA, S14 CNA, and S15 CNA) CNA personnel records reviewed. Findings: Review of CNA personnel records revealed the following: S11 CNA- date of hire was on 09/15/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. S12 CNA-date of hire was on 11/21/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. S13 CNA-date of hire was on 02/01/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. S14 CNA-date of hire was on 04/26/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-14 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 70. Findings: Observation on 01/12/2025 at 8:40 a.m. revealed a form for daily staffing dated 01/10/2025 was posted on a bulletin board near the nurse's station. Complete daily staffing information including census, and total number and actual hours worked by nursing staff were not posted for 01/10/2025, 01/11/2025, and 01/12/2025. Observation on 01/12/2025 at 9:06 a.m. revealed the posted daily staffing forms remained not updated for 01/10/2025, 01/11/2025, and 01/12/2025. Interview with S16 RN and S17 LPN at time of observation revealed they were unsure who was responsible for completing and posting the daily staffing hours over the weekend. S16 RN and S17 LPN confirmed the facility had not posted daily nurse staffing information on a daily basis, but should have. Interview on 01/12/2025 at 9:33 a.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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-14 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The facility failed to follow the menu in regards to recipe and portion size to ensure nutritional adequacy of the meal for 6 (#57, #41, #4, #1, #36 and #23) of 6 residents (#57, #41, #4, #1, #36 and #23), who received pureed diets. Review of the facility's recipe book located in the kitchen for pureed diets revealed in part . P/PU4 (coded for pureed foods-no lumps, require no chewing). Beef Meatballs f/Frz (fresh/frozen) w/mushroom gravy. [NAME] Method: Puree; Serving Utensil: #8 scoop; Serving Size: ½ Cup. Preparation Step: IDDSI (International Dysphagia Diet Standardization Initiative) Pureed foods: The number of portions served should equal the same number of portions pureed. Use Fork-Drip and Spoon-tilt test to ensure proper PU4 consistency is reached. Potato Mashed f (fresh)/ Inst (instant) Mix (Mashed Potatoes). Serving Utensil: #8 scoop; serving size: ½ cup. Ingredients: Water, Tap (Boiled) and Potato, Mashed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to store and prepare food under sanitary conditions in accordance with professional standards of food service safety, as evidenced by failing to: 1. Properly store food items located in the facility's refrigerator, freezer, resident dining area, and kitchen area. 2.Store clean dishes in an area that would remain free of food debris. 3. Monitor and record the temperatures of a refrigerator that was used to store prepared meal items for residents, from 12/01/2024 to current (01/12/2025). 4.Test and document the dishwasher's sanitizing solution concentration for dinner dishes on 01/10/2025 and 01/11/2025, and breakfast dishes on 01/12/2025. 5.Ensure dietary staff wore proper hair covering. Findings: Review of the facility's policy dated 10/2022, and titled Refrigerators and Freezers, read in part . Policy Statement: This facility will ensure safe refrigerator temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 2. Monthly tracking sheets for all refrigerators and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (#71) out of 1 resident reviewed for discharge. The total sample size was 29. Findings: Review of the facility's policy titled Transfer or Discharge Notice with a review date of 01/2023 read in part . Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. 6. A copy of the notice is sent to the Office of the State Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Record Review of Resident #71's Electronic Health Record (EHR) revealed an admission date of 11/06/2024 and a discharge date of 12/10/2024. Resident #71 had diagnoses that included in part .Displaced Comminuted Fracture of Shaft of Right Femur; Subsequent encounter for Closed Fracture with routine healing; Muscle Weakness; Primary Osteoarthritis other specified site; Unilateral Primary Osteoarthritis, Right Knee;…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · tag F0644 — isolated
    Coordinate 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 refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#5) of 1 residents investigated for PASARR in a final sample of 29 residents. Findings: Record Review of Resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part .Major Depressive Disorder, Anxiety Disorder, Cerebral Infarction without residual deficits, Vascular Dementia Unspecified Severity without Behavioral Disturbance. Further review revealed he was diagnosed with Schizoaffective Disorder on 10/10/2023. Record Review of Resident #5's Quarterly MDS with an ARD of 01/30/2025 revealed a BIMS summary score of 99, indicating BIMS was unable to be completed. Record Review of the Resident #5's Care Plan with a Target Date of 01/22/2025 revealed in part .The resident had the potential to be…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-14 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure the implementation of a comprehensive person centered care plan for 1 (Resident #44) of 29 sampled residents. The facility failed to ensure Resident #44's NPO status was implemented. Findings: Review of Resident #44's clinical record revealed an admit date of 03/28/2024, with diagnoses which included dysphagia-oropharyngeal phase; hemiplegia and hemiparesis following cerebral infarction protein-calorie malnutrition; dysphasia following other cerebrovascular disease; dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; adult failure to thrive and age-related physical debility. Review of Resident #44's Quarterly MDS with an ARD of 11/12/2024, revealed a BIMS score of 4. Resident had severe cognitive impairment. Resident had impairment on both sides for upper and lower extremities. Resident was dependent for eating, oral hygiene, toileting, showering/bathing; lower/upper…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-14 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to document a Discharge Summary when a resident was discharged from the facility for 1 (#71) out of 1 residents reviewed for discharge. The total sample size was 29. Findings: Review of the facility's policy titled Transfer or Discharge Documentation and Notice with a review date of 01/2023 read in part . When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Record Review of Resident #71's Electronic Health Record (EHR) revealed an admission date of 11/06/2024 and a discharge date of 12/10/2024. Resident #71 had diagnoses that included in part .Displaced Comminuted Fracture of Shaft of Right Femur; Subsequent encounter for Closed Fracture with routine healing; Muscle Weakness; Primary Osteoarthritis other specified site; Unilateral Primary Osteoarthritis, Right Knee; Cognitive Communication Deficit; Age-Related Osteoporosis without current pathological…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent possible cross contamination for 1 (#44) of 29 sampled residents by failing to use enhanced barrier precautions, when needed. Findings: Review on 01/14/2025 of the facility's policy and procedure dated 04/01/2024, and titled Enhanced Barrier Precautions read in part . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Indwelling medical device examples include central lines,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse for 1 (#6) of 8 (#1, #2, #3, #4, #5, #6, #7 and #8) residents reviewed for abuse. The facility failed to protect Resident #6 from physical abuse by Resident #8. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy on 09/17/2024, with a revision date of 05/17/2024 titled Abuse Prohibition Policy, read in part . Each resident has the right to be free from abuse, mistreatment neglect, corporal punishment, involuntary seclusion and financial abuse. Resident #6 Review of Resident #6's medical records revealed an admission date of 12/07/2022, with diagnoses that included: Heart Failure, Major Depressive Disorder, Osteoarthritis, Congestive Heart Failure, Hypertension, and Atrial Fibrillation. Review of Resident #6's Quarterly MDS with an ARD of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2024-09-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure an allegation of resident to resident sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the resident to resident sexual abuse was discovered for 2 (Resident #5 and Resident #7) of 8 residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse Prohibition Policy read in part . 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, and injuries of unknown source…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to implement the resident's comprehensive plan of care for 1 (#4) of 8 (#1, #2, #3, #4, #5, #6 ,#7 and #8) sampled residents. The facility failed to place a fall mat at the bedside for resident #4. Findings: Review of Resident #4's clinical record revealed an admit date of 01/04/2022, with diagnoses which included repeated falls; other spondylosis, cervical region; spondylolisthesis, lumbar region; other abnormalities of gait and mobility; displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing; schizoaffective disorder, bipolar type; anxiety disorder, unspecified; and Alzheimer's disease, unspecified. Review of Resident #4's Quarterly MDS with an ARD/ Target date of 04/19/2024, revealed a BIMS score of 11; Moderate Impairment. Resident #4 requires supervision and one person physical assist with bed mobility; and requires Supervision and set up help only with transfers, eating and toilet use. Review of Resident #4's clinical record revealed a Morse Fall…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-11 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure 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 record review, observation, and interview the facility failed to ensure a Certified Nursing Assistant (CNA) was competent in skills and techniques necessary to assure resident safety for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for accidents. The facility failed to ensure that an untrained CNA (S4) was not allowed to secure Resident #3, who was wheelchair bound, in a facility van prior to transportation. Findings: Review on 04/11/2024 of the facility policy revised on 03/2023 titled Facility Vehicle Log, A Part of the Driver and Vehicle Safety Policy revealed in part . Driver's Weekly Vehicle Safety Inspection- To be completed by the company vehicle driver once each week and prior to driving a vehicle that has been returned to service after repairs. If there are safety concerns noted during the inspection, they are to be noted on the Driver's Weekly Vehicle Safety Inspection form and reported immediately to Maintenance or the Administrator. The vehicle should immediately be taken out of service if the driver or others determine that the vehicle cannot be driven…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #2 was adequately supervised to protect Resident #1 and prevent physical and sexual abuse of Resident #1, for 1 (#2) of 3 (#1, #2, and #3) sampled residents. Findings: Resident #2 Review of Resident #2's medical record revealed an admit date of 10/04/2023, with diagnoses that included in part .Unspecified Dementia, moderate with agitation; Hypertension; Major Depressive Disorder; Schizoaffective Disorder, Depressive type; Emphysema; and Cognitive Communication Deficit. Review of Resident #2's Quarterly MDS with an ARD of 12/13/2023 revealed the resident had a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #2 had no impairment of the upper or lower extremities, was independent with walking 150 feet, independent with toilet transferring, independent with sitting to lying or lying to sitting, and required set up or clean up assistance with eating. Resident #2's Care Plan revealed a problem…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 (#2) of 3 (#1, #2, & #3) sampled residents that addressed his possessiveness over another resident and his combative behaviors with staff related to this resident. Findings: Resident #2 Review of Resident #2's medical record revealed an admit date of 10/04/2023 with diagnoses that included in part .Unspecified Dementia, moderate with agitation, Hypertension, Major Depressive Disorder, Schizoaffective Disorder, depressive type, Emphysema, and Cognitive Communication Deficit. Review of Resident #2's Quarterly MDS with an ARD of 12/13/2023 revealed the resident had a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #2 had no impairment of the upper or lower extremities, was independent with walking 150 feet, independent with toilet transferring, independent with sitting to lying or lying to sitting, and required set up or clean up assistance with eating. Review of Resident #2's nurses' notes revealed in part the following:…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Resident #69 A review of Resident #69's medical record revealed an admit date of 09/21/2023 with diagnoses that included: Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left side, Essential Hypertension, and Major Depression Disorder. A review of Resident #69's Care Plan with a target completion date of 01/04/2024 read in part . Resident #69 has oxygen therapy: Monitor nebulizer treatment prior to and after treatment, Ipratropium-Albuterol solution as ordered, Monitor for signs and symptoms of respiratory distress and report to medical director as needed. An observation on 12/11/2023 at 10:34 a.m. revealed Resident #69's nebulizer mask dated 12/5/2023 hanging on the nebulizer machine, left open to air, and uncontained. An observation on 12/12/2023 at 9:30 a.m. revealed Resident #69's nebulizer mask was observed hanging on the side of the nebulizer machine uncontained. An interview on 12/12/2023 at 9:40 a.m. with S2 DON confirmed the above findings. S2 DON stated all respiratory tubing should be dated and stored in a zip lock bag when not 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. The facility failed to ensure that expired/outdated items were not available for resident consumption and failed to ensure frozen food items were properly stored. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. Findings: Review of the facility policy titled: Food Receiving and Storage revealed in part . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by) date. Observation on 12/11/2023 at 10:00 a.m. of the facility cooler accompanied by S3 Dietary Manger, revealed the following items on the shelf for use: (1) 5lb container of cottage cheese with an expiration date of 10/28/2023 (1) opened gallon of yellow mustard dated 12/15. Interview with S3 Dietary Manager at the time of observation confirmed the above findings. S3 Dietary Manager stated she was unsure what year the mustard labeled 12/15 had been opened. On initial tour of the kitchen…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice as evidenced by failing to obtain an order for oxygen therapy for 1 (Resident #17) of 2 (#17 and #69) residents reviewed for respiratory care. Findings: Review of the facility's policy titled, Oxygen Administration read in part . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of Resident #17's medical record revealed an admit date of 02/27/2023 with diagnoses that included Gastrostomy status, Cerebral Infarction due to Embolism of Unspecified Middle Cerebral Artery, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Osteomyelitis of Vertebra, Sacral-coccygeal region, Type 2 DM with Hyperglycemia, Functional Quadriplegia and Personal…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (#13) of 4 (#6, #13, #26, and #64) residents reviewed for ADL care. Findings: Review of the Facility's Fingernail/Toenail Care policy read in part . Policy: The Purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1.Nail care includes daily cleaning and regular trimming. Review of Resident #13's Care plan with a target completion date of 12/06/2023 revealed in part Resident #13 requires assistance with ADLS. Personal hygiene- requires substantial/maximum assistance. An observation and interview on 12/11/2023 at 11:58 a.m. revealed Resident #13 with long and jagged fingernails. Resident #13 stated he has asked staff to cut his nails but he has been told they are unable to clip his nails because he is Type 2 Diabetic. Resident #13…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan 1 (Resident #11) of 1 sampled residents for edema. The facility failed to ensure Physician's Orders for an assistive device for support and positioning were implemented. Findings: Review of Resident #11's clinical record revealed an admit date of 10/17/2023. Resident #11 was noted to have diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Muscle Wasting and Atrophy, and Osteoarthritis. Review of Resident #11's MDS Assessment with ARD 11/16/2023 revealed Resident #11 had a BIMS score of 15, cognitively intact, and had functional limitation in range of motion in the upper and lower extremities on one side. Observation on 12/11/23 at 12:28 p.m. revealed Resident #11 seated in a wheelchair in the facility dining room. Mild edema was noted to Resident #11's left upper arm and hand. No assistive or supportive devices…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, 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: 1. Failing to ensure staff performed hand hygiene after touching contaminated areas during wound care for 1 (#56) of 1 residents observed for wound care. 2. Failing to ensure catheter tubing was kept off the floor for 1 (#17) of 1 resident reviewed for urinary catheter. Findings: Review of the Facility's Handwashing- Hand Hygiene policy read in part . Applying and removing gloves: 1. Perform hand hygiene before and after applying non sterile gloves. Resident #56 Review of Resident #56's medical records revealed an admit date of 12/16/2021 with diagnoses that included: Pressure Ulcer to Sacral Region Stage 4, Stemi Myocardial Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction, Unspecified Dementia, Obstructive Sleep Apnea, Heart Failure, and Essential Hypertension. Review of Resident #56's 12/2023…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$129,108 in federal fines across 4 penalties.

  • $16,149 — penalty dated 2025-07-09
  • $16,801 — penalty dated 2024-04-11
  • $88,715 — penalty dated 2023-12-13
  • $7,443 — penalty dated 2023-09-20

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

Part of a chain

This home belongs to NEXION HEALTH — 51 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.2-0.2 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 3 of 52.8+0.2 vs chain
Quality measures 3 of 52.6+0.4 vs chain
The other 50 homes this chain runs (chain average 2.2★, per CMS)
1 of 5Bay Ridge Healthcare CenterLa Porte, TX 1 of 5Claiborne Healthcare CenterShreveport, LA 1 of 5Cornerstone Rehabilitation And Healthcare CenterCorinth, MS 1 of 5Crystal Rehabilitation And Healthcare CenterGreenwood, MS 1 of 5Duncanville Healthcare and Rehabilitation CenterDuncanville, TX 1 of 5Flatonia Healthcare CenterFlatonia, TX 1 of 5Gonzales Healthcare CenterGonzales, LA 1 of 5Green Valley Healthcare and Rehabilitation CenterFort Worth, TX 1 of 5Grenada Rehabilitation And Healthcare CenterGrenada, MS 1 of 5Holly Springs Rehabilitation And Healthcare CenterHolly Springs, MS 1 of 5Indianola Rehabilitation And Healthcare CenterIndianola, MS 1 of 5Lily Springs Rehabilitation and Healthcare CenterLampasas, TX 1 of 5Meadowview Health & Rehab CenterMinden, LA 1 of 5New Iberia Manor SouthNew Iberia, LA 1 of 5Patterson Healthcare CenterPatterson, LA 1 of 5Picayune Rehabilitation And Healthcare CenterPicayune, MS 1 of 5Pierremont Healthcare CenterShreveport, LA 1 of 5Prairie Meadows Rehabilitation and Healthcare CentFloresville, TX 1 of 5The Bluffs Rehabilitation And Healthcare CenterVicksburg, MS 1 of 5Village Creek Rehabilitation and Nursing CenterLumberton, TX 1 of 5Willow Park Rehabilitation Health Care CenterClifton, TX 1 of 5Woodlands Rehabilitation And Healthcare CenterClinton, MS 1 of 5Yazoo City Rehabilitation And Healthcare CenterYazoo City, MS 2 of 5Great Oaks Rehabilitation And Healthcare CenterByhalia, MS 2 of 5Kaplan Healthcare CenterKaplan, LA 2 of 5New Iberia Manor NorthNew Iberia, LA 2 of 5North Star Ranch Rehabilitation and Healthcare CenBonham, TX 2 of 5Willow Park Rehabilitation And Care CenterWillow Park, TX 3 of 5Barton Valley Rehabilitation and Healthcare CenterAustin, TX 3 of 5Cedar Ridge Rehabilitation and Healthcare CenterPilot Point, TX 3 of 5Columbia Rehabilitation And Healthcare CenterColumbia, MS 3 of 5Cross Timbers Rehabilitation and Healthcare CenterFlower Mound, TX 3 of 5Delta Rehabilitation And Healthcare CenterCleveland, MS 3 of 5Golden Creek Healthcare And Rehabilitation CenterNavasota, TX 3 of 5Lakeview Rehabilitation and Healthcare CenterWinnsboro, TX 3 of 5Lone Star Ranch Rehabilitation and Healthcare CentKingsville, TX 3 of 5Midwestern Healthcare CenterWichita Falls, TX 3 of 5Natchez Rehabilitation And Healthcare CenterNatchez, MS 3 of 5Ridgecrest Healthcare And Rehabilitation CenterForney, TX 4 of 5Arbor Hills Rehabilitation And Healthcare CenterEagle Lake, TX

Showing 40 of 50; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
NEXION HEALTH OF OHI INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 09/14/2005
NEXION HEALTH LEASING, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/15/2002
NEXION HEALTH, INC.Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/15/2002
BOLT, BRETTONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/15/2002
KIRLEY, FRANCISIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/15/2002
BROADWAY, SUNNYIndividualW-2 MANAGING EMPLOYEEsince 02/14/2014
HERDRICH, WILLIAMIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2012
LEE, BRIANIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/15/2002
REID, JOHNIndividualCORPORATE DIRECTORsince 12/03/2018
RINER, MEERAIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 02/01/2012

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

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

Follow the money — this home’s finances

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

$7.0M
Net patient revenuemost recent cost report
+0.9%
Operating marginrevenue minus expenses
$425K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 8%Other / private 23%

This home reported $425K 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

$268per resident / day
operating cost
$8,146per month
≈ monthly operating cost
$270per day
avg. revenue, all payers

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

What families pay in LA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195310. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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.

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