Colonial Nursing and Rehabilitation Center
426 North Washington Street, Marksville, LA 71351 · For profit - Limited Liability company · 64 certified beds · (318) 253-4554 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $21,752 in federal fines (most recent 2025-11-24)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 18% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.5% | 17.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 3.6% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.4% | 2.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 2.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.2% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 20.5% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 34.6% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.2% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 37.9% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 16.1% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 40.9% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.0% | 14.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.97 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.49 | 2.74 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 57.1% 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 28 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 0.24 therapist hours per resident per day in 2026Q1 — more than 32% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 5.6–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 57.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 46.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.2%CMS range 4.7–18.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.34 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 64 beds and averages 61.0 residents a day — about 95% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.97 hrs/resident/day on weekends vs 3.71 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.52 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Immediate jeopardy · J2025-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place for a cognitively impaired resident who was identified as being at high risk for elopement, exhibited exit seeking behaviors, and voiced a desire to leave the facility did not exit the building for 1 (#156) of 11 (#2, #3, #23,#24, #25, #38, #44, #47, #48, #156 and #157) residents at risk for elopement. Findings: This deficient practice resulted in an immediate jeopardy situation for Resident #156 on 05/16/2025 at 8:15 a.m., when Resident #156, who had a BIMS of 4, was cognitively impaired, and exhibited exit seeking behaviors went out of a bathroom window. Resident #156 then walked to a nearby neighborhood approximately 0.5 miles away. At approximately 10:30 a.m., the local police department notified the facility that Resident #156 was in custody after being arrested for theft of a motor vehicle. On 05/16/2025 at 1:00 p.m., Resident #156 returned to the facility. The facility implemented corrective…
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.
- Actual harm · G2025-11-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's right to be free from staff to resident physical abuse, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Resident #1, a cognitive resident, experienced psychosocial harm as a result of the physical abuse by staff. This deficient practice resulted in psychosocial harm to Resident #1 on 10/11/2025 at 1:15 p.m., when Resident #1 reported to S2 CNA that S3 CNA entered his room without invitation and intentionally poured water on him in an attempt to stop him from masturbating. Resident #1, who had a BIMS score of 15 (cognitively intact), was tearful and fearful following the physical abuse from S3 CNA. 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 undated facility policy titled Abuse Prevention and Investigation revealed in part.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 resident's personal funds were available during non-business hours for 1 (Resident #23) of 34 sampled residents. Total facility census was 63.Findings:Review of a facility policy titled Availability of Resident Funds-After Business Office Hours, read in part.Policy: It is the practice of this facility to provide residents reasonable access to their personal funds after business office hours. Policy Explanation and Compliance Guidelines:2. During non-business office hours (e.g .nights, weekends, and holidays), the Business Office Manager, or designee, provides the Charge Nurse on duty at the time the business office closes a residents' fund petty cash box. 5. Staff members receive training on this policy in order to direct residents to the Charge Nurse when requests for personal funds are made during non-business office hours. Interview on 05/26/2026 at 1:20 p.m. with Resident #23 revealed when she asked for her money it usually took two days to receive it. Resident #23 revealed in the evenings and weekends, no staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #65) of 1 resident reviewed for transfer/discharge. The total sample size was 63.Findings:Review of Resident #65's medical record revealed an admission date of 02/16/2026 and a discharge date of 03/02/2026. Resident #65 had diagnosis of Emphysema, Heart Failure, Nutritional Anemia, Cocaine Use, Essential Hypertension, and Unspecified Viral Hepatitis CReview of the facility's March Emergency Transfer Log revealed a list of only hospitalization transfers and Resident #65's discharge was not listed.In an interview on 05/28/2026 at 3:40 p.m., S5 SSD revealed all discharges were reported to the Ombudsman monthly on the 15th for the previous month. She stated she sends the log via email to [NAME], Ombudsman. She confirmed Resident #65 was not on March Emergency Transfer Log, but should have been. In an interview on 05/28/2026 at 3:48 p.m., S1 Adm confirmed Resident #65 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-28 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the Residents' status for 3 (#6, #17, and #57) of 34 sampled residents by failing:1. to ensure the Significant Change MDS assessments were correct for Resident #6 and Resident #17; and2. to ensure Resident #57's 03/23/2026 Quarterly MDS contained accurate diagnoses.Findings: Review of the facility's undated policy titled, MDS – Conducting and Accurate Resident Assessment revealed the following, in part: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment of relevant care areas. Resident #6 Review of Resident #6's medical record revealed an admission date of 04/24/2024 and diagnoses that included, but are not limited to, Other Psychoactive Substance Abuse With Psychoactive Substance-Induced Psychotic Disorder with Delusions; Type 2 Diabetes Mellitus with Hyperglycemia; Abnormal Weight Loss; Anorexia; and Personal History of Traumatic Brain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews, and investigations, the facility failed to ensure the development and implementation of the residents' person-centered plan of care for 3 (#23, #51, and #52) of 34 sampled residents by failing to:1. to develop and implement a care plan for Resident #23's dialysis needs;2. to develop and implement a care plan for Resident #51's ADL needs; and3. to monitor effectiveness of diabetic medications on Resident #52.Findings: Resident #23 Review of Resident #23's medical record revealed an admit date of 07/10/2024 with diagnoses that included in part.Human Immunodeficiency Virus, End Stage Renal Disease, Peripheral Vascular Disease, Hypertensive Heart Disease with Heart Failure, and Generalized Anxiety Disorder. Review of Resident #23's Quarterly MDS with an ARD of 04/06/2026 revealed a BIMS score of 13 which indicated intact cognition. The MDS revealed Resident #23 was dependent with toileting, bathing, dressing and personal hygiene; and required substantial/maximal assistance with eating and oral hygiene. The MDS revealed Resident had End Stage Renal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-28 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to effect all 63 residents who resided in the facility. The facility failed to ensure:1. Expired Food items in the pantry were not available for use;2. Staff are wearing beard restraints to prevent hair from contacting food Findings: Review of an undated facility policy titled, Date Marking for Food Safety revealed in part.Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. Review of a facility policy dated January 2025 titled, Infection Control-Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revealed in part…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, record review, and interview the facility staff failed to use standard precautions by performing hand hygiene during medication administration for 4(Resident #9, Resident #11, Resident #38, Resident #47) of 4 residents observed.Review of policy Hand Hygiene Table dated January 2025 revealed, hand hygiene should be used between resident contacts- either antimicrobial Soap and Water or Alcohol Based Hand Rub.Observation of medication administration on 05/27/2026 with S7 LPN revealed that she did not perform hand hygiene by not washing or sanitizing her hands between medication administrations of the 4 observed residents.Interview on 05/27/2026 at 08:20 AM with S7 LPN confirmed, Absolutely, I should have used sanitizer between administrations of medication between residents.Interview on 05/27/2026 at 08:30 AM with S2 DON confirmed, that the nurse should have sanitized hands between residents.
- Potential for harm · Dcited before2025-11-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an allegation of abuse was reported immediately to the administrator of the facility for 1 (Resident #1) of 3 sampled residents reviewed for abuse. The facility failed to ensure staff reported an allegation of staff-to-resident abuse to facility Administrator. Findings:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included in part. Schizoaffective Disorder, Bipolar Disorder, Diabetes, Hemiplegia and Hemiparesis following Cerebral Vascular Disease affecting Left Non-Dominant Side, Vascular Dementia, Epilepsy, and Unspecified Other Behavioral Disturbance. Review of Resident #1's Quarterly MDS with an ARD of 08/20/2025, revealed Resident #1 had a BIMS score of 15, which indicated cognition was intact. The MDS revealed Resident #1 was dependent on staff for activities of daily living (ADLs). Review of Resident #1's Care Plan, with a review date of 01/08/2025, revealed in part.On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure a resident's person centered plan of care was reviewed and revised to include approaches/ interventions to address the resident's self pleasuring behavior for 1 (Resident #1) of 3 sampled resident's care plans reviewed. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses that included in part. Schizoaffective Disorder, Bipolar Disorder, Diabetes, Hemiplegia and Hemiparesis following Cerebral Vascular Disease affecting Left Non-Dominant Side, Vascular Dementia, Epilepsy, and Unspecified Other Behavioral Disturbance.An interview on 11/20/2025 at 1:35 p.m., with S2CNA revealed Resident #1 masturbates in his room frequently. S2CNA stated staff were aware of his sexual behaviors and have been instructed to close the door or pull the privacy curtain if Resident #1 engages in self-pleasure.A telephone interview on 11/20/2025 at 2:58 p.m., with S3CNA revealed on 10/11/2025 at approximately 1:00-1:15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-29 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #25 Based on observation, interview, and record review, the facility failed to implement and monitor interventions to maintain proper hydration and nutrition for 2 (Resident #25 and Resident #8) of 2 residents reviewed for nutrition. The facility failed to: 1. Implement and monitor hydration consistent with Resident #25's assessed needs; and 2. Notify the Registered Dietician of Resident #8's change in nutritional needs. Findings: Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Intake and Output, Monitoring Fluids revealed the following in part .4. For residents with a physician's order for fluid encouragement, fluids will be encouraged as per the resident's care plan. 6. The following residents require measurement and documentation of intake and output. A. Residents with a physician's order for intake and output measurement. Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Hydration Program revealed the following in part .to provide all residents with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-05-29 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 55 residents who resided in the facility. The facility failed to ensure: 1. Food items in pantry were stored in a sealed container; 2. Opened food items in refrigerator and freezer were labeled with an open date and stored in a sealed container; and 3. Snacks considered potentially hazardous food were stored appropriately. Findings: A review of the facility's undated policy titled, Storage: Freezer revealed in part . Keep all frozen foods tightly wrapped or packaged to prevent freezer burn . Label and date all items. A review of the facility's undated policy titled, Storage: Refrigerator revealed in part . Keep refrigerated foods wrapped or covered and in sanitary containers. A review of the facility's undated policy titled, Storage: Dry Food revealed in part .Keep all containers tightly closed from insects, rodents, and dust. Dry…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 11 citations
- Potential for harm · Ecited before2025-05-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
3. Resident #11 A review of Resident # 11's medical record revealed an initial admission date of 12/08/2023 and re-admission date of 01/23/2025 with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerosis of native arteries of extremities with intermittent claudication of bilateral legs, Phantom Limb Syndrome with pain, Peripheral Vascular Disease, acquired absence of right leg above knee, unspecified open wound of left great toe with damage to nail, subsequent encounter, cellulitis of left lower limb. On 05/28/2025 at 10:00 a.m. review of Resident #11's annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 02/24/2025, revealed Resident #11 had a BIMS score of 10, which indicated moderate cognitive impairment and had an open lesion on the foot. On 05/28/2025 at 11:04 a.m. review of Resident # 11's care plan with initiation date of 09/06/2024 revealed Resident #11 had actual skin impairment to the left great toe. Interventions included in part . Clean left foot great toe wound with NS/WC (normal saline/wound cleanser),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-05-29 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
On 05/27/2025 at 11:30 a.m. observation of the facility kitchen revealed one live fly flying throughout the food preparation area. On 05/29/2025 at 09:08 a.m. observation of the facility kitchen revealed one live fly flying throughout the kitchen area. On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed the facility recently began having issues with live flies. S8 Dietary Manager confirmed she has observed live flies in kitchen area and the kitchen should always be free of flies or any other insects/pest, but was not. Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests. The facility failed to provide an environment free of flies throughout the facility. This deficient practice had the potential to effect all 55 residents who resided in the facility. Findings: Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Pest Control Program revealed the following part .Facility will maintain an effective pest control program that eradicates 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.
- Potential for harm · Dcited before2025-05-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #156 Review of Resident #156's medical record revealed an admit date of 04/30/2025, with diagnoses that included, in part .Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Cocaine Abuse with Cocaine-Induced Mood Disorder/Sleep Disorder, and Anxiety Disorder. Review of Resident #156's admission MDS with an ARD of 05/02/2025, revealed a BIMS score of 04, which indicated severe cognitive impairment. The MDS revealed Resident #156 was independent for transfers and used a walker for mobility. Review of Resident #156's Care plan with a target completion date of 08/11/2025, read in part .Elopement risk related to reported history of Altered Mental Status, Cocaine use with wandering attempts to leave hospital noted. 05/15/2025-Elopement attempt noted: willfully attempted to leave facility without notifying staff, wanted to be discharged back home. Interventions included in part; Elopement precautions: Census checks every 1 hour, each shift related to history of Delirium and wandering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-29 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to provide a necessary communication aid for 1 (#35) of 1 Resident reviewed for communication. The total sample size was 30. Findings: Review of Resident #35's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . Type 2 Diabetes Mellitus, Major Depressive Disorder, Unspecified Dementia, and Generalized Anxiety Disorder. Review of Resident #35's Quarterly MDS with an ARD date of 05/21/2025 revealed Resident #35 had BIMS of 8 (Moderate Cognitive Impairment). Resident #35's ability to understand others was documented as- sometimes. Review of Resident #35's Comprehensive Person Centered Care Plan revealed resident had difficulty communicating related to language barrier. Interventions included: Provide a communication board. Interview and observation on 05/27/2025 at 12:14 p.m. with Resident #35 revealed he had difficulty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-15 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) out of 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) nursing/direct care staff records reviewed, were re-trained on their policy & procedure for abuse, after an incident of staff to resident verbal abuse occurred for 1 (#1) of 3 (#1, #2, and #3) sampled residents. This deficient practice had the potential to affect all 59 residents residing in the facility. Findings: A review of the facility's Policy & Procedure on Abuse revealed in part the following: Residents have the right to be free from abuse Training: Employees shall be trained in orientation, annually and as needed on the following topics which include: Prevention of Abuse, Neglect, and Exploitation Identifying what constitutes abuse Recognizing signs of abuse Review of Resident #1's medical record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (Resident #18) of 2 (Resident #18 and Resident #20) sampled residents investigated for abuse. The facility failed to report an allegation of staff to resident abuse. Findings: Review of a policy and procedure titled, Abuse Prevention and Investigation, revealed in part: The appropriate State Agency will be notified per regulations for any abuse, suspected abuse, and injury of unknown origin using the State-Mandated Protocol for Reporting. Review of the EHR revealed Resident #18 was admitted to the facility on of 09/23/2022 with diagnoses that included: Unspecified Psychosis, Hypertensive Heart Disease, and Type 2 Diabetes Mellitus with Diabetic Nephropathy, Depression, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease. Review of Resident #18's Quarterly MDS with an ARD of 01/15/2024 revealed Resident #10 had moderate cognitive impairment with adequate vision and hearing. Interview on 03/18/2024 at 1:00 p.m. with Resident #18,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-20 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the MDS Assessment accurately reflected a residents' status during the observation period for 1 (Resident #49) of 1 residents sampled for dental. The total sample size was 23 residents. Findings: Review of Resident #49's clinical record revealed Resident #49 was admitted to the facility on [DATE]. Resident #49 had diagnoses that included Peripheral Vascular Disease, Obstructive Sleep Apnea, Asthma, and Essential Hypertension Review of Resident #49's Significant Change MDS Assessment with ARD 11/23/2023 indicated Resident #49 had, none of the above, checked on his dental assessment. Interview on 03/18/2024 at 10:1a.m. with Resident #49 revealed he had been having dental pain on and off to his right upper molar. Observation of Resident #49's oral cavity and dentition at the time of interview revealed 1 decayed right upper molar, 1 decayed left upper molar and 4-5 broken, decayed, front bottom teeth, all other teeth missing. Interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-20 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #18) sampled resident in a total sample of 23 residents. The facility failed to ensure a comprehensive care plan was developed for a resident newly diagnosed with Dementia. Findings: Review of the EHR revealed Resident #18 was admitted to the facility on of 09/23/2022 with diagnoses that included: Unspecified Psychosis, Hypertensive Heart Disease, and Type 2 Diabetes Mellitus with Diabetic Nephropathy, Depression, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease. Additional Diagnoses on 01/10/2024 included Unspecified Dementia, Unspecified severity with Agitation, and Dementia with other Behavioral disturbances. Review of 03/2024 physician orders for Resident #18 revealed: Memantine 5 mg po bid - Dx: Unspecified Dementia- 01/10/2024 Review of Resident #18's Quarterly MDS with an ARD of 01/15/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure care and services were provided to meet professional standards of practice. The facility failed to accurately document administration of respiratory services provided for 1 resident (Resident #37) of 23 sampled residents. Findings: Review of Resident #37's Medical Record revealed an admission date of 10/28/2022 with diagnoses that included Acute Cough, Chronic Obstructive Pulmonary Disease, Disease of Upper Respiratory Tract, Allergic Rhinitis and Acute Upper Respiratory Infection. Review of Resident #37's Physician's Orders for March 2024 revealed an order dated on 11/08/2023 for Ipratropium-Albuterol 0.5-3(2.5) mg/3ml inhale one nebulizer BID Diagnosis Cough/ Wheeze Bilateral. Review of Resident #37's MARs for March 2024 revealed S5 LPN documented Ipratropium-Albuterol nebulizer treatment as administered on 3/19/2024 at 8:00 a.m. and on 3/20/2024 at 8:00 a.m. Review of Resident #37's Quarterly MDS with an ARD of 2/14/2024 revealed a BIMS score of 15, indicative of intact cognition. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 to dependent residents for 1 (Resident #40) of 7 residents (Resident #10, Resident #18,Resident #28, Resident #40, Resident #44, Resident #53, and Resident #58) sampled for ADL's. Findings: Review of the facility policy titled: Nail Care, revealed in part .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated. Review of the clinical record revealed Resident #40 admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following non-traumatic intracranial hemorrhage affecting left dominant side, Epilepsy, Encephalopathy, 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.
- Potential for harm · D2024-03-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 2 of 2 medication carts. Findings: Observation on 03/20/2024 at 2:10 p.m. of the X hall medication cart accompanied by S4 LPN revealed there were 8 loose pills in the second drawer of the medicine cart. S4 LPN confirmed the above findings and revealed it is the responsibility of each nurse to ensure their medication cart are clean and free of loose pills daily. Observation on 03/20/2024 at 2:22 p.m. of the Y hall medication cart accompanied by S5 LPN revealed there were 1 loose pill observed in the middle drawer of the medications cart. S5 LPN confirmed the above findings at the time of observation. Interview on 03/20/2024 at 2:40 p.m. with S2 DON revealed it was the responsibility of all nurses to ensure medication carts were clean and free of loose pills daily.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$21,752 in federal fines across 2 penalties.
- $9,110 — penalty dated 2025-11-24
- $12,642 — penalty dated 2025-05-29
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 RIGHTCARE HEALTH SERVICES — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 3.3 | -1.3 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 2 of 5 | 1.9 | +0.1 vs chain |
The other 12 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MANAGEMENT GROUP ELEVEN LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 04/01/2022 |
| SHM COLONIAL LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 04/01/2022 |
| ABINGTON FAMILY HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 04/01/2023 |
| B & J LIMITED PARTNERSHIP | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 11/01/2017 |
| CALVIN H JONES ESTATE | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 08/11/2025 |
| JHS-SNF LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 04/01/2022 |
| REVOCABLE TRUST OF ROY BUSH BRIDGES AND JUDY KAYE WINN BRIDGES | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 04/01/2022 |
| SRB INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 04/01/2022 |
| THE VERNICE C WRIGHT IRREVOCABLE TRUST | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 04/01/2022 |
| ABINGTON, LEONARD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2022 |
| BROUSSARD, SCOTT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; ADP OF THE SNF | 8% | since 04/01/2022 |
| DAVIS, JOHN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2022 |
| DAVIS, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2022 |
| DAVIS, THOMAS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 8% | since 04/01/2022 |
| SANDERS, JACK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 04/01/2022 |
| RIGHTCARE HEALTH SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/25/2025 |
CMS files one row per role, so the 26 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.
10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $998K paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in LA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195445. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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