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Oak Woods Home for the Elderly

1400 Davenport Avenue, Mer Rouge, LA 71261 · Non profit - Corporation · 119 certified beds · (318) 647-3691 Medicare & Medicaid certified

Call the home — (318) 647-3691 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Mar 2026$18,349 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $18,349 in federal fines (most recent 2023-09-25)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
301 1/2 Davenport Ave # 1/2 · (318) 647-5008 · Call to confirm hours
Pharmacy
2211 E Madison Ave · (318) 281-3284 · Call to confirm hours
Grocery
210 S 14th St · (318) 647-1698 · Call to confirm hours
Park
8015 Park Loop Dr · Typically dawn to dusk
Place of worship
418 Davenport Ave · (318) 647-3987

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 1 of 5
Short-stay residentsrehab / post-hospital 3 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 2 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.

Overall rating1★
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 increased29.7%17.8%15.4%worse
Long-stay residents who lose too much weight2.9%5.2%5.4%better
Long-stay residents with a catheter left in their bladder0.8%1.2%0.9%better
Long-stay residents with a urinary tract infection0.5%2.1%2.0%better
Long-stay residents with depressive symptoms0.0%2.3%6.5%check this — see note marked star 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 injury2.0%3.5%3.3%better
Long-stay residents whose ability to walk worsened23.3%17.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.9%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine83.3%94.9%95.3%worse
Long-stay residents with pressure ulcers7.7%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control12.3%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table24.6%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%3.1%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine3.6%76.3%79.4%worse
Short-stay residents rehospitalized after admission32.6%28.0%22.6%worse
Short-stay residents with an outpatient ER visit29.8%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.592.561.67worse
Long-stay outpatient ER visits per 1,000 resident days3.282.741.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

44.0% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.0%U.S. median 51.5%
Got home and stayed home
9.6%U.S. median 10.7%
Went back to hospital
65.8%U.S. median 56.6%
Met the expected recovery
0.06U.S. median 0.31
Therapy hours / resident / day
0.01hours / resident / day
Physical therapy
0.02hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 65.8% 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 41 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 0.06 therapist hours per resident per day in 2026Q1 — more than 3% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.0%CMS range 30.7–56.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.6%CMS range 6.7–14.710.7%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 discharge65.8%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 discharge53.7%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 discharge48.8%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 identified82.1%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 stay1.8%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 worsened1.8%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 3.0–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.931.02Oct 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

0.04
RN hours/ resident / day
0.21
LPN hours/ resident / day
0.55
Aide hours/ resident / day
0.80
Total nurse hours/ resident / day
0.03
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 119 beds and averages 54.9 residents a day — about 46% occupied, or roughly 64 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 0.80 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.04 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.55 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 0.57 hrs/resident/day on weekends vs 0.90 on weekdays — 37% thinner on weekends — a notable drop. RN hours go from 0.05 to 0.03 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

8
deficiencies at the latest standard inspection (2026-03-25)
13
at the previous standard inspection (2025-02-04)

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · E2026-03-25 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents have the right to be free from any chemical restraints by having PRN orders for psychotropic drugs exceeding the 14 day limit for 2 (#1 and #7) of 5 residents reviewed for unnecessary medications. Findings: Resident #1 Record review revealed Resident #1 was initially admitted to the facility on [DATE] with a readmit date of 12/17/2025. Resident #1 had diagnoses that included essential (primary) hypertension, unspecified sequelae of cerebral infarction, chronic respiratory failure, depression, anxiety, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, acute on chronic systolic (congestive) heart failure, and myocardial infarction. Review of quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognition for daily decision making. Review of the March 2026 physician orders revealed an order dated 11/25/2025 for Hydroxyzine HCL 25 mg, give 1 tablet every 6 hours as…

    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 · Ecited before2026-03-25 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide assistance for residents who were unable to carry out activities of daily living (ADL) by failing to maintain good grooming and personal hygiene for 3 (#2, #42, #57) of 3 residents reviewed for activities of daily living.Findings:Resident #2Review of the medical record for resident #2 revealed the resident had diagnoses in part of left above the knee amputation, nail dystrophy, atrial fibrillation, atherosclerosis of native arteries of extremities with gangrene, Type 2 Diabetes Mellitus, cardiomegaly, acute kidney failure, and cerebral infarct.Review of the significant change MDS dated [DATE] revealed the resident had a BIMS that was unable to be assessed. The resident was dependent on staff for personal hygiene. Review of the care plan revealed self-care deficit related to resident needs assistance with activities of daily living. Further review revealed the following approaches: resident will be clean, dry, dressed neatly,…

    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 · E2026-03-25 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure it provided routine drugs and biologicals to its residents by failing to have a medication available for administration for 1 (#57) of 2 residents observed during a medication pass.Findings:On 03/24/2026 at 8:50 a.m., a medication pass was observed with Resident #57.Staff S3LPN reported the medication Losartan 50 mg was due at the morning medication pass but it was not available for administration. Review of the March 2026 physician orders confirmed Losartan 50 mg was due to be administered during the morning medication pass.On 03/24/2026 at 10:45 a.m., S2DON was informed that Resident #57's Losartan 50 mg was not available for administration during the morning medication pass.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-25 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 each resident's drug regimen was free from unnecessary drugs by 1) failing to monitor the heart rate with the administration of metoprolol succinate for Resident #1 and 2) failing to obtain a lipid panel as ordered for Resident #1 of 5 residents reviewed for unnecessary medications.Findings:Record review revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included essential (primary) hypertension, presence of aortocoronary bypass graft, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified sequelae of cerebral infarction, chronic respiratory failure, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, acute on chronic systolic (congestive) heart failure, and myocardial infarction. Review of the current March 2026 Physician Orders revealed the following: Order dated 12/20/2025 - metoprolol succinate ER 25 mg tablet give 1…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-25 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure that its medication error rates are not 5 percent or greater by having a medication error rate of 17% for 2 (#57, #58) of 2 residents observed for a medication pass.Findings:Resident #57On 03/24/2026 at 8:50 a.m., a medication pass was observed with Resident #57.Staff S3LPN reported the medication Losartan 50 mg was due at the morning medication pass but it was not available for administration. This resulted in an error by omission.After the medication pass was completed, review of the March 2026 physician orders revealed there was an additional omission of the medication Xarelto 10 mg which was due on the morning medication pass. Resident #58On 03/24/2026 at 9:20 a.m., a medication pass was observed with S3LPN for Resident #58.After the medication pass was completed, review of the March 2026 physician orders revealed there was an omission of the medications Lisinopril 20 mg and Tamsulosin 0.4 mg.S3LPN administered Vitamin B-12 during the medication pass. Review of the March 2026 physician orders revealed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The facility failed to 1) implement enhanced barrier precautions for 1 (#6) of 1 residents reviewed for enhanced barrier precautions and 2) follow facility policy for the cleaning, storage and replacement of piston syringes for 1 (#26) of 1 residents reviewed for tube feedings.Findings: Resident #6 Review of the facility's Enhanced Barrier Precautions policy and procedure (undated) revealed the following in part: It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) to reduce the transmission of multidrug-resistant organisms (MDROs) and other infectious agents among residents. EBP will be applied according with current CDC guidelines and applicable federal and state regulations within the Oak…

    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 before2026-03-25 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure each resident was assessed using the quarterly review instrument approved by CMS not less frequently than once every 3 months by failing to ensure a quarterly MDS was completed timely for 1 (#18) of 1 residents reviewed for resident assessments.Findings:Review of the medical record for resident #18 revealed she had an admission date of 11/14/2025. The admission MDS was completed on 11/21/2025. The next quarterly MDS was due on 03/07/2026. There was no documentation that a quarterly MDS was completed by 03/07/2026.On 03/25/2026 at 9:20 a.m., interview with S1Administrator confirmed the MDS for Resident #18 was not completed and submitted by the due date.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for resident needs by having a nurse leave prescription medications at Resident #30's bedside unattended for 1 (#30) of 1 residents reviewed for nurse competency. Findings: Review of the facility's Medication Management Policy and Procedure (undated) revealed the following in part:2. PurposeThe purpose of this policy is to establish standardized procedures for prescribing, ordering, receiving, storing, administering, documenting, monitoring, and disposing of medications in a safe and consistent manner. 6.3 StorageMedications shall be stored securely and in accordance with manufacturer guidelines. Review of the medical record for Resident #30 revealed an initial admission date of 11/05/2025 with a readmit date of 11/17/2025. Resident #30 had diagnoses that included COPD, DM, hypertension, and tremors. Review of the quarterly MDS assessment dated…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-04 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to accurately submit mandatory direct care staffing information, based on payroll, to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30). Findings: Review of the PBJ (Payroll Based Journal) Staffing Report for FY Quarter 4 2024 (July 1- September 30) revealed the facility triggered for Failed to Submit Data for the Quarter, One Star Staffing Rating, Excessively Low Weekend Staffing, No Registered Nurse (RN) hours, and failed to have Licensed Nursing Coverage 24 hours/day. On 02/02/2025 at 11:20 a.m. interview with S1Administrator confirmed the former Human Resources Director was not submitting the staffing information based on payroll to CMS.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure appropriate treatment and services were provided to prevent potential complications from enteral feeding by failing to record feedings and water flush amounts for 1 (#7) of 2 (#7 and #22) residents reviewed for tube feedings. Findings: Resident #7 Review of the medical record revealed resident #7 received enteral feedings by way of a percutaneous endoscopic gastrostomy (PEG) tube for the diagnosis of adult failure to thrive. Further review of the February 2025 physician orders revealed an order for Two-Cal high nutrition (HN) tube feeding at 45 milliliters per hour from 6:00 p.m. to 6:00 a.m. There was also an order for the PEG tube to be flushed with 150 milliliters of water every four hours while the feeding was not infusing from 6:00 a.m., to 6:00 p.m. Review of the February medication administration record revealed there was no documentation of the PEG tube flushes or tube feedings. On 02/03/2025 at 4:00 p.m., an interview with S2Director of Nursing (DON) confirmed there should have been documentation of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2025-02-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to provide respiratory care consistent with professional standards for 4 (#2, #18, #35, #22) of 4 (#2, #18, #35, #22) sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was: 1) stored properly for resident #2, #18, #35, and #22, 2) changed in a timely manner for resident #2 and #35 and, 3) dated for resident #2 and #18. Findings: Resident #2: Review of the medical record for sampled resident #2 revealed an admission date of 10/13/2023 with diagnoses including chronic obstructive pulmonary disease, chronic bronchitis, and history of cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact for daily decision making. Review of the physician's orders dated 03/26/2024 revealed administer oxygen (O2) at 2 liters for comfort/shortness of breath…

    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 · E2025-02-04 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 #18 Review of the medical record for resident #18 revealed an admit date of 05/02/2023with diagnoses of essential hypertension, paroxysmal atrial fibrillation, generalized osteoarthritis, and unspecified dementia with behavioral disturbance. Review of the annual MDS assessment dated [DATE] revealed resident #18's BIMS score was 99, which indicated they were unable to complete the test. Further review of the MDS revealed she was dependent on staff for all activities of daily living. Review of the February 2025 physician orders revealed an order dated 01/31/2025 that resident #18 may use bilateral quarter rails to aide in bed mobility. Review of the current care plan revealed resident #18 required quarter bed rails. Interventions included that resident #18 may use bilateral quarter rails to assist with turning and repositioning. Review of the medical record revealed no documented evidence that resident #18 was assessed for the entrapment of bed rails prior to installation of the bed rails. On 02/04/2025…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interview, the facility failed to ensure there was sufficient staff available at all times to provide nursing and related services to meet the resident's needs and safety in a manner that promotes each resident rights, physical, mental and psychosocial well-being. The facility failed to ensure there was sufficient staff on 07/21/2024, 07/28/2024 and on 08/31/2024 to provide care and services to the residents residing in the facility. Findings: Review of the Payroll Based Journal (PBJ) staffing data submission for fiscal year 2024, Quarter 4 (July 1 - September 30) revealed one star staffing rating, excessively low weekend staffing and failed to have nursing coverage 24 hours/day triggered. Review of the facility's staffing patterns provided to the survey team revealed Sunday, 07/21/2024, hours provided to the residents were 135 hours and the required hours were 129.25 with 55 residents. Review of the actual time sheets for the staff providing care and services to the residents on 07/21/2024 revealed the total hours were 106.91 hours. Review of the…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · tag F0732 — pattern
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview the facility failed to ensure the nurse staffing data was posted daily. The facility failed to ensure the nurse staffing data was readily accessible to residents and visitors. Findings: On 02/02/2025 at 7:45 a.m., observation revealed a daily nurse staffing sheet dated 01/8/2025 in a glass case at the front entrance of the facility. The nurse staffing sheet was filled out correctly but was not for the correct day. On 02/03/2025 at 7:50 a.m., observation revealed a daily staff posting dated 02/01/2025 in a glass case at the front entrance of the facility. On 02/04/2025 at 7:50 a.m., observation revealed a daily staff posting dated 02/01/2025 in a glass case at the front entrance of the facility. On 02/04/2025 at 10:01 a.m., an interview with S1Administrator confirmed the daily staffing sheets were not posted daily.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director and director of nursing (DON) for 2 (#8 and #19) of 6 (#2, #8, #19, #24, #46 and #154) residents reviewed for unnecessary medications. Findings: Resident 19 Review of the medical record for resident #19 revealed an admit date of 04/03/2023 with diagnoses including atrial fibrillation, fatty liver, cardiac pacemaker, prosthetic heart valve, heart failure, anxiety, glaucoma, hyperlipidemia and major depression. Review of the current care plan revealed resident #19 was at risk for fluid volume deficit related to the use of diuretics. Interventions included to assess daily for signs and symptoms of dehydration and over hydration, and to assess for edema every day. Further review of the care plan revealed resident #19 had the potential for abnormal bleeding due to anticoagulant therapy use. Interventions included to monitor for signs and symptoms of abnormal bleeding. Review of the February 2025 physician's orders revealed an…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-04 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 #8 Review of the medical record revealed resident #8 received the blood thinner Clopidogrel 75mg daily with a supporting diagnosis of cerebral infarction. Review of resident #8's medication administration record revealed there was no documentation that the facility was monitoring the resident for bleeding. On 02/03/2025 at 4:00 p.m., interview with S2DON confirmed there was no recorded monitoring for bleeding related to resident #8. Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to 1) monitor edema for a resident who received a diuretic for 2 (#2, and #19), and 2) monitor for bleeding for a resident who received an anticoagulant for 3 (#8, #19 and #46) of 6 (#2, #8, #19, #24, #46 and #154) residents reviewed for unnecessary medications. Findings: Resident 19 Review of the medical record for resident #19 revealed an admit date of 04/03/2023 with diagnoses including atrial fibrillation, fatty liver,…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · 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 observations the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The failed practice was made evident by uncleanliness of the kitchen which included the food storage areas, meal serving area, cooking areas and the three compartment sink. Findings: On 02/02/2025 at 8:15 a.m., an initial tour of kitchen revealed grease buildup behind and underneath the deep fryer. Splattered food was observed on the wall and glass in front of the serving counter where the resident meal trays were prepared. Rust and food particles were observed on the storage shelf beneath the serving counter. Dust/dirt build up was observed on the circulating fan inside the walk in refrigerator which had blown the dust/dirt onto the ceiling and wall opposite of the fan inside the walk in refrigerator. Observation of the three compartment sink revealed what appeared to be a lime scale buildup on the top of the three compartment sink. On 02/02/2025 at 12:17 p.m., a confirmation interview/observation was conducted with S6Dietary…

    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 before2025-02-04 · tag F0880 — failed to prevent and control infections — pattern
    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 observations, record reviews and interviews the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and help to prevent the development and transmission of communicable diseases and infections by failing 1) to have signage on residents' doors that were COVID positive and/or Enhanced Barrier Precautions (EBP) that included specific personal protective equipment (PPE) required for staff use for 4 (#35, #43, #47, and #154), and 2) to ensure indwelling catheter tubing was not touching the floor for 2 (#35 and #154) of 5 (#14, #35, #43, #47, and #154) residents reviewed for infection control. Findings: Resident 43 Review of the medical record for resident #43 revealed the resident tested positive for COVID infection and was placed on isolation on 01/28/2025 through 02/07/2025. Review of the current care plan for resident #43 revealed the resident was COVID positive and isolation precautions were in place. Observation on 02/02/2025 at 8:05 a.m. of resident #43's door revealed there was no signage on 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-04 · tag F0919 — failed to provide a working call system — pattern
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance from toileting facilities. The failed practice was evidenced by a public bathroom having a call light pull cord wrapped around a grab bar which prevented it from being available to activate if a resident needed to activate the call light from the floor. Findings: On 02/02/2025 at 8:30 a.m., observation during a tour of the facility revealed there was an unlocked bathroom located near the chapel. The bathroom was accessible to residents. Observation of the bathroom revealed the call light pull cord was wrapped several times around the grab bar. The call light could not be activated by pulling on the end of the cord. On 02/03/2025 at 8:10 a.m., observation/interview with S3Houskeeping Supervisor revealed the bathroom remained unlocked and the pull cord remained wrapped around the grab bar. S3Houskeeping Supervisor also confirmed the call light cord was wrapped around the garb bar and could not be activated by a resident on the floor if they…

    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 before2025-02-04 · tag F0638 — isolated
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every 3 months for 2 (#36, #46) of 2 (#36, #46) residents reviewed for resident assessment out of a total of 18 sampled residents. Findings: Resident #46 Record review revealed resident #46 was admitted to the facility on [DATE] and remained as an active resident at the facility. The most recent quarterly Minimum Data Set (MDS) assessment was completed on 08/26/2024. Resident #36 Record review revealed resident #36 was admitted to the facility on [DATE] and remained as an active resident at the facility. The most recent quarterly MDS assessment was completed on 08/14/2024. 02/03/2025 at 3:44 p.m., an interview with S2Director of Nursing (DON) confirmed the MDS quarterly assessments had not been completed every 120 days for residents #36 and #46.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-04 · 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, interview, and observation, the facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents by failing to implement a new intervention following a fall for 1 (#51) of 2 (# 24, #51) residents reviewed for falls. Findings: Review of resident #51's record revealed an admission date of 12/13/2024 with diagnoses of encephalopathy, unspecified; anxiety disorder, unspecified; unspecified dementia, severe, with other behavioral disturbance; unspecified injury of urethra, initial encounter, fracture of one rib, right side, initial encounter for closed fracture, wedge compression fracture of fourth lumbar vertebra, and initial encounter for closed fracture. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated that the resident was severely impaired for cognition. Further review of the MDS revealed resident #51 required two person assistance with bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-01-24 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming and personal and oral hygiene for 2 (#42 and #201) of 2 sampled residents reviewed for activities of daily living. The facility failed to ensure Resident #42's fingernails were cleaned and trimmed in a timely manner and the facility failed to provide oral care for Resident #201. Findings: Resident #42 Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses that include the following: traumatic spinal cord dysfunction, paraplegia unspecified, pressure ulcer of sacral region, type 2 diabetes mellitus, Parkinson's disease, chronic pain related to trauma, essential hypertension, and depression. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 which represented the resident was cognitively intact. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-24 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid (CMS) system in a timely manner for 3 (#6, #18, & #25) of 5 (#6, #18, #25, #26, & #37) residents reviewed for the timeliness of MDS submissions. Findings: On 01/23/2024 at 3:15 p.m., interview with S2Director of Nursing confirmed the MDS assessment for Resident #6 was due on 09/22/2023 but was not transmitted until 09/27/2023. She also confirmed the MDS assessment for Resident #18 was due on 10/20/2023 and was not transmitted until 11/03/2023 and the MDS assessment for Resident #25 was due on 09/22/2023 and it was not transmitted until 09/27/2023.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-24 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (#201) of 1 sampled resident who was recently admitted . Findings: Review of the medical record for Resident #201 revealed the resident was admitted on [DATE] with diagnoses of anemia, chronic pain, multiple myeloma, closed nondisplaced subtrochanteric fracture of left femur (pathological) and depression. Review of the medical record revealed there was not a baseline care plan. An interview with S4Assistant Director of Nursing/Minimum Data Set (ADON/MDS) on 01/23/2024 at 1:50 p.m. revealed she was responsible for the baseline care plans. S4ADON/MDS confirmed there was not a baseline care plan for Resident #201. An interview with S2Director of Nursing (DON) on 01/23/2024 at 2:10 p.m. confirmed Resident #201 should have a baseline care plan.

    Resident Assessment and Care Planning 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

$18,349 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $4,587 — penalty dated 2023-09-25
  • $13,762 — penalty dated 2023-09-05
  • Medicare payment denial — starting 2026-06-25 for 8 days

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

Who owns this facility

Owner / managerTypeRoleSince
ANDERSON, TERRIIndividualW-2 MANAGING EMPLOYEEsince 11/30/2018
BONNER, WILLIAMIndividualCORPORATE OFFICERsince 07/01/2012

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$2.8M
Net patient revenuemost recent cost report
-90.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 36%Medicare 5%Other / private 60%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$142per resident / day
operating cost
$4,310per month
≈ monthly operating cost
$74per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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 195598. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-25, 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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