Legacy Nursing and Rehabilitation of Morgan City
740 Justa Street, Morgan City, LA 70380 · For profit - Corporation · 88 certified beds · (985) 384-1726 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 Aug 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $109,359 in federal fines (most recent 2025-08-07)
- 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.
| 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
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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 8.2% | 17.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 11.4% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.8% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 8.4% | 2.3% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.9% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.4% | 17.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 30.6% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 71.6% | 94.9% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 6.6% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 13.1% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.4% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.6% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 30.3% | 76.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.2% | 28.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 23.3% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.43 | 2.56 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.96 | 2.74 | 1.80 | typical |
‡ 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.
38.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.2% 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 51 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% 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 | 38.9%CMS range 30.7–48.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 8.5–15.8 | 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 | 39.2% | 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 | 64.7% | 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 | 31.4% | 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 | 98.7% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.2% | 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 | 7.2%CMS range 4.4–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.42 | 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 88 beds and averages 80.5 residents a day — about 91% occupied, or roughly 8 beds typically open. It runs fairly full. 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 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.67 hrs/resident/day on weekends vs 3.62 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 0.31 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · G2025-08-07 · 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 observations, interviews, and record reviews, the facility failed to protect a resident's right to be free from verbal and mental abuse by another resident for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse. This deficient practice resulted in an actual harm on 07/06/2025 at approximately 9:30PM, when Resident #15, a resident with known aggressive behaviors towards staff and other residents, was overheard by her roommate, Resident #30, during a telephone conversation where Resident #15 used racial slurs so loudly that Resident #30 overheard the conversation. On 07/07/2025 at approximately 2:30PM, Resident #30 was observed by staff crying. Resident #30 informed S9Certified Nursing Assistant (CNA) of the conversation that was overheard on 07/06/2025 when Resident #15 used racial slurs. Resident #15 who was in the room during the conversation reacted to S9CNA and Resident #30 by using racial slurs, cursing, and kicking the trash can. Resident #30…
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 · G2024-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure residents were supervised and kept free from thermal burns for 2 (Resident #19 and Resident #49) of 2 (Resident #19 and Resident #49) sampled residents investigated for an accident/hazard related to burns. This deficient practice resulted in actual harm when on 02/04/2024 for Resident #49 and on 02/21/2024 for Resident #19, when Resident #19 and Residnet #49 were left unsupervised and sustained first degree superficial burns from spilled coffee. Findings: Review of Appendix PP of the State Operations Manual, last revised on 08/08/2024, revealed, in part, third degree burns can occur within 1 to 2 seconds with hot water temperatures between 140 degrees Fahrenheit (F) and 155 degrees F. Review of the National Library of Medicine's Burn Evaluation and Management article, last revised on 08/08/2023, revealed, in part, burns may be caused by hot liquids. Further review revealed superficial burns (first degree) are red on the skin. Resident #19 Review of Resident #19's Electronic Medical Record (EMR) 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 before2025-12-30 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure the resident's medical record was complete for 1 (Resident #1) of 3 sampled residents reviewed for activities of daily living documentation. Findings:Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 10/22/2025 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15 (a score of 13-15 indicated Resident #1 was cognitively intact). Further review revealed Resident #1 was dependent on staff for toileting, showering, and bathing. Review of Resident #1's care plan revealed Resident #1 required staff assistance for all activities of daily living with a goal date of 02/06/2026 with approaches that included, in part, certified nursing assistant (CNA) staff were to assist Resident #1 with hygiene and grooming tasks as needed. Further review of Resident #1's care plan revealed Resident #1 refused showers at times with a goal date of 02/06/2026 with approaches that included, in part, allow Resident #1 opportunities to make choices and participate in care.…
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 before2025-08-07 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record reviews, the facility failed to:1. Ensure expired medications were not available for resident use (Medication Cart A);2. Ensure the facility's shift verification of controlled substances count sheet was completed every shift (Medication Cart A); and,3. Ensure medications were documented as administered on the electronic Medication Administration Record (eMAR) when administered (Resident #83).This deficient practice was identified for 1 (Medication Cart A) of 2 (Medication Cart A, Medication Cart B) sampled medication carts observed during medication storage observations and 1 (Resident #83) of 1 (Resident #83) sampled residents investigated for hospice. Findings:1. Review of the facility's undated Storage of Medications policy and procedure revealed, in part, no discontinued, outdated, or deteriorated medications were available for use in the facility. Further review revealed all discontinued, outdated, or deteriorated medications were to be destroyed. Observation of Medication Cart A on 08/06/2025 at 3:30PM revealed, in part: -Advair…
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 before2025-08-07 · 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
Based on observations, interviews, and record reviews, the facility failed to:1. Ensure the scoop used to serve ice did not have the handle submerged in the residents' ice (Ice Chest A); 2. Ensure staff properly handled soiled linen (S12Certified Nursing Assistant); and, 3. Ensure staff implemented Enhanced Barrier Precautions (EBP) for a resident (Resident #76). This deficient practice was identified for 1 (Ice Chest A) of 2 (Ice Chest A, Ice Chest B) ice chests used to provide ice to residents; 1 (S12CNA) of 1 (S12CNA) CNAs observed during random linen handling observations; and, 1 (Resident #76) of 12 (Resident #5, Resident #9, Resident #10, Resident #17, Resident #32, Resident #70, Resident #76, Resident #77, Resident #81, Resident #85, Resident #90, Resident #91) sampled residents observed on EBP. Findings: 1.Observation on 08/04/2025 at 8:46AM revealed a blue and white ice chest located in the dining room with the ice scoop handle submerged in water and ice. In an interview on 08/04/2025 at 8:55AM, S2Director of Nursing (DON) confirmed the ice scoop handle was inside the ice…
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 · D2025-08-07 · 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 interviews and record reviews, the facility failed to report an allegation of verbal and mental abuse to the state agency for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents reviewed for abuse.Findings:Cross Reference F600Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents. Further review revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Further review revealed staff should immediately report their knowledge related to abuse allegations to the Administrator or DON without fear of reprisal. Further review revealed an alleged violation of abuse will be reported immediately, but not later than 2 hours if the alleged violation involved abuse or had resulted…
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 · D2025-08-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to have documented evidence a thorough investigation was completed following allegations of verbal and mental abuse for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse. Findings:Cross Reference F600 Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents. Further review revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Review revealed an abuse investigation included interviewing employees who worked…
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 before2025-08-07 · 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 observations, interviews, and record reviews, the facility failed to implement interventions for residents who were identified at risk for falls for 2 (Resident #3, Resident #7) of 8 (Resident #3, Resident #7, Resident #8, Resident #12, Resident #16, Resident #17, Resident #30, Resident #73) sampled residents investigated for accidents.Findings:Resident #3: Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2025 revealed, in part, a Brief Interview for Mental Status score of 4. A score of 4 which indicated Resident #3 had severe cognitive impairment. Review of Resident #3's electronic medical record (EMR) chart revealed, in part, a special instruction for Resident #3 to have an auto lock brakes feature. (An auto lock brake feature engages the wheelchair's brakes when the user's weight is removed from the seat, preventing the chair from rolling away unintentionally). Review of Resident #3's Fall Risk assessment dated [DATE] revealed, in part, a score of 55 (A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to:1. Follow a physician's order for oxygen administration (Resident #33, Resident #63); and, 2. Ensure oxygen tubing was changed and dated weekly (Resident #33, Resident #63). This deficient practice was identified for 2 (Resident #33, Resident #63) of 2 (Resident #33, Resident #63) sampled residents investigated for respiratory care. Findings:1.Review of the facility's undated Oxygen Administration policy and procedure revealed, in part, staff should check the physician's order for liter flow rate of oxygen and method of administration. Further review revealed staff should adjust the liter flow rate of oxygen to the rate ordered by the physician. Resident #33Review of Resident #33's August 2025 Physician Orders revealed, in part, an order dated 09/29/2023 for oxygen to be administered at 2 liters per minute (LPM) via nasal cannula continuously related to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident #33's care plan…
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 before2025-08-07 · 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 observations, interviews, and record review, the facility failed to: 1. ensure food stored in the facility's refrigerator was labeled with an opened date and/or discarded prior to the item's expiration date; and,2. ensure scoops were not stored inside the dry goods storage bins. Findings:1.Review of the facility's undated Food Safety and Sanitation policy and procedure revealed, in part, leftovers were to be dated when stored, and foods with expiration dates were to be used prior to the use by date on the package. Observation on 08/04/2025 at 8:30AM of the facility's kitchen with S14Dietary Manager revealed an opened gallon size container of ranch dressing stored in the facility's refrigerator. Further review revealed the container of ranch dressing had not been labeled with an opened date and had an expiration date of 07/24/2025. In an interview on 08/04/2025 at 8:39AM, S14Dietary Manager confirmed the container of ranch dressing, as mentioned above, was not labeled with an opened date and had an expiration date of 07/24/2025. S14Dietary Manager indicated the opened…
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 · E2025-04-03 · tag F0725 — failed to have enough nursing staff — patternProvide 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 interviews and record reviews, the facility failed to ensure the required number of nursing staff members were present and working in the facility for 22 (10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/10/2024, 11/16/2024, 02/16/2025, 02/18/2025, 02/22/2025, 02/23/2025, 02/24/2025, 03/01/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/13/2025) of 53 (10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/30/2024, 12/07/2024, 12/08/2024, 12/14/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024, 12/29/2024, 02/16/2025, 02/17/2025, 02/18/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 02/28/2025, 03/01/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/15/2025) days reviewed for sufficient…
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 · D2025-04-03 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to ensure a resident received the required physical therapy services for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents investigated for rehabilitation services. Findings: Review of Resident #1's February and March 2025 physician's orders revealed, in part, an order dated 02/27/2025 for physical therapy (PT) to evaluate and treat Resident #1, five times per week for 8 weeks as indicated. Further review revealed an order dated 03/06/2025 for PT to evaluate and treat Resident #1 five times per week for 8 weeks as indicated. Review of Resident #1's Electronic Medical Record (EMR) revealed she did not receive physical therapy services between 02/27/2025 and 03/06/2025. In an interview on 04/01/2025 at 9:20AM, S2Director of Rehabilitation (DOR) indicated when a resident required PT the physical therapist would write orders for the resident to be evaluated and treated for PT services, then the resident's physician would sign those orders. S2DOR further indicated Resident #1 did not receive PT services…
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 21 citations
- Potential for harm · Ecited before2024-08-22 · 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
Based on record review, observations, and interviews, the facility failed to ensure: 1. S8Certified Nursing Assistant (CNA) performed hand hygiene after providing incontinence care for 1 (Resident #19) of 1 (Resident #19) sampled residents observed during incontinence care; 2. S5Treatment Nurse (TN) performed hand hygiene during wound care for 2 (Resident #5 and Resident #17) of 3 (Resident #5, Resident #14, and Resident #17) sampled residents observed for wound care; 3. S6Licensed Practical Nurse (LPN) did not handle Resident #86's medication with ungloved hands for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration; 4. S6LPN performed hand hygiene after removing her gloves and prior to applying clean gloves for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration; 5. Clean items in the facility's laundry room were not kept in the contaminated laundry area; and, 6. Staff identified and took corrective action when a cluster of 3 bacterial urinary tract infections were identified for residents who resided…
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 · D2024-08-22 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure a pressure reducing wheelchair cushion was being utilized for a resident assessed as being at high risk for skin breakdown for 1 (Resident #5) of 3 (Resident #5, Resident #14, and Resident #17 sampled residents investigated for pressure injuries, pressure ulcers, or skin integrity. Findings: Review of Resident #5's Electronic Medical Record revealed, in part, Resident #5 had diagnoses which included, a Non-Pressure chronic ulcer of the left lower leg, chronic venous hypertension with ulcer and inflammation of the bilateral lower extremities, and diabetes. Further review revealed Special Instructions: wheelchair cushion listed in Resident #5's care tasks. Review of Resident #5's Minimum Data Set with an Assessment Reference Date of 05/22/2024 revealed, in part, Resident #5 had a Brief Interview for Mental Status score of 9 which indicated Resident #5's cognition was moderately impaired. Review of Resident #5's Braden Scale…
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 before2024-08-22 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record reviews, and interviews the facility failed to ensure S6Licensed Practical Nurse (LPN) disposed of a resident's medication as required for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration. Findings: Review of the facility's Medication Administration Policy and Procedure with effective date of 03/03/2022 revealed, in part, medication shall be prepared immediately prior to administration. Further review revealed if a medication was held because of the nurse's discretion, a notation shall be made on the resident's medication record. Review also revealed wasted control drugs shall be witnessed and co-signed. Review of Resident #86's August 2024 Physician's Orders revealed, in part, Resident #86 was to be administered Oxycodone/Acetaminophen (a controlled medication to treat pain) 10/325 milligrams (mg) one tablet by mouth every 6 hours as needed for pain. Observation on 08/20/2024 at 1:09 p.m. revealed S6LPN assessed Resident #86 for pain. Resident #86 voiced he had a pain level of 8 out 10 (0 indicating no pain 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 · D2024-08-22 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, the facility failed to: 1. Ensure a resident's most recent hospice plan of care and recertification of terminal illness was obtained from the contracted hospice agency (Resident #13); and, 2. Ensure facility staff were aware of the contracted hospice agency's responsibilities in implementing the hospice plan of care (Resident #13). This deficient practice was identified for 1 (Resident #13) of 1 (Resident #13) sampled resident reviewed for hospice services. Findings: Review of Resident #13's Significant Change Minimum Data Set with an Assessment Reference Date of 05/08/2024 revealed, in part, Resident #13 received hospice services while a resident in the facility. Review of Resident #13's facility hospice care plan initiated on 04/26/2024 revealed, in part, the facility should coordinate Resident #13's care with the contracted hospice agency. Review of Resident #13's August 2024 Physician's Orders revealed, in part, an order to admit Resident #13 to the contracted hospice agency on 04/26/2024. 1. Review of the facility and contracted hospice…
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 · E2023-10-05 · tag F0655 — patternCreate 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a baseline care plan was initiated with 48 hours of admission for 3 (Resident #21, Resident #74, and Resident #237) of 19 (Resident #1, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12. Resident #14, Resident #19, Resident #21, Resident #27, Resident #36, Resident #49, Resident #69, Resident #72, Resident #74, Resident #82, Resident #235, and Resident #237) sampled residents whose care plan was reviewed in the final investigation sample. Findings: Resident #21 Review of Resident #21's electronic medical record (EMR) revealed, in part, Resident #21 was admitted to the facility on [DATE]. Further review revealed Resident #21 had the following admit diagnoses which included, but not limited to, generalized anxiety disorder, depression, bipolar disorder, and schizoaffective disorder. Review of Resident #21's care plan revealed, in part, a plan of care was not developed related to the above until 10/03/2023. 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 · E2023-10-05 · tag F0693 — failed to provide proper feeding-tube care — patternEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation, and interviews, the facility failed to administer a resident's water flush per physician orders for 1 (Resident #11) of 1 (Resident #11) sampled residents investigated for enteral feedings. Findings: Review of the facility's Care Of Enteral Feeding Tube Policy and Procedure revealed, in part, all enteral tube feedings shall have care according to physician orders. Review of Resident #11's October 2023 physician orders revealed, in part, an order with a start date of 09/29/2023 for Resident #11 to receive 35 milliliters (ml) of flush of water for 22 hours per day. Observation on 10/02/2023 at 10:25 a.m. revealed, Resident #11's enteral feeding pump was set to infuse a water flush of 35mL every 4 hours. Observation on 10/02/2023 at 11:43 a.m. revealed, Resident #11's enteral feeding pump was set to infuse a water flush of 35mL every 4 hours. Observation on 10/03/2023 at 10:00 a.m. revealed, Resident #11's enteral feeding pump was set to infuse a water flush of 35mL every 4 hours. Observation on 10/03/2023 at 1:35 p.m. revealed, Resident #11's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 observation, interview, and record review the facility failed to ensure a resident's continuous positive airway pressure (CPAP) mask was contained for 1 (Resident #6) of 4 (Resident #5, Resident #6, Resident #27, and Resident #237) sampled residents reviewed for respiratory care. Findings: Review of Resident #6's record revealed Resident #6 was admitted [DATE] with diagnoses of, in part, Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea (OSA), Chronic Pulmonary Edema, and Legal blindness. Review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/06/2023 revealed, in part, Resident #6's vision was severely impaired; Brief Interview for Mental Status (BIMS) score of 12 (score of 08-12 indicated moderate cognitive impairment). Further review revealed Resident #6 received fifteen minutes of respiratory therapy for one day. Review of Resident #6's Physician Orders for October 2023 revealed, in part, Resident #6's CPAP should be applied at bedtime…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-05 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to ensure the accurate dispensation of controlled medications for 1 (medication cart c) of 2 medication carts (medication cart a and medication cart c) observed and reviewed for accurate dispensation of controlled medications. Findings: On 10/03/2022 at 5:35 p.m., a reconciliation was completed of controlled substances on medication cart c, and the controlled substance binder for medication cart c revealed the following: Review of Resident #27's medication card for Hydrocodone-Acetaminophen 5-325 milligrams (mg) (a medication used to treat pain) revealed Resident #27 had 23 tablets available. Review of Resident #27's Individual Narcotic Record revealed, in part, Resident #27 had 24 Hydrocodone-Acetaminophen 5-325mg tablets available Review of Resident #28's medication card for Alprazolam 0.25 mg (a medication used to treat anxiety) revealed Resident #28 had 44 tablets available. Review of Resident #28's Individual Narcotic Record revealed, in part, Resident #28 had 45 Alprazolam 0.25 mg tablets available. 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 · Ecited before2023-10-05 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews, observations, and interviews, the facility failed to ensure expired medications and dressings were not available for residents use. Findings: Observation of medication cart a on 10/04/2023 at 5:16 p.m. revealed, in part, a box of 14 Bisacodyl Stimulant Laxative Suppositories (medication administered rectally and used to treat constipation) 10 mg had expired in 09/2023. In an interview on 10/04/2023 at 5:16 p.m., S4Liscensed Practical Nurse (LPN) confirmed the 14 Bisacodyl Stimulant Laxative Suppositories 10 mg expired in 09/2023. S4LPN further stated the 14 Bisacodyl Stimulant Laxative Suppositories 10 mg should not be in medication cart a and available for resident use. Observation of treatment cart b on 10/05/2023 at 9:09 a.m., revealed, in part, 1 ManukAhd Super Lite Honey Coated absorbent dressing (a honey impregnated super absorbent gelling fiber dressing) had an expiration date of 09/2023. In an interview on 10/05/2023 at 9:09 a.m., S3Treatment Nurse (TN) stated the above listed dressings was expired and should not have been in treatment cart b 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 · Ecited before2023-10-05 · 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, interview, and record review, the facility failed to: 1. Ensure expired food was not available for resident consumption; and 2. Appropriately date and label food that was opened and available for use. Findings: Review of the facility's Food Safety And Sanitation Policy And Procedure revealed, in part, foods with expiration dates were to be used by the date on the package. Observation on 10/02/2023 at 9:21 a.m. of the facility's 3 door refrigerator revealed, in part: -A half pint whole milk with an expiration date of 09/20/2023; -Two 32 ounce containers of chopped garlic with expiration dates of 09/17/2023; -32 ounce container of lemon juice with an expiration date of 02/2023; -5 pounds of shredded cheese with no open date or expiration date present; and -One large container of fresh diced tomatoes uncovered with no open date present. Observation on 10/02/2023 at 9:23 a.m. of the facility's main meat freezer revealed, in part: - One opened bag of frozen egg rolls with no expiration date or open date present; - One bag of opened frozen diced chicken with no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-05 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure staff did not present a medical record as being accurate prior to a resident's death and ensure staff did not alter a medical record after a resident had expired. This deficient practice was identified for 1 (Resident #74) of 3 (Resident #19, Resident #74, and Resident #82) closed records reviewed. Findings: Review of Resident #74's electronic medical record (EMR) revealed, in part, Resident #74 expired on [DATE]. Further review of Resident #74's EMR revealed Resident #74's plan of care was last revised on [DATE]. Review of Resident #74's care plan provided to survey team as Resident #74's accurate care plan revealed, in part, 21 goals and 117 interventions were initiated by S27Corporate Nurse on [DATE] in Resident #74's care plan. In an interview on [DATE] 2:40 p.m., S5Minimum Data Set (MDS) Licensed Practical Nurse (LPN) stated Resident #74's care plan was revised on [DATE] after Resident #74 was deceased , and the care plan presented to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to: 1. Ensure S26Certified Nurse Assistant (CNA) performed hand hygiene during catheter care for 1 (Resident #234) of 4 residents (Resident #21, Resident #27, Resident #234, and Resident #236) investigated for infection control; 2. Ensure proper use of personal protective equipment (PPE) for 3 Coronavirus Disease 2019 (COVID-19) positive residents (Resident #21, Resident #27, and Resident #236) of 7 (Resident #5, Resident #16, Resident #21, Resident #27, Resident #39, Resident #41, and Resident #236) COVID-19 positive residents; 3. Identify and test residents and staff that were in close contact with COVID-19 positive residents per the facility's COVID-19 Policy; and 4. Ensure signage was placed at the front door to notify family and visitors of the current COVID-19 outbreak. Findings: 1. Review of Resident #234's care plan revealed, in part, the facility's staff would provide catheter care to Resident #234 every shift. Observation 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 · E2023-10-05 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interviews, the facility failed to provide in-service training for nurse aides to ensure the continuing competence of nurse aides and no less than 12 hours per year for 1 (S11Certified Nurse Assistant (CNA) Coordinator) of 5 (S11Certified Nurse Coordinator, S12Certified Nurse Assistant, S13Certified Nurse Assistant, S14Certified Nurse Assistant, S24Agency Certified Nurse Assistant) staff training records reviewed for in-service training. Findings: Review of S11Certified Nurse Coordinator's personnel record revealed, in part, a hire date of 07/17/2020. Further review revealed, in part, 4 of the 12 hours of training was completed. There was no documented evidence and the facility did not provide any documented evidence that S11CNA Coordinator completed the required training. In an interview on 10/05/2023 at 3:23 p.m., S2Administrator stated she did not have the documentation that S11CNA Coordinator completed the required training.
- Potential for harm · Dcited before2023-10-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 3 ( Resident #12, Resident #19, and Resident #69) of 19 (Resident #1, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12, Resident #14, Resident #19, Resident #21, Resident #27, Resident #36, Resident #49, Resident #69, Resident #72, Resident #74, Resident #82, Resident #235, and Resident #237) sampled residents whose care plan was reviewed in the final investigation sample. Findings: Resident #12 Review of the Resident #12's Electronic Medical Record (EMR) revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Dementia and Generalized Anxiety. Review of Resident #12's October 2023 Physician's orders revealed, in part, an order with a start date of 08/28/2023 for Ativan (a medication used to treat anxiety) 1 milligram (mg) by mouth every 8 hours as needed and an order dated 08/16/2023 for Sertraline (a medication used to treat…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-05 · tag F0727 — failed to provide required RN coverage — isolatedHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility failed to ensure the facility had eight consecutive hours per day of registered nurse (RN) services for 2 of the 40 days reviewed for RN staffing hours. Findings: Review of the facility's time card report dated 09/23/2023 revealed S10Registered Nurse (RN) clocked in for 6.10 hours. Review of the facility's time card report dated 09/30/2023 revealed S10RN clocked in for 7.70 hours. There was no documented evidence and the facility did not present any documented evidence of having eight consecutive hours per day of registered nurse (RN) services for the above mentioned dates. In an interview on 10/05/2023 at 3:23 p.m., S2Administrator confirmed the facility did not have RN coverage for eight consecutive hours on 09/23/2023 and 09/30/2023. In an interview on 10/05/2023 at 4:38 p.m., S8Director of Nursing (DON) stated she was aware S10RN did not work 8 consecutive hours on 09/23/2023.
- Potential for harm · D2023-10-05 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to have the nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors. Findings: Observation on 10/02/2023 at 10:00 a.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors. Observation on 10/02/2023 at 3:35 p.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors. Observation on 10/03/2023 at 9:32 a.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors. Observation on 10/03/2023 at 4:10 p.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors. Observation on 10/04/2023 at 9:05 a.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors. In an interview on 10/04/2023 at 11:42 a.m., S19Ward Clerk indicated the daily nurse staffing data 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 · D2023-10-05 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement program was developed, implemented, and/or maintained. Findings: Review of the facility's Quality Assurance Policy and Procedure revealed, in part, the facility must identify quality assessment and assurance issues and develop, implement, and oversee the implementation of appropriate plans of correction for identified quality deficiencies. There was no documented evidence and the facility was unable to present any documented evidence the facility had a Quality Assurance program in place. In an interview on 10/05/2023 at 4:07 p.m., S1Regional Administrator stated the facility had no current or up to date Quality Assurance program.
- Potential for harm · D2023-10-05 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to: 1. Ensure the Quality Assessment and Assurance committee met at least quarterly to identify facility issues and coordinate and evaluate performance improvement projects; and, 2. Ensure the Quality Assessment and Assurance committee included the required members. Findings: Review of the facility's Quality Assurance Policy and Procedure revealed, in part, the facility's Quality Assurance committee will meet at least quarterly to identify issues and develop, implement, and/or oversee implementation of appropriate plans of correction for identified quality deficiencies. Further review revealed the Quality Assurance committee will consist of the medical director, the administrator, the director of nursing, and 3 other staff members designated by the facility. There was no documented evidence and the facility was unable to present any documented evidence the facility's Quality Assessment and Assurance committee met at least quarterly or was composed of the required members. In an interview on 10/05/2023 at 4:07 p.m., S1Regional…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record reviews, the facility failed to provide a nutritional supplement as ordered for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed. Findings: Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/2023 revealed Resident #1 received a therapeutic diet. Review of Resident #1's July 2023 Physician Orders revealed, in part, an order for a magic cup (magic cup is a dessert cup that is an option for adding calories and protein for those who experience involuntary weight loss) three times a day for supplement. Review of Resident #1's Care Plan revealed Resident #1 was at risk for weight loss and had a physician prescribed caloric supplement. Observation on 07/31/2023 at 12:03 p.m. at lunch revealed Resident #1's magic cup supplement was not provided. Observation on 08/01/2023 at 12:19 p.m. revealed S3 Certified Nursing Assistant (CNA) served Resident #1 her lunch tray. Resident #1's tray did not include a magic cup. In an interview 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.
- No harm found · B2025-08-07 · tag F0577 — patternAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to post the most recent survey results in a place readily accessible to residents.Findings: Review of the facility's survey history revealed the last survey conducted was a complaint survey with an exit date of 04/03/2025. Observation on 08/05/2025 at 2:27PM of the facility's past survey results binder posted in the hallway next to the dining room revealed the last survey results available for review were dated 08/22/2024 for the recertification survey. There was no documented evidence, and the facility was unable to provide any documented evidence, the last survey results were posted in a place readily accessible to residents as required. In an interview on 08/05/2025 at 3:59PM, S1Administrator confirmed the complaint survey with an exit date of 04/03/2025 was not in the survey results binder.
- No harm found · B2024-08-22 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days of completion for 3 (Resident #28, Resident #44, and Resident #241) of 5 (Resident #4, Resident #28, Resident #44, Resident #73, and Resident #241) residents reviewed for resident assessments. Findings: Resident #28 Review of Resident #28's Quarterly MDS with an Assessment Reference Date (ARD) of 07/17/2024 revealed, in part, the MDS was completed on 07/18/2024. Review of the facility's MDS 3.0 Nursing Home (NH) Final Validation Report revealed, in part, Resident #28's Quarterly MDS with an ARD of 07/17/2024 was transmitted on 08/20/2024, which was greater than 14 days after the completion date. Resident #44 Review of Resident #44's record revealed, in part, Resident #44 was admitted to the facility on [DATE] and discharged from the facility on 07/18/2024. Review of Resident #44's Quarterly MDS with an ARD of 07/17/2024 revealed, in part, Resident #44's Quarterly MDS 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.
“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
$109,359 in federal fines across 2 penalties. 2 Medicare payment denials on record.
- $11,364 — penalty dated 2025-08-07
- $97,995 — penalty dated 2024-08-22
- Medicare payment denial — starting 2025-09-09 for 6 days
- Medicare payment denial — starting 2024-09-20 for 6 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.
Part of a chain
This home belongs to LEGACY NURSING & REHABILITATION — 9 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 | 1 of 5 | 1.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 1 of 5 | 1.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 2.3 | -0.3 vs chain |
The other 8 homes this chain runs (chain average 1.2★, 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 |
|---|---|---|---|---|
| VDG LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/01/2020 |
| RYMAN, JEREMY | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2020 |
| GUM, VICTOR | Individual | CORPORATE OFFICER | — | since 01/01/2020 |
| LEGACY MANAGEMENT GROUP, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2020 |
2 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 74% 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 $444K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 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 195386. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, 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.