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Natchitoches Community Care Center

781 Highway 494, Natchitoches, LA 71457 · Non profit - Corporation · 120 certified beds · (318) 352-8296 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Oct 20233 immediate-jeopardy citations$123,305 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
  • 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 (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $123,305 in federal fines (most recent 2024-07-18)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 18% of its spending goes to commonly-owned related companies

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1029 Keyser Ave · (318) 352-2971 · Call to confirm hours
Pharmacy
1053 Parkway Dr · (318) 354-0501 · Call to confirm hours
Grocery
1013 Clarence Dr · (318) 354-6518 · Call to confirm hours
Park
1815 South Dr · (318) 356-0029 · Typically dawn to dusk
Place of worship

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 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 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 improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.8%17.8%15.4%typical
Long-stay residents who lose too much weight7.5%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.2%0.9%better
Long-stay residents with a urinary tract infection0.3%2.1%2.0%better
Long-stay residents with depressive symptoms2.2%2.3%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.0%3.5%3.3%worse
Long-stay residents whose ability to walk worsened16.1%17.9%16.1%typical
Long-stay residents on antianxiety or hypnotic medication25.3%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.9%95.3%typical
Long-stay residents with pressure ulcers2.2%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control13.8%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.4%22.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%3.1%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine100.0%76.3%79.4%better
Short-stay residents rehospitalized after admission20.7%28.0%22.6%typical
Short-stay residents with an outpatient ER visit16.2%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.892.561.67worse
Long-stay outpatient ER visits per 1,000 resident days3.192.741.80worse

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.

49.1% 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 64 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
79.7%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 79.7% 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 59 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF49.1%CMS range 38.0–59.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 6.3–15.310.7%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 discharge79.7%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 discharge79.7%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 discharge72.9%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 identified100.0%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay1.4%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 worsened0.0%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 hospitalization5.9%CMS range 2.8–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 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

0.31
RN hours/ resident / day
1.21
LPN hours/ resident / day
2.90
Aide hours/ resident / day
4.42
Total nurse hours/ resident / day
0.16
RN hoursweekends
44.1%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 109.2 residents a day — about 91% occupied, or roughly 11 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 4.42 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.90 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.46 hrs/resident/day on weekends vs 4.81 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.37 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

0
deficiencies at the latest standard inspection (2025-09-17)
8
at the previous standard inspection (2024-07-18)

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.

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

  • Immediate jeopardy · K2024-07-18 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's Administration failed to ensure an adequate system was in place to ensure RD recommendations for PEG tube feedings were accurately transcribed into the medical record, failed to provide adequate nutrition to maintain weight, and failed to notify the physician when a resident complained of hunger, nausea, and requested to have her tube feeding rate increased for 1 (#26) of a total of 5 (#4, #16, #26, #96, and #98) residents who received nutrition by PEG tube feedings in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #26 on 07/05/2024 at 3:02 p.m., when S4 RN Clinical Coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended rate of 45 ml/hr. S19's RD Progress Notes dated 07/05/2024,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-07-18 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure services were provided to meet professional standards of quality, by failing to accurately transcribe and implement recommendations from the Registered Dietician, and failing to notify the physician when a resident complained of hunger, nausea, and requested to have her tube feeding rate increased for 1 (#26) of a total of 5 (#4, #16, #26, #96, and #98) residents receiving nutrition by PEG tube feedings in the facility; and failing to perform and document a Comprehensive Skin Assessment for 1 (Resident #19) of 3 (Resident #19, Resident #28, Resident #101) Residents reviewed for Pressure Ulcers. The total Sample Size was 34. Findings: This deficient practice resulted in an Immediate Jeopardy situation for Resident #26 on 07/05/2024 at 3:02 p.m., when S4 RN Clinical Coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended rate of 45 ml/hr. S19RD's Progress Notes…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-07-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide 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 observation, interview, and record review the facility failed to ensure a resident with a PEG tube maintained acceptable parameters of nutritional and hydration status consistent with the resident's comprehensive assessment for 1 (#26) of a total of 5 (#4, #16, #26, #96, and #98) residents receiving nutrition by PEG tube feedings in the facility. This deficient practice resulted in an Immediate Jeopardy situation for Resident #26 on 07/05/2024 at 3:02 p.m., when S4 RN Clinical Coordinator incorrectly entered a physician's order for a nutritional feeding rate at 25 ml/hr instead of the recommended rate of 45 ml/hr. S19 RD's Progress Notes dated 07/05/2024, revealed recommendations for Diabetisource AC (nutritional feeding) at 45 ml/hr. Review of Resident #26's medical record revealed she had received Diabetisource AC at 25 ml/hr from 07/05/24 to 07/15/2024, instead of the recommended Diabetisource AC at 45 ml/hr. Review of Resident #26's progress notes dated 07/13/2024 revealed, Resident #26, who was cognitively intact, and able to communicate by typing messages on her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-29 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure nurse practitioner's orders were transcribed as ordered. The facility failed to transcribe a verbal wound care order for 1 (#2) of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's policy and procedure dated 01/09/2022 titled, Wound Care read in part . Wound Care Orders .; Each individual wound site requires a separate wound care order .; Orders should include; Wound location, Method for cleaning the wound, Primary Dressing . and Frequency of dressing change. Review of Resident #2's clinical record revealed an admit date of 02/10/2025, with diagnoses which included Type 2 Diabetes Mellitus With Foot Ulcer, Cerebral Infarction, Foot Drop- Left Foot; Muscle Wasting And Atrophy; Muscle Weakness and Abnormalities Of Gait And Mobility. Review of Resident #2's Care Plan revealed in part I have actual impairment to skin integrity of the right rear thigh r/t abrasion. Review of Resident #2's Physician's Orders…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to follow infection control practices to prevent the development and transmission of infection. The facility failed to ensure staff prepared a clean work area prior to providing wound care and sanitize hands between glove changes for 1 (Resident #2) of 3 (#1,#2, and #3) sampled residents reviewed for infection control. Findings: Review of the facility's policy and procedure dated 01/09/2022 titled, Wound Care read in part . Steps in the Procedure; Prepare a clean, dry work area at bedside; Remove gloves, perform hand hygiene, reapply gloves. Review of Resident #2's clinical record revealed an admit date of 02/10/2025, with diagnoses which included Type 2 Diabetes Mellitus With Foot Ulcer, Cerebral Infarction, Foot Drop- Left Foot; Muscle Wasting And Atrophy; Muscle Weakness and Abnormalities Of Gait And Mobility. Review of Resident #2's Care Plan revealed in part Fungal Skin Infection with Interventions to include Administer anti-fungal medication as ordered. I am at risk for developing multi-drug resistant organism (MDRO)…

    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 · E2025-02-12 · tag F0576 — pattern
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure the resident's right to receive mail in a timely manner for 1 (#1) resident out of 3 (#1, #2, & #3) sampled residents reviewed for resident rights. Findings: Review on 02/12/2025 of the facility's policy titled Mail and Electronic Communication revised on May 2017 revealed in part .4. Mail and packages will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box (including Saturday deliveries). Review of Resident #1's medical record revealed an admit date of 01/10/2023 with diagnoses that included in part . Type 2 DM, Unspecified Protein-Calorie Malnutrition, Metabolic Encephalopathy, and Unspecified Atrial Fibrillation. Review of Resident #1's Quarterly MDS with an ARD of 12/04/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #1 required setup or clean-up assistance with eating, substantial to maximal assistance with toileting hygiene, showering, rolling left and right, sitting to lying, lying…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life. The facility failed to treat a resident with respect and dignity by failing to adhere to and honor religious dietary preferences for 1 (#1) of 4 (#1, #2, #3, and #4) residents sampled for resident rights. Findings: Review of the facility policy titled Resident Food Preferences revealed in part .individual food preferences will be assessed upon admission and communicated to the interdisciplinary team; upon the resident's admission (or within 24 hours after admission) the Dietary Manager or designee with identify a resident's food preferences; staff with interview the resident directly to determine current food preferences based on history and life patterns related to food. Record Review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses that included…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-30 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure their grievance policy was followed. The facility failed to record a grievance within the appropriate timeframe for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents sampled for resident rights. Findings: Review of the facility policy titled Resident Care Grievance Policy revealed, in part . The facility will investigate all grievances and filed complaints relating to any Resident; Grievances/Complaints are to be submitted to the Administrator who is named as the Grievance Official or their designee who will lead a thorough and impartial investigation of the allegations; Written grievances may be recorded on the Resident Grievance Form and all other grievances should be recorded in the Risk Management section of the resident's electronic health record; A review of the grievance should be available within five business days of receiving the grievance; The Grievance Official or designee will review the finding…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-30 · tag F0756 — failed to review each resident's drug regimen — isolated
    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 interview and record review, the facility failed to ensure the provider documented a clinical rationale for a denial of a psychoactive medication dosage reduction for 1 (#3) of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to ensure the provider documented in the medical record a clinical rationale when the dosage reduction was clinically contraindicated. Findings: Review of the facility's current policy titled, Unnecessary Drugs Psychotropic and Antipsychotic Medications and Non-Pharmacological Intervention with an effective date of 09/06/2022 stated in part .The physician shall respond to reports of untoward medication response by changing or stopping problematic medications/medication dosing or provide clear documentation (based on resident and data assessment) of the rationale for the benefit/risk of medication/medications dosages .Initiate a Gradual Dose reduction (GDR) . In instances that GDRs are contraindicated, documentation of a clinical rationale initiating why a GDR is contraindicated should be documented by the prescribing/treating clinician.…

    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 · E2024-11-07 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to ensure MDS (minimum data set) assessments were accurate for 1 (#3) of 3 (#1, #2 and #3) sample residents. The facility failed to ensure resident #3's MDS accurately reflected her skin conditions and nutritional status at the time of the ARD (assessment reference date). Findings: Review of resident #3's clinical records revealed most recent admission on [DATE] entered from skilled nursing facility with diagnoses that include but not limited to congestive heart failure, Alzheimer's disease with late onset, vascular dementia, diabetes mellitus with diabetic neuropathy, peripheral vascular disease, acquired absence of other left toe, and essential hypertension. Review of resident #3's Quarterly MDS with ARD 10/16/2024 revealed Resident #3 was on a prescribed weight loss management. Further review of Resident #3's Quarterly MDS revealed nothing was entered for ulcers, wounds and skin problems. During an interview on 11/07/2024 at 10:45 a.m. S4 MDS…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to ensure nursing staff provided nursing and related services to assure residents maintained the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by individual plans of care. The facility to notify the Registered Dietician (RD) in a timely manner when 1 (#1) of 2 (#1, #2) residents who received tube feedings order was changed to an equivalent tube feeding. Findings: Review of Resident #1's face sheet revealed an initial admit date of 06/18/2024 and a re-entry to facility on 07/01/2024 with the following medical diagnoses but not limited to cerebral infraction, gastrostomy status and ileus. Review of Resident #1's November 2024 Physician Orders revealed: 9/26/2024: Enteral feed: two times a day Peptamen 1.5 @ 40ml (milliters)/hr (hour) continuous will provide: 1440 kcals (kilocalories), 65 grams protein, 739 mls free water. 11/4/2024: Enteral Feed: every day and night shift; Give Pivot 1.5 Equivalent till Peptamen is available Review of Resident #1's Quarterly MDS (Minimum…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure a resident was treated with respect and dignity for 1 (Resident #1) of 3 (Resident #1, Resident #2, & Resident #3) sampled residents. Findings: Review of Resident #1's medical record revealed an admit date of 02/26/2021 with diagnoses that included in part .Cerebral Infarction, Gout, Hypertension, and Major Depressive Disorder. Review of Resident #1's annual MDS with an ARD of 05/14/2024 revealed a BIMS score of 12 which indicated the resident had moderately impaired cognition. Review of the MDS revealed Resident #1 was independent with eating, toilet hygiene, and rolling left and right. Resident #1 required set up assistance with sitting to lying or lying to sitting on the side of the bed and with transferring from chair/bed to chair. Review of Resident #1's care plan with a target completion date of 08/25/2024 revealed a problem area of having a behavior problem that stated the resident occasionally uses profanity and aggressive language when irritated. Interventions included I will be assisted to develop more…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 ( #19, and #32) out of 34 sampled residents. The facility failed to: 1. Ensure the privacy of Resident #19 while staff provided wound care. 2. Ensure staff did not stand while assisting Resident #32 during a meal service. Findings: Review of the facility's policy titled Dignity dated 02/2021 read in part . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Review of the facility's policy titled Assistance with Meals dated 03/2022 read in part . Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2024-07-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#33 and #77) of 7 (#4, #5, #26, #30, #33, #42, and #87) Residents reviewed for ADL's. The facility failed to ensure a Resident (#33) received nail and oral care, and failed to ensure a Resident (#77) received incontinent care. The total Sample Size was 34. Findings: Review of the facility policy titled: Activities of Daily Living (ADLs), Supporting dated 03/2018 read in part . Appropriate care and services will be provided for Residents who are unable to carry out ADLs independently, with the consent of the Resident and in accordance with the plan of care including: a. Hygiene (bathing, dressing, grooming, and oral care.) c. Elimination (toileting). Resident #33 Review of Resident #33's Electronic Health Record revealed Resident #33 was admitted to the facility on [DATE].…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure appropriate care and services had been provided for 1(Resident #19) of 1 resident reviewed for dialysis. The facility failed to ensure a Dialysis Communication Form was completed to include the resident's status prior to sending resident to dialysis facility. The total Sample Size was 34. Findings: Record Review revealed Resident #19 was admitted to the facility on [DATE]. Resident #19 had diagnoses that included in part . Chronic Kidney Disease, Stage 5, Type 2 Diabetes Mellitus, Congestive Heart Failure, Unspecified Protein Calorie Malnutrition, Dependence on Renal Dialysis, Chronic Pulmonary Edema, Cerebral Infarction, and Generalized Muscle Weakness. Review of Resident #19's Quarterly MDS with an ARD of 04/10/2024 revealed Resident #19 had a BIMS of 15 (cognition intact). Review of Resident #19's Care Plan with target completion date of 10/15/2024 revealed the following in part . I have chronic Kidney disease. I have a Catheter…

    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 · D2024-07-18 · tag F0757 — failed to avoid unnecessary drugs — isolated
    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

    Based on record review and interview, the facility failed to adequately monitor 1 (#18) resident out of 5 (#1, #18, #58, #71, & #82) reviewed for unnecessary medications. The facility failed to adequately monitor Resident #18 for edema while on a diuretic and for side effects and effectiveness while on an antidepressant. Findings: Review of Resident #18's medical record revealed an admit date of 01/07/2015 with diagnoses that included in part .Alzheimer's Disease, Heart Failure, Hypertension, and Other Depressive Disorders. Review of Resident #18's Quarterly MDS with an ARD of 06/26/2024 revealed a BIMS score of 4, which indicated severe cognitive impairment. Review of the MDS revealed the resident required partial to moderate assistance with eating, substantial to maximal assistance with toilet hygiene and sitting to standing, and partial to moderate assistance with sitting to lying and lying to sitting on side of bed. Review of Resident #18's current physician's orders revealed the following orders: 09/29/2023: Furosemide (a diuretic) Tablet 40 mg-Give 40 mg by mouth one time 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following: 1. Staff performed proper hand hygiene during meal service. 2. Staff followed proper infection control practices during wound care. This deficient practice had the potential to affect all residents who reside in the facility. The total resident census was 108. Findings: 1. Observation on 07/15/2024 at 11:45 a.m. of meal service on X Hall dining room revealed S11 CNA assisted Resident #12, and Resident #33 whom were seated together at a table. Review of Resident #12's dietary card revealed she was a full assist with all meals. Review of Resident #33's dietary card revealed she required adaptive equipment: Sippy Cup, Weighted Utensils, and Divider Plate for every meal. Observation revealed S11 CNA assisted Resident #12, and Resident #33 while seated between each resident. S11 CNA physically…

    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 · D2023-10-11 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (#2) of 3 (#1, #2, & #3) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse Components Plan, Elder Justice Act and Affordable Care Act revealed in part . Reporting 1. All alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds or a reasonable suspicion of a crime and/or other reportable incidents will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification: a. LDH online tracking system, Statewide Incident Tracking System (SIMS). b. . 2. An alleged violation involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds, and/or any other reportable incident will be reported immediately, but no later than: a. Two (2) hours if the alleged…

    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 · D2023-10-11 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to ensure food served to residents was palatable and at an appetizing temperature for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for dietary services. Findings: Resident #2 Review of Resident #2's medical record revealed an admit date of 03/18/2021 with diagnoses that included in part .Malignant Neoplasm of Left Breast, Seizures, Major Depressive Disorder, and Generalized Anxiety Disorder. Review of Resident #2's quarterly MDS with an ARD of 06/27/2023 revealed a BIMS score of 13 which indicated intact cognition. Review of the MDS revealed Resident #2 was independent with bed mobility, toilet use, transferring, and eating with set up help only. In an observation and interview on 10/09/2023 at 11:20 a.m., Resident #2 was observed eating lunch in the dining room of her household. Resident #2's tray had Salisbury steak, mashed potatoes and gravy, greens, cornbread, and water. Resident #2 stated she couldn't eat the Salisbury steak because it was cold and too hard to eat. On 10/09/2023 at 11:28 a.m.,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-12 · tag F0580 — failed to tell family and doctor about changes — pattern
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the physician was consulted, and orders were obtained for wound care for 1 (#161) resident out of 3 (#44, #93, #161) residents reviewed for pressure ulcers. Findings: Review of Resident #161's medical record revealed an admit date of 05/17/2023, with diagnoses that included in part .Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominant side, and Muscle Wasting and Atrophy. Review of Resident's 05/23/2023 admission MDS revealed a BIMS assessment could not be completed as Resident #161 was rarely or never understood. The MDS revealed Resident #161 required extensive two person physical assist with bed mobility, transferring, and toilet use; and extensive assistance of one person with eating. Review of Resident #161's nurse's note dated 06/23/2023 at 10:34 a.m. revealed in part .Resident #161 was sent to the ER for shortness of breath, left arm weakness. B/p 106/78, P 55 weak…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-12 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to perform an accurate and thorough weekly skin inspection as ordered for 1 (#93) of 3 (#44, #93, #161) Resident's reviewed for Pressure Ulcers. Findings: Review of Resident #93's Medical Record revealed she was admitted to facility on 12/02/2022 with diagnoses including in part . Chronic Kidney Disease Stage 4, Type 2 Diabetes Mellitus, Acquired Absence of Right Leg Below Knee, and Dehiscence of Amputation Stump. Review of Resident #93's Quarterly MDS with ARD of 05/23/2023 revealed Resident had a BIMS of 14. Resident required extensive assistance, with 2 person physical assist for bed mobility, and was totally dependent on staff for transfers and toileting. Review of Resident #93's Care Plan with target completion date of 06/23/2023 revealed Resident #93 had impairment to skin integrity of right leg related to below knee amputation. Approaches included weekly treatment that required documentation to include measurements of each…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-12 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident who required dialysis received such services, consistent with professional standards of practice, and the comprehensive person-centered care plan by failing to administer an ordered medication required related to dialysis for 1 (#90) of 1 resident reviewed for dialysis. Findings: Review of Resident #90's medical record revealed an admit date of 07/21/2022 with diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis. Review of Resident #90's Minimum Data Set, dated [DATE] revealed a BIMS score of 15 which indicated the resident was cognitively intact. In an interview on 07/10/2023 at 2:55 p.m., Resident #90 reported he does not receive his Renvela like he should and stated he was supposed to get three before meals and one before snack. Review of Resident #90's physician's orders revealed the resident had dialysis ordered on Monday, Wednesday, and Friday. Renvela (a medication used to lower the amount of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-12 · 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 — an excerpt from the official record, may be distressing

    Based on observation, record review and interview, the facility failed to maintain accurate reconciliation records of controlled medications for 1 (Hall 1 Nurse Medication Cart) of 2 (Hall 1 Nurse Medication Cart and Hall 2 Nurse Medication Cart) medication carts observed. Findings: During an observation of medication administration pass on Hall 1 on 07/11/2023 at 8:13 a.m., S4 LPN punched one whole and a half pill of Clonazepam 0.5 mg out of the blister pack and administered them to Resident #57. After administering the medication, S4 LPN documented giving the medication on Resident #57's Narcotic Record. S4 LPN documented on the Narcotic Record that there were 38 pills on hand prior to administration, one was given, and 37 remaining after administration of the medication. An observation of the medication card on 07/11/2023 at 8:15 a.m. with S4 LPN revealed there were one and a half pills in each punch on the blister card and there were 21 punches remaining. In an interview and observation at this time, S4 LPN confirmed the count on Resident #57's Narcotic Record was incorrect 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. This deficient practice had the potential to affect the 113 residents that received meals prepared by the kitchen. Findings: Initial tour of the kitchen on 07/10/2023 at 9:20 a.m. accompanied by S8 Dietary Manager revealed the following items on shelves for use: (1) box containing 12 (1oz.) packets of instant grits with an expiration date of 12/26/2022, (2) 46 oz. cartons of Ready Care Thickened Orange Juice with an expiration date of 06/14/2023, (1) case of 46 oz. cartons of Ready Care Thickened Orange Juice with an expiration date of 06/14/2023 and (1) case of 4 oz. thickened orange juice containers with an expiration date of 06/30/2023. Findings confirmed with S8 Dietary Manager at the time of observation. Observation of the facility cooler on 07/10/2023 at 9:35 a.m. accompanied by S8 Dietary Manager revealed it contained the following items on a shelf for use: : 1 opened, undated gallon of tartar sauce and (3) undated and unlabeled…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #55) of 2 (Resident #55 and Resident #12) Residents sampled for dignity, by failing to ensure she was free of facial hair. Total sample size was 31. Findings: Review of Resident #55's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's Disease, Unspecified Parkinson's Disease, Unspecified Protein-Calorie Malnutrition, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease and Repeated Falls. Review of Resident #55's Quarterly MDS with an ARD of 05/09/2023 revealed she had a BIMS score of 7 (indicating severe cognitive impairment). The MDS revealed Resident #55 required two person physical assistance with bed mobility, transfer and toilet use and the assistance of 1 person physical assistance with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#87) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records regarding code status consistently reflected the Resident's wishes to be a DNR (Do Not Resuscitate). The total sample size was 31. Findings: Review of the facility's policy titled Advance Directives read in part . The Director of Nursing Services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of Resident # 87's Electronic Medical Record revealed he was admitted to the facility on [DATE] and had diagnoses including in part .Spondylosis, Unspecified Dementia, Abnormalities of Gait and Mobility, Anxiety, and Alzheimer's Disease. Review of Resident #87's Medicare 5 day MDS with ARD of 07/04/2023 revealed the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure services were provided according to the resident's plan of care for 1 (#56) of 31 sampled residents. The facility failed to ensure weekly weights were obtained. Findings: Review of Resident #56's clinical record revealed an admit date of 05/03/2023 with diagnoses that included: Dysphagia following Cerebral Infarction, Gastrostomy status and unspecified Protein Calorie Malnutrition. Review of Resident #56's CPOC (Comprehensive Plan of Care) with target date of 08/03/2023 revealed in part I have unplanned/unexpected weight loss related to poor appetite. Approaches include: I will be weighed at same time of day and record: weekly. Review of Resident #56's Physicians orders revealed in part Weekly weights one time a day every Monday. Start date 07/03/2023. Review of Resident #56's Dietician recommendations dated 06/22/2023 revealed recommendations for the facility to obtain weekly weights on Resident #56. Review of Resident #56's weights and vitals summary for date ranges 04/01/2023-07/31/2023 revealed Resident #56 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the Facility failed to ensure that Residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The Facility failed to provide clean fingernails to dependent Residents for 1 (Resident #12) of 2 (Resident #12 and Resident #76) Residents sampled for ADL's. Total sample size was 31. Findings: Review of the Facility policy titled: Activities of Daily Living (ADL's), revealed in part .Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: (A) Hygiene (bathing, dressing, grooming, and oral care). Review of Resident #12's clinical record revealed an admission date of 04/11/2016 with diagnoses which included: Unspecified Dementia, Vascular Dementia Moderate with Other Behavioral Disturbances, Anemia, and Major Depressive Disorder. Review of Resident #12's Quarterly MDS…

    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 · D2023-07-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (#31) of 1 resident reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored. The total survey sample size was 31. Findings: Review of the facility policy titled: Departmental (Respiratory Therapy) Prevention of Infection, revealed in part Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1.Store the circuit in plastic bag, marked with date and resident's name between uses. Observation on 07/10/2023 at 1:05 p.m. revealed Resident #31 observed seated in a wheelchair at her bedside wearing supplemental oxygen via nasal cannula, no date observed on tubing. An Aerosol mask attached to a nebulizer was observed on Resident #31's nightstand OTA (open to air). Observation on 07/11/2023 at 9:29 a.m. revealed Resident #31 seated on the side of her bed wearing supplemental oxygen via nasal cannula. An Aerosol mask attached to a nebulizer was observed on Resident #31'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.

    Quality of Life and Care 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

$123,305 in federal fines across 1 penalty.

  • $123,305 — penalty dated 2024-07-18

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 COMMCARE CORPORATION — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.7-1.7 vs chain
Health inspection 2 of 53.6-1.6 vs chain
Staffing 4 of 53.4+0.6 vs chain
Quality measures 4 of 53.8+0.2 vs chain
The other 13 homes this chain runs (chain average 3.7★, 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 / managerTypeRoleShareSince
COMMCARE CORPORATIONOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/01/1994
HARVEY PSARELLIS, DAWNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2010
LUNDBERG, ALECIndividualW-2 MANAGING EMPLOYEEsince 02/01/2020
PRECHTER, PATRICIAIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/2020
FORD, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2021
MANGUN, GAROLDIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 06/09/1997
PLAISANCE, WAYNEIndividualCORPORATE DIRECTORsince 01/01/2022
TUCKER, JAMESIndividualCORPORATE DIRECTORsince 01/01/2010
COMMCARE MANAGEMENT CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2018
GARDNER, GEORGEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2018
HUDSON, MARYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/12/2013

CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$13.2M
Net patient revenuemost recent cost report
+11.2%
Operating marginrevenue minus expenses
$2.1M
Related-party expense18% of expenses
Who pays — share of resident-days
Medicaid 76%Medicare 5%Other / private 19%

About 76% 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 $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$290per resident / day
operating cost
$8,807per month
≈ monthly operating cost
$326per 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 195405. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-17, 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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