St Frances Nsg & Rehab Center
417 Industrial Drive, Oberlin, LA 70655 · For profit - Limited Liability company · 100 certified beds · (337) 639-2934 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $30,702 in federal fines (most recent 2024-11-06)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 25.9% | 17.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.9% | 5.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 2.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 5.4% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.3% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 27.7% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.9% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 10.8% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.7% | 22.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 3.1% | 1.4% | typical for the state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.9% | 28.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.6% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.89 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.56 | 2.74 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 53.9% 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 26 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.1–17.3 | 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 | 53.9% | 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 | 38.5% | 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 | 61.5% | 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 | 100.0% | 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 | not 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.6% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.44 | 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 100 beds and averages 75.1 residents a day — about 75% occupied, or roughly 25 beds typically open. It usually has some room. 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 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.78 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 3.55 hrs/resident/day on weekends vs 4.21 on weekdays — 16% thinner on weekends. RN hours go from 0.23 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-11-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #2, who had been assessed to be at high risk for elopement, received adequate supervision to prevent the resident from eloping from the facility, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement. Findings: This deficient practice resulted in an immediate jeopardy situation on 10/26/2024 at 1:55 a.m., when Resident #2, who was moderately impaired cognitively, had a history of exit seeking behaviors, had been identified as a high elopement risk, and wore a wanderguard bracelet, exited the facility through the front door without staff knowledge. The alarm sounded and S6 LPN walked outside to investigate why the alarm had sounded; however, S6 LPN did not alert facility staff to immediately perform a census check on all residents in the facility when no resident was observed outside the building. Facility staff became knowledgeable of Resident #2's elopement when a family member notified the facility at 2:13…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-11-06 · tag F0835 — failed to run the facility competently — isolatedAdminister 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview on record review, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement. The Administration failed to have an effective system in place to respond when Resident #2, who was assessed to be at risk for elopement, eloped from the facility on 10/26/2024 at 1:55 a.m. The likelihood continued for the remaining 3 residents (#1, #3 and #4), who were assessed as being at risk for elopement. This deficient practice resulted in an immediate jeopardy situation on 10/26/2024 at 1:55 a.m., when Resident #2, who was moderately impaired cognitively, had a history of exit seeking behaviors, had been identified as a high elopement risk, and wore a wanderguard bracelet, exited the facility through the front door without staff knowledge. The alarm sounded and S6 LPN walked outside to investigate why the alarm had sounded; however,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-06 · tag F0585 — failed to handle grievances — isolatedHonor 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
Based on interview and record review, the facility failed to ensure their grievance policy and procedure was followed for 1 (Resident #20) of 1 resident reviewed for missing personal property. The facility failed to initiate a grievance for Resident #20 regarding the reported missing money. Total sample size was 47. Findings:Review of the facility's undated policy titled, Grievances/Complaints read in part.1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint to the facility other entity that hears grievances concerning treatment, medical care, behavior of other residents, staff members, theft of property, and other concerns regarding their LTC facility stay without fear of threat or reprisal in any form.4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations. Review of Resident #20's medical record revealed an admission date of 09/10/2025, with diagnoses that included, in part.Type 2 Diabetes with Hyperglycemia, Hypertensive Heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
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 grooming for 1 (Resident #64) of 3 residents reviewed for ADL care. The total sample size was 47.Review of facility undated policy titled, Activities of Daily Living (ADLs) revealed in part. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of Resident #64's medical record revealed an admission date of 09/26/1986, with diagnoses that included, in part. Unspecified Vision Loss, Unspecified Intellectual Disabilities, and Communication Deficit.Review of Resident #64's Significant Change MDS with ARD 04/10/2026 revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Resident #64 required substantial/maximal assistance with showering/bathing and all personal hygiene/grooming.On 05/04/2026 at 10:18 a.m., observation revealed Resident #64…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-06 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure the planned menus were followed to meet the nutritional needs of the residents that required mechanically altered diets. The facility failed to provide bread or bread substitute for 2 (#68 and #69) of 2 residents who received mechanically altered diets. Findings:Resident #68Review of Resident #68's Quarterly MDS with an ARD of 03/25/2026 revealed Resident #68 had a BIMS score of 99, indicating an assessment could not be completed. Resident #68 required a mechanically altered diet. Resident #69Review of Resident #69's Quarterly MDS with an ARD of 03/19/2026 revealed Resident had a BIMS score of 9, indicating moderate cognitive impairment. Resident #69 required a mechanically altered diet. On 05/04/2026 at 11:10 a.m., observation of two lunch trays for Resident #68 and #69, who were prescribed mechanical soft diets revealed the following:1. Resident #68, who was prescribed a mechanical soft diet, did not receive cornbread or a substitute for bread with her lunch meal. 2. Resident #69, who was prescribed a mechanical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-06 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure open food items stored in the pantry and refrigerator were properly sealed and labeled with an open date. This deficient practice had the potential to affect all 44 residents who received meals served from the kitchen. Findings:Review of an undated policy titled Storage: Dry Food read in part.Dry food storage pertains to those foods not likely to support bacterial growth in their normal state.Procedure:2. Keep all containers tightly closed from insects, rodents, and dust. Dry foods can become contaminated, even if they don't need refrigeration. An observation on 05/04/2026 at 9:18 a.m. of the facility pantry and refrigerator revealed the following:1. One package of vanilla wafers was observed open to air.2. One gallon of mayonnaise was observed opened without a date indicating when the item was opened.3. Two plastic cereal containers were labeled with an open date of 04/14/2025.4. One plastic cereal container was labeled with an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-06 · 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 record review and an interview, the facility failed to ensure a resident's medical record was accurately documented in accordance with accepted professional standards and practices. The facility failed to ensure activities of daily living tasks performed for Resident #2 were accurately documented in the resident's medical record. Findings:Review of an undated policy titled Documentation read in part.The purpose of charting and documentation is to provide:1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc. for the continuity of care, treatment decisions, and to support services provided for payment. Review of Resident #2's medical record revealed an initial admit date of 05/06/2024 and a re-entry date of 03/27/2025, with diagnoses that included in part:., Displaced Intertrochanteric Fracture of the Right Femur, Type 2 Diabetes, Severe Protein Calorie Malnutrition, Dementia, Viral Hepatitis C, and Cirrhosis of the Liver. Review of Resident #2's MDS with an ARD of 02/02/2026 revealed Resident #2 had a BIMS score of 6, indicating…
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 · F2025-04-30 · tag F0576 — widespreadEnsure 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 interview and record review the facility failed to ensure residents received mail on Saturdays. This has the potential to affect all 73 residents residing in the facility. Findings: Review of an undated facility policy on 04/29/2025 at 11:45 a.m. titled, Resident Right to Privacy in Communication revealed the following in part .The facility will honor the resident's right to privacy in written communication including the right to: 1.Send and promptly receive mail that is unopened. 1. The social service designee, or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly. On 04/28/2025 at 1:30 p.m., the Resident Council Meeting was conducted and revealed the residents did not receive mail on Saturdays. In an interview on 04/29/2025 at 10:09 a.m., S11 [NAME] Clerk stated her duty as [NAME] Clerk on Saturdays included gathering the facility mail from the mail box located outside the facility. S11 [NAME] Clerk stated she would then lock the facility mail in the medication room companied by the nurse on duty.…
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 · E2025-04-30 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 residents were free of any significant medication errors for 1 (#29) of 3 (#1, #23, and #29) Residents observed during medication administration, by failing to administer Spironolactone (antihypertensive) medication as ordered. Review of the facility's undated policy titled Medications- Administering on 04/30/2025 at 11:31 a.m. read in part . Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Observation on 04/29/2025 at 7:54 a.m. revealed S12 LPN performed medication administration for Resident #29. Observation revealed S12 LPN placed 9.5 tablets into medication cup for administration. S12 LPN confirmed count of 9.5 tablets, and then administered the medications to Resident #29.…
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 · D2025-04-30 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Based on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident # 22) of 4 (Resident #9, Resident #22, Resident #43, and Resident #225) sampled Residents reviewed for dignity in a total sample size of 25. The facility failed to ensure S7 CNA did not stand while feeding Resident #22 during meal service. Findings: Review of Resident # 22's Clinical Record revealed an admit date of 10/19/2023 with diagnoses that included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin deficiency; Hyperlipidemia; Depression; Psychotic Disorder with Delusions d/t know Psychological Condition; Delusions; Alzheimer's disease. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 revealed a potential for Malnutrition with interventions that included in part . Resident to be fed meals per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#74) of 25 Sampled Residents. Findings: Review of the facility's undated policy on 04/30/2025 at 11:31 a.m. titled Abuse Prevention and Investigation read in part . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including…
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 before2025-04-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #9) resident of 25 sampled residents. The facility failed to ensure Resident #9's care plan for Psychotropic drugs: Risperdal, Buspirone, and Trazodone was developed and/or initiated. Findings: Review of a facility's undated policy on 04/30/2025 at 1:18 p.m. titled, Care Plan-Comprehensive revealed the following in part . 11. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of a facility's undated policy on 04/30/2025 at 1:18 p.m. titled, Care Plans-Preliminary revealed the following in part .A preliminary…
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 15 citations
- Potential for harm · D2025-04-30 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented. The facility failed to ensure supplements were administered as ordered for 1 (Resident #22). Total sample 25. Findings: Review of Resident # 22's Clinical Record revealed an admit date of 10/19/2023 with diagnosis which included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin Deficiency; Hyperlipidemia; Depression; Psychotic Disorder with Delusions d/t known Psychological Condition; Delusions; Alzheimer's Disease. Review of Resident # 22's Significant Change MDS with ARD of 03/02/2025 revealed a BIMS summary score not conducted due to Resident # 22 was rarely/never understood. Resident #22 required extensive assistance for bed mobility, transfers, eating, and toileting. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 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 before2025-04-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision while smoking for 1 (Resident #178) of 1 resident reviewed for smoking. Findings: Review of the facility's undated policy on 04/29/2025 at 10:20 a.m. titled Smoking Policy read in part . Residents who smoke will be assessed for safety awareness and for willingness and ability to follow the facility's safety rules for smoking upon admission, and thereafter as needed but at least quarterly. A standardized form will be used and incorporated into the care planning process. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas, smoking in room, using lighter to start fire of any kind, giving or loaning lighter to other residents,…
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 before2025-04-30 · 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 observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #4) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly changed. Findings: Review of Resident 4's medical record revealed an admit date of 03/01/2017 with diagnosis that included in part .Chronic Obstructive Pulmonary Disease, Chronic Systolic (Congestive) Heart Failure and Shortness of Breath. Review of Resident #4's active Physician orders revealed the following: Oxygen at 2 Liters per nasal cannula PRN Shortness of Breath Desaturation and or Chest Pain as needed related to Chronic Obstructive Pulmonary Disease. Review of Resident #4's Care Plan with a Target date of 07/31/2025 revealed in part .At risk for respiratory distress related to diagnosis Chronic Obstructive Pulmonary Disease. Oxygen at 2 Liters per nasal cannula PRN Shortness of Breath Desaturation and or Chest Pain with interventions that included change oxygen mask/nebulizer tubing/mask every week and PRN nurse to…
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 · D2025-04-30 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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 maintain a medication error rate of less than 5%. The facility failed to: 1. Follow the manufacturer's instructions of Do Not Crush for a medication administered to Resident #23; and 2. Administer a medication as ordered for Resident #29. A total of 36 opportunities were observed for the 3 Residents (#1, #23, and #29) observed during medication administration, which included 2 medication errors for a medication error rate of 5.56%. Findings: Review of the facility's undated policy titled Medications- Administering on 04/30/2025 at 11:31 a.m. read in part . Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #23 Observation on 04/29/2025 at 7:57 a.m. revealed S12 LPN performed…
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 · D2025-04-30 · 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 interview and record review, the facility failed to include the Medical Director or his designee and Director of Nursing in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 73. Findings: Review of an undated facility policy titled, Quality Assessment and Assurance revealed the following in part .1. The Committee will be made up of, at a minimum, the Director of Nursing; the Medical Director or his designee, and at least three (3) other members of the facility staff, at least one of whom must be the administrator, owner, a board member or other individual in a leadership role; and the infection preventionist officer. Review of the facility's documented quarterly Quality Assurance (QA) meeting held on 04/24/2025 revealed S1 ADMIN and eight (8) other leadership personnel in attendance. There was no documentation of the Medical Director nor the Director of Nursing in attendance of the QA meeting held on 04/24/2025. In an interview on 04/30/2025 at 1:17 p.m., S1 ADMIN revealed S5 Corp RN was the designated…
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 · D2025-04-30 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, and record review 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 infection for 2 (Resident #7 and Resident #22) sampled residents by failing to: 1. Ensure staff wore PPE for Resident #7 who was on Enhanced Barrier Precautions; and 2. Ensure staff did not blow on Resident #22's food to cool it while feeding her. Findings: Resident #22 Review of Resident # 22's Clinical Record revealed an admit date of 10/19/2023 with diagnoses which included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Hypertensive Heart Disease without Heart Failure; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin deficiency; Hyperlipidemia; Overactive Bladder; Depression; Psychotic Disorder with Delusions d/t known Psychological Condition; Delusions; Alzheimer's Disease. Review of Resident # 22's Care Plan with a revision date of 04/17/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an injury of unknown source was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#1) of 4 (#1, #2, #3, and #4) sampled residents reviewed for abuse. Findings: Review of the facility's undated policy on 11/04/2024 at 4:00 p.m. titled Abuse Prevention and Investigation read in part . The facility has implemented abuse prevention including 7 key components which are: Employee Screening, Training, Prevention, Identification, Investigations, Protection of residents during investigations, and Response and Reporting of incidents of suspected & actual abuse, according to current federal and state laws and regulations. 16. Reporting: a. All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately, but not later than 2 hours after the allegation is made 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.
- Potential for harm · E2024-02-07 · 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 observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall A) of 2 (Hall A and Hall B) medication carts and 1 of 1 medication storage rooms. Findings: Review of the facility policy titled: Medications-Storage, revealed in part The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on 02/07/2024 at 9:00 a.m. of the Hall A medication cart accompanied by S15 LPN revealed the second drawer of the medication cart contained 3 loose pills and the bottom drawer of the medication cart contained an opened 100ct box of 28G safety lancets with an expiration date of 02/01/2024. Findings confirmed with S15 LPN at the time of observation. S15 LPN revealed it was the responsibility of all nurses to ensure carts were kept clean and free of loose pills and to check dates on boxes. Observation on 02/07/2024 at 9:30 a.m. of the facility medication storage room…
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 before2024-02-07 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 28 residents that received mechanically altered diets prepared by the facility kitchen. Findings: Review of the facility's policy titled: Menu Planning read in part .Purpose: To assure that a variety of nutritious foods that meet the residents' needs are purchased, prepared and served to the residents. Policy: 1. Menus must be planned in advance and meet the nutritional needs of the residents in accordance with recommended dietary requirements. Review of the facility's policy titled: Use of Recipes read in part .Policy: Recipes are to be used when preparing menu items. Procedure: 1. Recipes (in appropriate portion sizes) for each set of cycles menus are provided and maintained in the facility. Review of the facility's approved 2023 Fall/Winter Menu revealed on 02/05/2024 the facility was on week 1, day 2.…
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 · E2024-02-07 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 5 (Resident #30, Resident #35, Resident #40, Resident #61 and Resident #119) of 5 Residents who were ordered and served pureed diets. Findings: Review of the facility's policy and procedure titled Use of Recipes read in part: Policy: Recipes are used when preparing menu items. Procedure: 3. Cooks are expected to use and follow the recipes provided. Review of the facility's approved 2023 Fall/Winter Menu Recipes read in part: Pureeing food can alter the taste, consistency and sometimes the volume of the food. Liquids should be added gradually and may need to increased or decreased slightly to ensure foods are served at a proper consistency. Cooking liquid, broth, or other suitable liquids may be used when pureeing food. Pureed chili with beans. Ingredients/Prep Method- Chilli with beans. Place prepared recipe portion(s) into blender or food processor.…
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 before2024-02-07 · 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, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) store dishes and utensils under sanitary conditions; 2) ensure food preparation equipment was clean. This deficient practice had the potential to affect the 64 residents that received meals prepared in the kitchen. Findings: Review of the facility's policy and procedure titled Cleaning Equipment/Wiping Cloths read in part: Policy: A detailed procedure for cleaning each piece of equipment should be maintained in the dietary department and reviewed periodically with the staff. 4. Sanitize all surfaces with a double-strength detergent, solution, and clean cloths used only for this purpose. 5. Allow to air dry. Can Opener and base: Proper sanitation and maintenance of the can opener is important to sanitary food preparation. The can opener must be thoroughly cleaned each work shift and, when necessary. Wash handle portion of the can opener in dish machine. Review of the facility's policy…
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 before2024-02-07 · 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
Based on interview and record review the facility failed to ensure that the resident's person centered plan of care for malnutrition was followed for 1 (#5) of 26 sampled residents by failing to: 1. Identify and report significant weight loss to Resident #5's physician and RP (Responsible Party), 2. Request an RD (Registered Dietician) consult, 3. Have RD assess Resident #5 at least annually, and 4. Perform a Weight Change Evaluation. Findings: Review of the facility's policy titled Weight Monitoring read in part .A weight loss of 5% in 30 days or less, will be considered significant regardless of resident's ideal body weight. Identification of why a resident is losing weight is important in determining what interventions to provide. All significant, unplanned weight losses will be reported to the physician, and the resident's responsible party as soon as is practical by the Nursing Department. Documentation of weight change review, physician notification, and responsible party notification will be documented in the medical record. Standardized assessment entitled Weight Change…
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 before2024-02-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care to dependent resident for 1 (Resident #61) of 26 sample size residents. Findings: Review of the facility policy titled: Activities of Daily Living (ADLs)revealed in part: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices. Care and services will be provided for the following activities of daily living: 1. Oral care. Policy Explanation and Compliance Guidelines: 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident #61's Annual MDS with an ARD of 11/14/2023 revealed a BIMS of 8 (moderately impaired cognition), with impairment of upper/lower extremity on one side, and required partial/moderate…
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 before2024-02-07 · 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 observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #9) of 1 residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored. Findings: Review of the facility policy titled Respiratory equipment-Infection Control Guidelines revealed in part . Medication Nebulizer/Continuous Aerosol Machines: Administration sets and tubing will be dated before using and will be changed at least weekly and whenever contamination is suspected. Equipment, administration sets, and tubing must be covered with plastic or clean towel when not in use. Observation on 02/05/24 at 11:03 a.m. revealed a nebulizer with aerosol mask and tubing attached open to air on top of a PTAC unit in Resident #9's room. Interview with Resident #9 at the time of observation revealed she received nebulizer treatments as needed. Observation on 02/06/2024 at 9:25 a.m. revealed Resident #9 seated on the side of her bed, rolling cigarettes. A nebulizer with aerosol mask and tubing…
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 · D2024-02-07 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure 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 — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to comply with the requirement of yearly in-service training for CNAs. The facility failed to provide documentation for the required 12 hours of training which included dementia management and abuse prevention trainings for 2 (S11 CNA and S13 CNA) of 5 (S9 CNA, S11 CNA, S12 CNA, S13 CNA, and S14 CNA) CNA personnel records reviewed. Findings: Review of S11 CNA's personnel record revealed a hire date of 08/10/2020 and no documentation that S11 CNA had received the required yearly 12 hours of dementia management and abuse prevention training since 12/22/2022. Review of S13 CNA's personnel record revealed a hire date of 09/18/2022 and no documentation that S13 CNA had received the required yearly dementia management training. Interview on 02/07/2024 at 2:30 p.m. with S7 Administrator revealed S11 CNA and S13 CNA were agency staff. S7 Administrator confirmed the facility had no documentation that S11 CNA had received the required 12 hours of yearly trainings which included dementia management and abuse prevention trainings. S7…
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
$30,702 in federal fines across 2 penalties.
- $15,351 — penalty dated 2024-11-06
- $15,351 — penalty dated 2024-11-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to RIGHTCARE HEALTH SERVICES — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 3 of 5 | 3.3 | -0.3 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 1 of 5 | 1.9 | -0.9 vs chain |
The other 12 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DAVIS, JOEL G | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 20% | since 01/01/2003 |
| DAVIS, JOHN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 25% | since 01/01/2003 |
| DAVIS, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 20% | since 01/01/2003 |
| DAVIS, THOMAS | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 35% | since 01/01/2003 |
| BROUSSARD, SCOTT | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 01/01/2025 |
| RIGHTCARE HEALTH SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 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 $510K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 195499. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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