Our Lady Of Prompt Succor Nursing Facility
954 E Prudhomme St, Opelousas, LA 70570 · For profit - Limited Liability company · 120 certified beds · (337) 948-3634 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- 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
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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 | 22.3% | 17.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.9% | 5.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 3.7% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.8% | 2.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 2.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.3% | 3.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.1% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 39.2% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.3% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.7% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.9% | 22.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 5.2% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 98.0% | 76.3% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.7% | 28.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.2% | 14.8% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.98 | 2.56 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.78 | 2.74 | 1.80 | typical |
* 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.
41.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 122 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 73.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 67 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 41.8%CMS range 33.5–47.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.7%CMS range 10.0–17.2 | 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 | 73.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 65.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.6% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.0% | 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 | 2.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.8%CMS range 5.4–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.14 | 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 120 beds and averages 110.4 residents a day — about 92% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.450 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 3.37 hrs/resident/day on weekends vs 3.86 on weekdays — 13% thinner on weekends. RN hours go from 0.30 to 0.09 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · E2026-02-25 · tag F0732 — patternPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interview, the facility failed to ensure staffing information that was posted daily was accurate and current. The facility's census was 112.Findings:On 02/23/2026 at 8:20 a.m., an observation of the daily posted staffing information revealed a date of 02/20/2026. On 02/23/2026 at 1:39 p.m., a second observation of the daily posted staffing information remained unchanged with a date of 02/20/2026.On 02/23/2026 at 4:15 p.m., a third observation of the daily posted staffing information remained unchanged with a date of 02/20/2026. An interview was conducted at this time with S2HR. S2HR stated she posts the staffing information from the day prior and not the current date. S2HR also affirmed that no staffing information was posted for the weekend dates.
- Potential for harm · Dcited before2026-02-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, policy review, personnel file review, and interviews, the facility failed to treat each resident with respect and dignity in a manner and in an environment that promotes maintenance of his or her quality of life for 1 (#44) out of a finalized sample of 38 residents. Findings: A review of the facility's policy, Resident Rights, with a last review date of 08/20/2025, revealed in part: 5. Respect and dignity. The resident has a right to be treated with respect and dignity. A review of the facility's policy, Promoting/Maintaining Resident Dignity, with a last review date of 08/20/2025, revealed in part: Compliance Guidelines: 10. Speak respectfully to residents; avoid discussions about residents that may be overheard. A review of Resident's [NAME] of Rights Acknowledgment signed by Resident #44's representative on 02/12/2026, revealed in part: 9.The right to be treated courteously, fairly, and with the fullest measure of dignity. A review of Residents Rights In-Service on 07/23/2025,…
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 · D2026-02-25 · 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 interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (#10) of 5 residents (#5, #8 #10, #74, #98) investigated for accidents. Findings:Review of the facility's policy with a review date of 08/20/25 titled Abuse Prevention and Investigation, read in part; IV. Identification of Abuse, Neglect and Exploitation. B. Possible indicators of abuse include, but are not limited to. 3. Physical injury of a resident, of unknown source.; VII. Reporting/ Response. 1. Reporting of all alleged violations to the Administrator, state agency. within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury. Serious Bodily Injury means an injury. requiring medical intervention. Review of Resident #10's electronic medical records…
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 · D2026-02-25 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (Resident #1) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a total census of 126 residents. Findings:Resident #6Review of Resident #6's completed Level I PASARR form, dated 11/16/2024, revealed it was completed prior to the resident's admission to the nursing home. Section III Mental Illness section revealed a question that read, Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? The response checked was no, indicating the resident did not have a mental illness.Review of Resident #6's nursing home admission record revealed she was initially admitted to the facility on [DATE] with diagnoses that included but were not limited to: major depressive disorder, recurrent, unspecified…
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 before2026-02-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to implement a comprehensive person-centered plan of care and follow physician's orders for 2 (Resident #3 and Resident #74) out of 38 sampled residents as evidenced by failing to: 1. implement the comprehensive plan of care for keeping the resident's call light in reach and bed in the lowest position for Resident #3, and2. implement the comprehensive plan and physician's order for two person assistance when transferring Resident #74. Findings:Resident #3 Resident #3 was admitted to the facility on [DATE] with the following diagnoses including, but not limited to: dementia with psychotic disturbance, atrial fibrillation, long term (current) use of anticoagulants and repeated falls. Review of Resident #3's February 2026 physician's orders revealed an order dated 10/24/2025, ensure bed is in lowest position. Review of Resident #3's care plan revealed the resident was at risk for falls r/t (related to) decreased mobility, poor safety…
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 · D2026-02-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to maintain an accurately documented medical record in accordance with accepted professional standards and practices as evidenced by failing to accurately document the use of a CPAP (Continuous Positive Airway Pressure) machine in the resident's EHR (Electronic Health Record) for 1 (#16) out of a census of 112 residents.Findings:Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included, and not limited to: sleep apnea, chronic obstructive pulmonary disease, asthma, and stage 3 chronic kidney disease.Record review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her BIMS (Brief Interview for Mental Status) score was 11, meaning the resident had moderate problems with thinking and memory.On 02/23/2026 at 9:30 a.m., an observation and interview with Resident #16 revealed she had a CPAP machine on her night stand. Resident #16 stated she had been refusing to use it…
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 before2026-02-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record and policy review, the facility failed to maintain an effective infection prevention and control program, by failing to ensure:1. Staff wore appropriate Personal Protective Equipment (PPE) while providing incontinence care to a resident on enhanced barrier precautions (EBP) for Resident #39; and 2. Resident #63's urinary catheter drainage bag avoided contact with the floor.Findings:Resident #39 Record review of the facility's policy last reviewed 08/20/2025, titled Enhanced Barrier Precautions read in part, It is the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). EBP refers to the use of gown and gloves for use during high-contact resident activities for residents known to be colonized or infected with a MDRO. Implementing of EBP-a. Gowns and gloves will be available immediately near the residents room.High Contact residents care activities: d. providing hygiene, f.…
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 · E2025-01-08 · 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 observations, record review, and interview, the facility failed to ensure that medications were stored and labeled properly in accordance with current accepted professional principles by: 1. having loose medications at the bottom of a drawer in the medication cart; and 2. staff failing to conduct and record daily temperature on the medication refrigerator in the medication storage room. Findings: Review of the facility's policy, with no revision date, titled Medications-Storage read, The facility shall store all drugs and biologicals in safe, secure, and orderly manner .Policy Interpretation and Implementation .2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1. On 01/07/2025 at 01:40 p.m., an observation was conducted of the medication cart on Hall A nurse's station with S2LPN (Licensed Practical Nurse). One peach and one white colored pill was observed on the bottom of the first large drawer in the medicine cart. During the observation, S2LPN confirmed that loose pills should not be…
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 · E2025-01-08 · 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 observations, record review and interview, the facility failed to store food in accordance with professional standards for food service safely as evidenced by the nursing staff failing to conduct and record daily temperatures for the resident snack/supplement refrigerator in the medication storage room. Findings: Review of the facility's policy with no revision date titled Refrigerators & Snack/Supplements Handling read in part, .Food kept on the nursing units must be maintained as indicated below: a. Refrigerator temperatures must be checked and recorded daily, maintaining temperature between 32-40 degrees Fahrenheit . On 01/08/2025 at 11:15 a.m., an observation was conducted with S3LPN of the medication room on the Hall B nurse's station. Review of the resident's snack/supplement refrigerator temperature logs for November 2024 through December 2024 revealed missing temperatures on the following dates: 11/01/2024, 11/02/2024, 11/03/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/16/2024,11/17/2024, 11/18/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · 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 interview, observations, 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 by failing to apply a privacy cover to an indwelling catheter urinary drainage bag for 1 (#37) of 32 sampled residents. Findings: Review of Resident #37's medical record revealed an admission date of 07/25/2019, with diagnoses that included in part .Dementia with Agitation, Alzheimer's Disease, Disorder of Kidney and Ureter, Acute Kidney Failure, and Encounter for Fitting and Adjustment of Urinary Device . Review of Resident #37's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/23/2024 revealed a BIMS score of 99, which indicated severe cognitive impairment. Resident #37 required extensive assistance with two person physical assistance for bed mobility and toilet use. Resident #37 used an indwelling urinary catheter for urine elimination. Review of Resident #37's current clinical physician's orders revealed an order 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.
Show the remaining 14 citations
- Potential for harm · D2025-01-08 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review the facility failed to assess 1 (#55) of 1 (#55) residents investigated to self -administer medication out of a finalized sample of 32 residents. The right to self-administer medications was the responsibility of the interdisciplinary team to assess and determine that this practice was clinically appropriate. Findings: Review of the facility's policy titled, Medications - Self-Administration without a review or revision date revealed in part: A resident who wishes to self-administer medications may do so after evaluation of competency by the care plan committee and upon approval and orders from the attending physician. 1.) The attending physician must write or give a verbal for the resident to self-administer medications and/or to keep at bedside. 2.) The resident must be evaluated by the care plan committee and be determined to be cognitively and physically competent to self-administer medications. This evaluation will be documented and maintained in the resident's chart. Review of Resident #55's EMR (Electronic Medical Record)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for antibiotic use for 1 (#65) of 32 sampled residents whose records were reviewed. Findings: A review of Resident #65's EMR (Electronic Medical Record) revealed an admission date of 06/26/2023 with diagnoses that included Pneumonitis, Urinary Tract Infection, and Sepsis. A review of Resident #65's December 2024 Physician's Orders revealed an order for Levofloxacin (an antibiotic) 500mg (milligrams) via g-tube (gastrostomy tube) one time a day for infection for 10 days. A review of resident #65's EMAR (Electronic Medication Administration Record) for December 2024 revealed he received Levofloxacin 500mg once daily from 12/17/2024 through 12/27/2024. Further review of resident #65's medical record revealed a Quarterly MDS assessment with an ARD (Assessment Reference Date) of 12/22/2024, read in part . Section N. Medications .High Risk Drug Classes Use and Indication .antibiotics were not indicated. On 01/08/2025 at 11:20 a.m., a concurrent record review and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · 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 interview, observations, and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 2 (#1 and #27) out of 32 sampled residents. Findings: Review of a facility policy with an unknown date titled, Activities of Daily Living (ADLs) read in part .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 a facility policy with an unknown date titled, Nail Care read in part .1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .2. Routine nail care, to include trimming and filing . Resident #1 Review of Resident #1's medical record revealed an admission date of 12/19/2022, with diagnoses that included in part . Hemiplegia and Hemiparesis Following Other Cerebrovascular Disease Affecting Left Non-Dominant Side, Contracture Left Wrist, and Contracture Left Hand. Review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (#86, #37) out of 32 sampled residents as evidenced by failing to ensure: 1. staff removed PPE (Personal Protective Equipment) prior to exiting a resident's room that was on enhanced barrier precautions for Resident #86; and 2. failing to maintain a resident's urinary catheter in a sanitary manner for Resident #37. Findings: 1. Review of the facility's policy and procedure titled Enhanced Barrier Precautions dated May 2023 read in part, Policy: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities…
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 · D2024-11-13 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, S4CNA (Certified Nursing Assistant) failed to utilize and implement effective approaches of care for a resident with dementia to assure resident safety as evidenced by the CNA failing to call for assistance when the resident (#1) became combative while providing care, resulting in the resident sustaining injuries to his face and left arm for 1 (#1) out of 3 (#1, #2, and #3) sampled residents. Findings: Review of Resident #1's electronic record revealed he was admitted to the facility on [DATE]. His diagnoses included in part, but not limited to, Dysphasia following other Cerebrovascular Disease, Hypertensive Heart Disease without Heart Failure, Aphasia following Cerebral Infarction, Unsteadiness on feet, Generalized Anxiety Disorder, Repeated Falls, Cognitive Communication Deficit, Unspecified Dementia, severe, with other behavioral disturbance, Muscle Weakness (generalized). Review of the resident's MDS (Minimum Data set) dated 10/23/2024 revealed the resident had a BIMS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-06 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered care plan for 5 (#24, #47, #48, #53, and #91) out of 5 investigated for care plans out of a total sample of 37 residents by: 1. Failing to follow physician's orders for applying knee high compression stockings for Resident #24. 2. Failing to follow care plan by not monitoring edema for Resident #47. 3. Failing to develop a care plan for elevating lowering extremities and failing to implement a care plan for applying compression stockings for Resident #48. 4. Failing to develop a care plan to include interventions for the use of Regular Insulin for Resident #53. 5. Failing to develop the care plan to include interventions for the diagnosis of Dementia for the resident #91. Findings: Review of facility's policy, titled Care Plans-Comprehensive, read in part .Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: .f. Resident specific…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center of Medicare And Medicaid Services) in a timely manner for 3 (#17, #24, #59) out of a final sample of 37 residents. Findings: Resident #17 Resident #17 was admitted to the facility on [DATE] with diagnoses including Dysphagia and Generalized Anxiety. Review of Resident #17's electronic health record revealed a quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE]. Section Z of the assessment was not signed by a registered nurse, and the assessment had not been submitted. On [DATE] at 12:00 p.m., an interview was conducted S3MDSIP (Minimum Data Set/ Infection Preventionist ) who stated that she was responsible for signing and submitting Resident #17's MDS assessment. A review of Section Z of Resident #17's MDS assessment with ARD [DATE] was reviewed with S3MDSIP. S3MDSIP confirmed the MDS assessment was not signed, had not…
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 before2023-12-06 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to accurately assess 1 (#76) of 37 sampled residents' oral status. This had the potential to affect the 104 residents that reside in the facility. Findings: Record review revealed Resident #76's was admitted to the facility on [DATE] with Diagnosis of, Nicotine Dependence, Major Depressive disorder Type 2 Diabetes, Anxiety, Chronic Obstructive Pulmonary Disease, Anorexia, Gastroesophageal Reflux Disease, Vitamin D deficiency, Emphysema, Server proteins-Calorie Malnutrition, Dysphagia, Osteoarthritis, Iron Deficiency Anemia, and Dementia. On 12/04/2023 at 9:53 a.m., an observation of Resident #76's oral cavity confirmed she had broken and missing teeth. Record review of Resident #76's dental progress notes dated 04/13/2023 read in part, Oral Assessment, D. Suspect area or broken natural teeth .Tooth #11 is broken down, lingual cusp is broken. Root tips: #15 and #16. Record review of Resident #76's MDS ((Minimum Data Set (Oral Assessment)) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 all required members of the IDT (Interdisciplinary Team) attended the care plan meeting for 1 (#60) out of 37 sampled residents. Findings: Review of the facility's policy titled Care Planning - Interdisciplinary Team read in part .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietitian; d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator; f. Therapists (speech, occupational, recreational, etc. ) g. Consultants (as appropriate) h. The Director of nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care .5. The comprehensive care plan will be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored when not in use for 1(#23) out of 2 (#23 and #24) sampled residents reviewed for respiratory care out of a total sample of 37 residents. Findings: Review of facility's policy, titled, Respiratory Equipment-Infection Control Guidelines, read in part .Oxygen Concentrators: .5. Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. Review of Resident #23's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses including Acute Pulmonary Edema, Chronic Obstructive Pulmonary Disease (COPD), and Acute and Chronic Respiratory Failure with Hypoxia. Review of Resident #23's December 2023 physician's order revealed an order dated 01/21/2023 for O2 (oxygen) at 2 Liters per Nasal Cannula as needed for SOB (shortness of breath), may use simple facemask if necessary for COPD. Review of Resident #23's care plan read in part .Potential for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-06 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to coordinate care as evidenced by failing to obtain pertinent information from the hospice agency for 1 (#19) out of 1 resident investigated for hospice and end of life care out of a total sample of 37 residents. Findings: Resident #19. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Cerebral Infarction, Major Depressive Disorder, Dysphagia and Aphasia Following Cerebral Infarction, Anorexia, and Atherosclerotic Heart Disease. Review of the resident's hospice binder revealed that the most recent hospice IDG (Interdisciplinary Group) plan of care in the binder was dated 10/25/2023. Further review of the hospice binder revealed that there was no evidence of a hospice election form and no evidence of the physician's certification and recertification of the resident's terminal illness. On 12/6/2023 at 9:15 a.m., an interview was conducted with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by staff failing to appropriately change gloves and sanitize hands during perineal care for 1 (#43) resident out of a total sample of 37 residents. Findings: Review of the facility's policy titled Hand Hygiene read in part .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .6. The use of gloves does not replace hand washing. Wash hands before donning and after removing gloves. Resident #43 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Vitamin D Deficiency, and Contractures. Review of Resident #43's plan of care revealed in part . an intervention to assist with perineal cleansing as needed. On 12/05/2023 at 1:28 p.m., 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 · D2023-10-31 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 record review and interviews the facility failed to notify the physician of a change in condition for 2 (#1, #2) of 3 (#1, #2, #3) sampled residents. Findings: Review of a facility policy titled Physician Notification read in part . Regulatory Guidance: A facility must immediately inform the resident's physician when there is an accident involving he resident which results in injury and has the potential for requiring physician intervention; (A) A significant change in the resident's physical, mental , or psychosocial status. (C) A need to alter treatment significantly. Policy Interpretation and Implementation: 3. In general, the charge nurse will notify the resident's attending physician: 3. B. immediately or as soon as is practical if the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; c. the resident is involved in any accident. D. there is a significant change in the resident's physical, mental or psychosocial status. Resident #1:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-31 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 that a physician or nurse practitioner provided orders for the resident's immediate care and needs for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: Review of Resident #1's electronic record revealed an admission date of 09/14/2023 with diagnoses that included Pervasive developmental disorder, Neuralgia and neuritis, Epilepsy, Severe intellectual disabilities, and Hydronephrosis. Resident #1 was non verbal. Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score that was left blank, which indicated the resident had severe cognitive impairment. Review of Resident #1's Incident and Accident report, read in part .on 10/05/2023 at approximately 11:34 a.m., S2LPN (Licensed Practical Nurse) went to Resident #1's room to provide care. After S2LPN completed his treatment, he placed S2LPN's hand on his left leg. S2LPN assessed the left leg, and did not observe any negative…
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
No federal fines in the current CMS record.
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 | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 3.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 1.9 | +1.1 vs chain |
The other 12 homes this chain runs (chain average 2.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ABINGTON FAMILY HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 04/01/2023 |
| B & J LIMITED PARTNERSHIP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 11/01/2022 |
| HEALTHCARE ADVISORY LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | since 11/01/2022 |
| JSSS-SNF LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 10% | since 11/01/2022 |
| OPELOUSASHPOPS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 11/01/2022 |
| SHM OPELOUSAS PFU LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 40% | since 11/01/2022 |
| THE VERNICE C WRIGHT IRREVOCABLE TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 11/01/2022 |
| JONES, CALVIN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 6% | since 11/01/2022 |
| STEVENS, VIKKI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | 6% | since 07/08/2025 |
| SRB INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 11/01/2022 |
| BROUSSARD, SCOTT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 11/01/2022 |
| DAVIS, JOHN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 11/01/2022 |
| DAVIS, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 10% | since 11/01/2022 |
| DAVIS, THOMAS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2022 |
| SANDERS, JACK | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 11/01/2022 |
| RIGHTCARE HEALTH SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/27/2025 |
| PERRY, BRANDIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/27/2025 |
CMS files one row per role, so the 21 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted.
9 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.
This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in LA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195369. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.