Hilltop Nursing & Rehabilitation Center
336 Edgewood Drive, Pineville, LA 71360 · For profit - Limited Liability company · 130 certified beds · (318) 442-9552 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
- it has 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
- it has a citation for mishandling residents’ money or property (F0568)
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- 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 $15,387 in federal fines (most recent 2025-08-28)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 21% 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 13.9% | 17.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.6% | 5.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 1.2% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.4% | 2.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.2% | 2.3% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 7.4% | 3.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.8% | 17.9% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 44.5% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.8% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.5% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.8% | 22.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 3.4% | 3.1% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 56.4% | 76.3% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.0% | 28.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 18.8% | 14.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.23 | 2.56 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.33 | 2.74 | 1.80 | better |
‡ 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.
39.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.5% 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 58 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 0.24 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 39.1%CMS range 27.6–53.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 6.8–15.2 | 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 | 53.5% | 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 | 46.5% | 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 | 55.2% | 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 | 96.8% | 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 | 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 | 6.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.3% | 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 | 11.0%CMS range 6.1–16.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 130 beds and averages 89.7 residents a day — about 69% occupied, or roughly 40 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.57 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 3.72 hrs/resident/day on weekends vs 4.02 on weekdays — 7% thinner on weekends. RN hours go from 0.43 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.
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 · J2025-08-28 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's right to be free from neglect by failing to provide the necessary care and services to 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 was found on the floor by S3 LPN and complained of neck pain. Resident #1 was placed back into bed and S3 LPN failed to notify the Physician of Resident #1's fall and failed to medicate Resident #1 for complaints of pain. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. and then complained of neck, back, and head pain at that time. Resident #1 was transported to the hospital on [DATE] at 7:40 a.m. and was diagnosed with a fracture of his C-4, C-5 and C-6. Pain medications that were ordered and available for Resident #1 were not administered.S1 Administrator was notified of the Immediate Jeopardy situation…
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 · J2025-08-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to provide care and services that met professional standards of quality for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents, by failing to ensure physician orders were followed timely for the management of pain, and timely hospital transfer after a fall.Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 complained of neck pain after being found on the floor by S3 LPN. S3 LPN failed to notify the physician of the fall and failed to administer pain medications that were ordered and available to give. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. and complained of neck, back, and head pain at a 10 out of 10 on the pain scale at that time. Resident #1 was not transferred to the hospital for evaluation until 3 hours after transfer orders had been given to S3 LPN. On 07/24/2025 at 1:20 p.m. the hospital notified…
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 · E2026-02-11 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 1 (Resident #11) of 3 residents reviewed for nutrition/weight loss. The facility failed to provide dietary interventions for a resident with significant weight loss. Findings:Review of the undated facility Nutrition/Hydration Management Policy revealed in part .It is the goal of the ID team, with participation by the RD consultant, that residents of this facility maintain acceptable parameters of nutritional status to the extent medically possible. At a minimum, the following residents will be referred to the High Risk committee: Significant weight change (5% or greater in 30 days or less, 10% or greater in 180 days or less). Review of Resident #11's medical record revealed an admission date of 12/29/2025 with a re-entry date of 02/05/2026 with diagnoses that included in part .Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side,…
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 · E2026-02-11 · 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 — the official record, unedited, may be distressing
Based on observation and interview the facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 9 residents who received a puree diet. The facility failed to ensure staff were wearing a beard restraint during meal preparation.Findings:Observation on 02/09/2026 at 11:15 a.m., revealed S13 [NAME] with a hair net on and a full beard/goatee with no beard restraint while preparing the puree recipe for all 9 residents. S13 [NAME] stated he always prepared the puree meals for the residents in the facility.In an interview on 02/09/2026 at 12:45 p.m., S4 Dietary Manager confirmed, S13 [NAME] did not have on a beard restraint net to cover his beard during puree meal preparation and should have.
- Potential for harm · E2026-02-11 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff by failing to provide an adequate number of clean washcloths and towels. This deficient practice had the potential to affect all 89 residents residing in the facility.Findings:On 02/09/2026 at 1:30 p.m., the Resident Council Meeting was conducted, and it was revealed that two of the residents expressed concerns over not having enough towels or washcloths available in the clean linen storage on the hall to properly clean and dry themselves.Interview with S7 Laundry on 02/10/2026 at 8:58 a.m. revealed that linens, towels, and washcloths are delivered to the halls between 8:00 a.m. and 9:00 a.m.Observation of linen closets on 02/10/2026 at 12:10 p.m. revealed that Hall X had six towels and no washcloths.Observation of linen closets on 02/10/2026 at 3:02 p.m. revealed that Hall V had no towels and four washcloths and Hall W had one towel and four washcloths.Interview with S8 Laundry on 02/10/2026 at 3:45 p.m. revealed that linens, towels,…
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 · D2026-02-11 · tag F0576 — isolatedEnsure 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 interviews and record review, the facility failed to ensure residents received mail on Saturdays. This has the potential to affect all 89 residents residing in the facility.Findings:Review of the facility admission packet dated 02/2023, revealed in part- under the Mail section of Resident Rights .The resident has the right to- (1) Send and promptly receive mail that is unopened.On 02/09/2026 at 1:30 p.m., the Resident Council Meeting was conducted, and it was revealed that the residents did not receive mail on Saturdays. The Resident Council were in agreement that if resident mail was delivered on a Saturday, they would like to received their personal mail on the same day as it was delivered to the facility. During this same Resident Council meeting, the S5 SSD stated that the residents do not receive mail on Saturdays and that she received all of the weekend mail on Monday mornings to then sort and distribute to the residents on Monday.In an interview on 02/11/2026 at 9:31 a.m., S2 Assistant Admin stated that the Weekend Activity Director should distribute resident mail on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-11 · 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 implement 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 #11) residents of 3 sampled residents reviewed for nutrition. The facility failed to ensure the Physician and Registered Dietician was notified of significant weight loss for Resident #11, who was at high risk for malnutrition according to their plan of care.Findings: Review of the undated facility Nutrition/Hydration Management Policy revealed in part .It is the goal of the ID team, with participation by the RD consultant, that residents of this facility maintain acceptable parameters of nutritional status to the extent medically possible. At a minimum, the following residents will be referred to the High Risk committee: Significant weight change (5% or greater in 30 days or less, 10% or greater in 180 days or less). Review of Resident #11's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-11 · 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, record review and interviews the facility failed to ensure residents who are unable to carry out Activities of Daily Living (ADL) received the necessary services to maintain bed mobility. The facility failed to provide bed mobility/repositioning as ordered for 1 (Resident #5) of 2 sampled residents reviewed for ADLs. Findings:Review of undated policy on 02/11/2026 at 2:15 p.m. titled, Positioning (Movement in Bed) revealed the following on page 6.4) Change position at least every 2 hours if resident is unable to move in bed without assistance, base frequency decisions on the resident's age, size, weight, circulatory and integumentary status and medical diagnosis. Review of Resident #5's medical record revealed an admit date of 03/21/2022 and a re-entry date of 11/04/2024 with diagnoses that included in part.Parkinson's Disease without Dyskinesia, Other Persistent Atrial Fibrillation, Bipolar Disorder, Generalized Anxiety Disorder, Other Specified Depressive Disorder, Alcohol Abuse, and Other Hypotension. Review of Resident #5's Quarterly MDS with an ARD date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-11 · 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 #34) of 1 resident reviewed for smoking. Findings: Review of the facility's undated policy on 02/11/2026 at 9:59 a.m. titled Smoking Policy read in part . Residents and Visitors: Do Not Allow residents who have been classified as non-responsible to smoke alone. Review of Resident #34's medical record revealed she was admitted to facility on 06/06/2011 and had diagnoses that included in part Primary Generalized Osteoarthritis, Lack of Coordination, Anxiety Disorder, and Drug Induced Subacute Dyskinesia. Record review of Resident #34's Quarterly MDS with an ARD of 01/09/2026 revealed Resident #34 had a BIMS of 12, and was a current tobacco user. Record review of Resident #34's 02/2026 physician orders revealed in part.Resident is an unsafe smoker. Smoking plan is…
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 · D2026-02-11 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 the residents received a mechanically altered diet as ordered by the physician for 3 (#4, #49, #50) of 3 residents reviewed. This deficient practice had the potential to affect 9 residents receiving pureed diets. Findings: Resident #4 Review of Resident #4's medical record revealed an admit date of 09/26/2025.with diagnoses that included in part.Generalized Anxiety Disorder, Essential (Primary) Hypertension, Chronic Embolism and Thrombosis of Other Specified Veins, and Localized Edema. Review of Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 01/09/2026 revealed a Brief Interview for Mental Status (BIMS) of 11, which indicated moderate cognitive impairment. Resident #4 required setup or clean-up assist with eating. Review of Resident #4's physician orders dated 01/26/2026 revealed an order for Regular NSOT (no salt on tray) diet, pureed texture, and Regular/thin consistency liquids. Review of Resident's #4's care plan revealed in part. Intervention:…
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 before2026-02-11 · 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 observations and staff interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to ensure personnel stored and processed linens so as to prevent the spread of infection by not drying and storing laundered lift slings, privacy curtains, mattress protectors, and Geri-chair cushions in a sanitary manner. This deficient practice had the potential to affect the 89 residents living in the facility. On 02/10/2026 at 3:45 p.m. and on 02/11/2026 at 7:45 a.m., an observation was conducted of an area outside the laundry room door which revealed lift slings and a privacy curtain draped on a metal rack. These items were piled on top of each other and open to outside air and elements.In an interview on 02/11/2026 at 7:45 a.m. with S9 Laundry revealed this was how lift slings and privacy curtains were dried and stored because the laundry had nowhere else to dry or store large items.On 02/11/2026 at 1:00 p.m., an observation was conducted of the area outside the laundry 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 · F2025-08-28 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview the facility failed to ensure that the nurse staffing pattern was posted daily. The facility census was 89.Findings: Observation on 08/25/2025 at 11:00 a.m. of the posted facility staffing pattern revealed a date of 08/13/2025. Observation and interview on 08/25/2025 at 2:35 p.m. with S2 DON and S10 RN/Charge Nurse stated the [NAME] Clerk had quit abruptly and she was responsible for the daily posting of the facility's staffing pattern. S2 DON confirmed the posted facility staffing sheet was dated 08/13/2025 and did not reflect the current date or staffing, and it should.
Show the remaining 15 citations
- Potential for harm · E2025-01-09 · tag F0568 — patternProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to provide quarterly personal funds statements for 3 residents of 3 (Resident #44, Resident #67 and Resident #75) residents review for personal funds. The facility held personal funds for a total of 52 residents. Findings Review of the facility's policy from the admission Packet dated February 2023 and titled Resident Rights read in part . Resident Rights The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident, including each of the following rights: (c) Protection of resident funds. (4) Accounting and Records (ii) The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative. Resident #67 Review of Resident #67's records revealed a Resident Fund Authorization form dated 06/07/2024 signed by Resident #67 authorizing the nursing facility to manage all monies received by or…
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 · E2025-01-09 · tag F0868 — patternHave 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 ensure the Quality Assessment and Assurance (QAA) committee meeting was held at least quarterly and included the required staff members. Findings: Review of the facility's undated policy titled Quality Assurance and Performance Improvement and Performance Improvement (QAPI) Guidelines read in part . The committee will identify any issues which negatively affect the quality of care and services provided to residents. *Quarterly-Include Medical Director and Consultants. On a quarterly basis, the Medical Director will review a summary of the Quality Assurance and Performance Improvement activities. Review of the facility's quarterly Quality Assessment and Assurance (QAA) committee sign in sheets revealed the last meeting was conducted on 07/11/2023. Interview on 01/09/2025 at 10:03 a.m. with S2 DON revealed the facility had not conducted quarterly QA committee meetings. Review of the last Quarterly Quality Assurance/Performance Improvement Report and sign in sheet dated 07/11/2023 with S2 DON. S2 DON confirmed that was the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-09 · 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, interviews and record review the facility failed to ensure the interdisciplinary team assessed and determined if a resident was clinically appropriate for self-administration of medication for 1 resident of 1 (Resident #75) residents reviewed for medication administration. Findings Review of the facility's policy and procedure undated and titled Self-Administration of Medication read in part . Policy: It is the policy of this facility that each resident has the right to self-administer medications, but is the responsibility of the interdisciplinary team to determine that it is safe prior to the resident exercising that right. Procedure: 2. If the resident wishes to self-administer medications, the Interdisciplinary Team must assess the resident's overall ability to safely administer his/her own medications. 3. To assess whether the resident is able to self-administer medications, the criteria on the Assessment for self-administration of medications form will be used . If the right is granted, a specific order to self-administer must be obtained which includes…
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 · D2025-01-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs. The facility failed to provide reasonable accommodation of needs by failing to ensure call light was accessible by a resident for 1 (Resident #42) of 1 Resident reviewed for Positioning. The total sample size was 44. Findings: Review of facility policy titled Call Light System revealed, in part .each resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of resident ability to use it. When resident is in bed, the call bell should be fastened to the side rail or side of bed he/she is facing. Record Review revealed Resident #42 was admitted on [DATE]. Resident #42 had diagnoses that included, in part . Other Specified Disorders Of The Skin And Subcutaneous Tissue, Other Chronic Pain, Contracture Of Muscle, Other Site, Other Sequelae Of Other Cerebrovascular Disease, Hemiplegia And Hemiparesis Following…
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 · D2025-01-09 · 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 observation, interview and record review, the facility failed to ensure that all alleged violations were reported to the State Survey Agency in accordance with State law through established procedures for 3 (#42, #93, and #96) of 6 (#42, #50, #65, #75, #93, and #96) residents reviewed for Accidents. The total Sample Size was 44. The facility failed to: 1. Ensure serious bodily injury of Resident #42 was reported within 2 hours in accordance with State law through established procedures. 2. Ensure serious bodily injury of Resident #93 was reported within 2 hours in accordance with State law through established procedures. 3. Ensure serious bodily injury of Resident #96 was reported within 2 hours in accordance with State law through established procedures. Findings: Review of the facility policy titled Abuse/Neglect Prevention Program stated, in part . 1.Possible indicators of potential abuse and neglect include: a. Injuries of unknown origin b. Contusions, sprains, lacerations, fractures, strains,…
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 · D2025-01-09 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 required discharge documentation was completed for 1 (#99) out of 1 Residents reviewed for discharge. The total sample size was 44. Findings: Review of the facility's undated policy titled Discharge Planning read in part . It is important to ensure that there is a planned program of continuing care to meet each resident's discharge needs. 3. Once completed the Discharge Planning form becomes part of the permanent clinical record. 5. All transfers/discharges of care are coordinated by the Admissions/Discharge Coordinator and conducted according to the following steps: c. Ensure that the physician is contacted regarding the anticipated discharge and necessary orders are obtained. i. Nursing Department completes transfer form and discharge summary information, including current medical information relative to diagnosis, and rehabilitation potential, summary of source of treatment, physician's orders, and pertinent information. Record Review of Resident #99's Electronic Medical Record (EHR) revealed an admit date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-09 · 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 observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for a resident. The facility failed to implement a care plan intervention by failing to ensure a hand roll was used for contracture of hand for 1 (Resident #42) of 44 sampled residents. Findings: Record Review revealed Resident #42 was admitted on [DATE]. Resident #42 had diagnoses that included, in part . Other Specified Disorders Of The Skin And Subcutaneous Tissue, Other Chronic Pain, Contracture Of Muscle, Other Site, Other Sequelae Of Other Cerebrovascular Disease, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #42's Quarterly MDS with ARD of 12/31/2024 revealed BIMS Score of 02, indicating severe cognitive impairment. Resident #42 required extensive one person physical assist with bed mobility and toilet use. Resident #42 was totally dependent, requiring 2 person physical assistance with transfers. Resident #42 required…
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 · D2025-01-09 · 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
Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered plan of care was reviewed and revised for 2 residents (Resident #31 and Resident #75) of 44 sampled residents. The facility failed to ensure care plans were updated: 1. To include resident was educated to notify nursing staff of need to increase her oxygen if needed for Resident #31 who required oxygen therapy; and 2. To include physician ordered nasal spray in resident's room to be included with self-administered medications for Resident #75. Findings: Review of Resident #31's medical record revealed an admission date of 05/23/2022, with diagnoses that included in part . COPD, Chronic Renal Failure with Hypoxia, Nicotine Dependence, unspecified, Dependence on supplemental Oxygen, Chronic Cough and other specified Anxiety Disorders. Review of Resident #31's Physician's Orders revealed an order dated 12/01/2024 for Oxygen at 2 liters/ nasal cannula while in room every shift for shortness of breath related to COPD, unspecified. Review of Resident #31's Quarterly MDS 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 · D2025-01-09 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document a Discharge Summary for 2 residents (Resident #98 and Resident #99) of 3 (Resident #98, Resident #99 and Resident #100) residents reviewed for closed records. The total Sample Size was 44. Findings: Resident #98 Review of resident #98's face sheet revealed he was initially admitted on [DATE]. He had a re-admission date of 02/12/2024 with a primary diagnoses of Type 2 DM with foot ulcer. Other diagnoses included in part . Alzheimer's Disease with late onset, Osteophyte, Vertebrae, Spinal Stenosis, Cervical region, Dementia in other diseases classified elsewhere, Mild, with Mood Disturbance, Other Impulse Disorders, Other Specified Depressive Episodes, Vascular Dementia, [NAME]-[NAME] Syndrome, Essential (primary) hypertension and Acute Kidney Failure. The face sheet further revealed the resident was discharged on 11/04/2024 to a nursing home. Review of Resident #98's electronic medical record revealed there was no evidence of a Discharge Summary…
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 · D2025-01-09 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 2 (S16 CNA, and S17 CNA) of 5 (S5 CNA, S7 CNA, S16 CNA, S17 CNA, and S18 CNA) CNA personnel records reviewed. Findings: Review of the facility's undated policy titled Performance Evaluations read in part . It is the policy of this facility that the job performance of each employee be reviewed and evaluated at least annually. Performance evaluations will be completed by the employee's department director and reviewed by management. Review of personnel records revealed the following: S16 CNA- date of hire was on 12/01/2022. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. S17 CNA-date of hire was on 08/19/2021. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months. In an interview on 01/08/2025 at 11:10 a.m. S9 HR…
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 before2023-12-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents for 1 (#62) of 1 sampled residents for incidents and accidents. The facility failed to ensure Resident #62 received 2 person assist for lift transfers in accordance with the CPOC(Comprehensive Plan of Care). Findings: Review of the facility policy titled Hydraulic Lift revealed in part . The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese or too weak to transfer without complete assistance. It can require two or three staff members to safely operate and accomplish the transfer with some lifts. Review of Resident #62's clinical record revealed an admit date of 10/10/2019 with diagnoses that included Osteoarthritis, Chronic Systolic Congestive Heart Failure, Type II Diabetes Mellitus, Repeated Falls, and Muscle Wasting and Atrophy. Review of Resident #62's CPOC with target date 01/12/2024 revealed in part . Physical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-21 · tag F0698 — failed to provide proper dialysis care — patternProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interviews, the facility failed to ensure appropriate care and services had been provided for 1 (#3) of 1 residents reviewed for dialysis. The facility failed to ensure Resident #3's vital signs were checked pre and post dialysis and failed to ensure communication including the resident's status with the dialysis facility prior to and post dialysis. Findings: Observation on 12/19/23 at 10:18 a.m. revealed Resident #3 awake in bed, watching television. A dressing was observed to Resident #3's right upper arm. Interview at the time of observation revealed Resident #3 was on dialysis and was dialyzed Mondays, Wednesdays, and Fridays. Review of the face sheet revealed the resident had an admit date of 02/23/2022, with diagnoses that included Dependence on Renal Dialysis, Essential Hypertension, Type II Diabetes Mellitus, and Chronic Pulmonary Edema. Review of Resident #3's Physicians orders revealed the following Hemodialysis schedule: Resident to have hemodialysis 3 times a week on Monday, Wednesday and Friday at dialysis center. Check…
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 · D2023-12-21 · 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 a resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her own quality of life. The facility failed to ensure a resident's urinary catheter drainage bag was covered to ensure privacy for 1 (#33) of 1 resident reviewed for dignity. Findings: Review of Resident #33's clinical record revealed an admit date of 11/02/2023 with diagnoses that included hydronephrosis with ureteropelvic junction obstruction, muscle wasting and atrophy, and neuromuscular dysfunction of bladder. Review of an admission MDS Assessment with an ARD of 11/07/2023 revealed Resident #33 had a BIMS of 8, indicating moderate cognitive impairment, and required extensive assistance with transfers, dressing, and personal hygiene. Review of Resident #3's CPOC revealed in part . Potential for UTI and/or complications related to use of indwelling catheter due to retention. Observation on 12/20/2023 at 8:33 a.m. revealed Resident#33 awake in bed, watching television. A urinary catheter drainage bag was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents' assistive devices were maintained in clean and sanitized condition for 2 Residents (Resident #38, and Resident #74) of 30 sampled Residents. Findings: Review of the facility policy titled Nasogastric/Gastrostomy Tube Feedings revealed in part: Essential Points to Remember: 9. Feeding pumps should be cleaned and maintained per manufacturer's instructions. Review of the facility policy titled Oxygen Administration (concentrator or tank) revealed in part: Policy: Concentrator filter should be cleaned weekly or as needed as well. Review of Resident #38's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/02/2023 revealed a BIMS (Brief Interview for Mental Status) of 15 (intact cognition). Observation of Resident #38's oxygen concentrator on 12/19/2023 at 10:30 a.m. revealed it was powered on at 3L. The concentrator was noted to have a layer of grayish dust on the top portion; and the filter and outflow vents were…
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 before2023-12-21 · 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 establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of infection for 1 (#39) of 1 sampled Resident reviewed for catheters. Findings: Interview on 12/20/2023 at 2:05 p.m. with S2 DON revealed there was no facility policy related to catheter tubing or catheter bag placement. Observation on 12/19/2023 at 9:44 a.m. revealed Resident #39 lying in bed sleeping. Resident #39's catheter drainage bag was lying on the floor. Observation on 12/20/2023 at 9:53 a.m. revealed Resident #39 asleep in bed. Resident #39's bed was in low position and his catheter bag and tubing was resting on the floor. Observation on 12/20/2023 at 10:40 a.m. revealed Resident #39's catheter drainage bang and tubing was on the floor. Review of Resident #39's Electronic Health Record revealed an admit date of 12/05/2022. Resident #39 had the following diagnoses including Neuromuscular Dysfunction of Bladder and UTI. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$15,387 in federal fines across 1 penalty.
- $15,387 — penalty dated 2025-08-28
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 CENTRAL MANAGEMENT COMPANY — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.6 | -1.6 vs chain |
| Health inspection | 1 of 5 | 2.8 | -1.8 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 2.4 | -0.4 vs chain |
The other 20 homes this chain runs (chain average 2.6★, 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 |
|---|---|---|---|---|
| KISATCHIE HEALTH, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 52% | since 01/01/2006 |
| PRICO, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 48% | since 01/01/2006 |
| MAUMALANGA, HOLLY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 6% | since 03/31/2025 |
| ZIMMERMAN, FREDA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 12% | since 03/31/2025 |
| CENTRAL MANAGEMENT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2006 |
| PRICE, TEDDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2025 |
| BOLWAHNN, SHEILA | Individual | ADP OF THE SNF | — | since 12/01/2008 |
| CANTRELL, JEFFREY LEE | Individual | ADP OF THE SNF | — | since 10/01/2013 |
| ROGERS, DAWN | Individual | ADP OF THE SNF | — | since 01/01/2006 |
| SHELTON, JAMES | Individual | ADP OF THE SNF | — | since 01/01/2006 |
CMS files one row per role, so the 16 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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 $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in LA
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 195390. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, 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.