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Shreveport Manor Skilled Nursing & Rehabilitation

3302 Mansfield Road, Shreveport, LA 71103 · For profit - Partnership · 127 certified beds · (318) 222-9482 Medicare & Medicaid certified

Call the home — (318) 222-9482 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0568)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0568)
  • 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
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (62%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2551 Greenwood Rd · (318) 212-8681 · Call to confirm hours
Pharmacy
1868 Kings Hwy · (318) 459-3719 · Call to confirm hours
Grocery
2709 Midway St · (318) 631-1867 · Call to confirm hours
Park
2900 Hearne Ave · (318) 212-0220 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 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 fell from 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.5%17.8%15.4%typical
Long-stay residents who lose too much weight7.1%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%1.2%0.9%better
Long-stay residents with a urinary tract infection0.0%2.1%2.0%better
Long-stay residents with depressive symptoms1.8%2.3%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.8%3.5%3.3%better
Long-stay residents whose ability to walk worsened25.7%17.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication9.7%23.2%18.9%better
Long-stay residents given the seasonal flu vaccine98.5%94.9%95.3%typical
Long-stay residents with pressure ulcers3.1%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control14.6%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table32.3%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.6%3.1%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine87.5%76.3%79.4%better
Short-stay residents rehospitalized after admission19.1%28.0%22.6%better
Short-stay residents with an outpatient ER visit4.2%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.672.561.67typical
Long-stay outpatient ER visits per 1,000 resident days1.052.741.80better

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.

33.7% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

33.7%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
0.49U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF33.7%CMS range 21.6–52.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.6–16.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.9%CMS range 5.8–18.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.471.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.23
RN hours/ resident / day
0.91
LPN hours/ resident / day
1.61
Aide hours/ resident / day
2.76
Total nurse hours/ resident / day
0.23
RN hoursweekends
61.8%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 127 beds and averages 68.3 residents a day — about 54% occupied, or roughly 59 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 2.76 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.61 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.33 hrs/resident/day on weekends vs 2.93 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.24 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above 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

8
deficiencies at the latest standard inspection (2025-08-27)
8
at the previous standard inspection (2024-07-30)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

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 · E2026-07-01 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to ensure a performance review was completed at least once every 12 months for 1 (S4 CNA [Certified Nursing Assistant]) of 2 CNA personnel files reviewed. Findings: Review of S4 CNA's personnel file revealed a hire date of 09/16/2016. Further review of S4 CNA's personnel file failed to reveal an annual performance evaluation had been completed since 09/01/2024. During an interview on 06/30/2026 at 4:10 p.m., S5 HR (Human Resources) confirmed S4 CNA had not had an annual performance evaluation since 09/01/2024 and further reported an annual performance evaluation should have been done annually.

    Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Ecited before2025-08-27 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations, and interviews the facility failed to accommodate the needs of 2 (#37 and #48) of 4 (#6, #37, #48, and #78) residents reviewed for environment. The facility failed to ensure the residents' call lights remained in reach. Findings:Review of Resident Call Light System revised 06/2023 revealed:PurposeThe purpose of this procedure is to respond to the resident's requests and needs.Policy implementationA call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities.General Guidelines3. Return demonstration may be utilized to ensure the resident can operate the system.4. Ensure that the call light is easily reachable by the resident.Resident #37Observation on 08/27/2025 at 7:50 a.m. revealed Resident #37 was in bed and call light on the floor and not in reach.Observation on 08/27/2025 at 10:05 a.m. revealed 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-27 · tag F0568 — pattern
    Properly 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview the facility failed to ensure quarterly statements for residents' personal funds entrusted to the facility were provided for 1 (#41) of 1 resident reviewed for personal funds. The facility failed to provide quarterly statements to Resident #41. Findings: Review of admission packet documents provided to residents revealed a Resident Funds Letter which included:Dear Resident:Our facility provides each resident with an opportunity to deposit his/her personal funds into a resident's trust fund account.Should you elect to deposit funds into the resident's trust fund: .You or your legal representative will receive a confidential quarterly statement of funds. Review of Resident #41's medical record revealed Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's 06/12/2025 Quarterly Minimum Data Set (MDS) revealed Resident #41 had a BIMS (Brief Interview Mental Status) score of 15, which indicated intact cognition. During an interview on 08/25/2025 at 2:43…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 record reviews, observations and interviews the facility failed to ensure a resident that was cognitively impaired and at risk for falls had an environment free of accidents hazards for 1 (#48) of 2 (#31, #48) residents reviewed for accidents. Findings: Review of facility's Managing Falls and Fall Risk policy (Revised November 14, 2024) revealed:Policy StatementBased on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of Resident #48's face sheet revealed an admission date of 07/31/2023 with the following diagnoses but not limited to sequelae of cerebral infarction, generalized muscle weakness, unspecified lack of coordination, unspecified psychosis not due to a substance or known physiological condition, muscle wasting and atrophy to multiple sites, dementia, mood disturbance, anxiety, insomnia, pain, restless legs syndrome, and Alzheimer's disease. Review of Annual MDS (Minimum Data Set) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observations and interviews the facility failed to provide appropriate infection control practices for 1(#37) of 1 resident reviewed for urinary catheter/ UTI (Urinary Tract Infection). The facility failed to ensure a resident with a supra pubic catheter received the appropriate care and services to prevent urinary tract infections by failing to ensure (1) the suprapubic catheter was properly secured in a manner to promote drainage and (2) the catheter tubing and bag did not come in contact with the floor. Findings: Review of Resident #37's face sheet revealed an admission date of 03/12/2024 with the following diagnoses but not limited to history of urinary tract infection, chronic, bladder-neck obstruction, benign neoplasm of prostate, obstructive and reflux uropathy, and benign prostatic hyperplasia without lower urinary tract symptomsReview of Resident #37's August 2025 EMAR (Electronic Medication Administration Record) revealed:03/14/2025: Catheter: urinary catheter ensure tubing anchor and privacy bag is intact and secure every shiftReview 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure the low temperature dishwasher met wash cycle temperature recommendations. The deficient practice had the potential to affect the 70 residents who received meals from the kitchen as per S4 Housekeeping/Dietary Manager.Findings: Review of Policy: Mechanical Cleaning and Sanitizing of Utensils and Portable EquipmentDate approved: October 1, 2018Policy: The facility will follow the cleaning and sanitizing requirements of the state and US (United States) Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards.Procedure: .If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120 degrees F (Fahrenheit). Observation on 08/27/2025 at 09:15 a.m. revealed a sticker on the front of the kitchen dishwasher which…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-27 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, observations and interviews, the facility failed to ensure staff practices were consistent with current infection control principles and practices to prevent infection and cross contamination. The facility failed to ensure:(1) PPE (Personal Protective Equipment) was used during contact with contaminated medical equipment and hand hygiene performed, and(2) Proper cleaning and disinfection of medical equipment Findings:Review of facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy revised 10/2018 revealed: Policy Interpretation and Implementation2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.Review of facility's Handwashing/Hand Hygiene policy revised 12/22/2023 revealed: This facility considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.8. Hand hygiene is the final step after removing and disposing 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0575 — isolated
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and observations, the facility failed to post the correct telephone number of pertinent state agencies in a form and manner accessible and understandable to residents/resident representatives. Findings:During an interview on 08/26/2025 at 3:01 p.m. S1 DON (Director of Nursing) reported the state complaint hotline number for nursing homes was posted on the main hallway bulletin board.Observation on 08/26/2025 at 3:02 p.m. with S2 Corporate Nurse failed revealed to reveal the correct number to file a complaint with the state survey agency was posted. During an interview on 08/26/2025 at 3:02 p.m. S2 Corporate Nurse verified the number was incorrect by calling the posted number, on speaker, in the presence of surveyors.Observation on 08/27/2025 at 11:30 a.m. revealed hand written state complaint hotline number for nursing homes was only posted on main dining room hallway bulletin board and was above eye level while standing.During an interview on 08/27/2025 at 11:32 a.m. S3 Human Resources reported the state complaint hotline number for nursing homes was only posted…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to develop and implement an individualized care plan for 1 (#52) out of 29 total sampled residents reviewed. The facility failed to develop Resident #52's care plan for dependent assistance with activities of daily living (ADL) and refusal to wear socks and shoes.Findings:Review of Resident #52's medical records revealed an admit date of 07/11/2025 with the following diagnoses, including in part: other impulse disorders, other disorders of psychological development, developmental disorder of scholastic skills unspecified and other specified anxiety disorders.Review of Resident #52's MDS (Minimum Data Set) assessment dated [DATE] revealed a functional status of dependent with eating, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear and personal hygiene.Review of Resident #52's comprehensive care plan revealed the following problem and approach for ADL self-care performance deficit .(initiated 7/11/25) -…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-09 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure nurses had the appropriate competencies and skilled sets to provide nursing and related services necessary to care for resident's needs. The facility failed to ensure lab blood work had been completed as order for 1 (#1) of 3 (#1, #2 and #3) sample residents. Findings: Review of resident #1's medical record revealed an admission date of 07/14/2022 and diagnoses which included, in part, iron deficiency anemia, rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints. Review of resident #1's current Physician orders revealed the following active orders: Order date 07/26/2022 CBC (complete blood count) every month Order date 08/16/2022 Lipid Panel yearly in August Review of resident #1's medical record revealed the results of a CBC dated 12/22/2024 which had been completed during a hospitalization stay. Review of resident #1's medical record failed to reveal a CBC had been completed for 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Dcited before2025-04-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 record review, observation, and interviews the facility failed to accommodate the needs of 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure resident #1's call light was within reach. Findings: The facility's Resident Call Light System policy/procedure (revised date 06/2023) presented by the S1 Corporate Nurse revealed in part: Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Policy Implementations: A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities. General Guidelines: 4. Ensure that the call light is easily reachable by the resident. Resident #1 was admitted to this facility 07/14/2022. Diagnoses included rheumatoid arthritis, muscle weakness (generalized), need for assistance with…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview the facility failed to ensure 1 (#1) of 3 (#1, #2 and #3) sampled residents who were unable to carry out ADL (activities of daily living) received the necessary services to maintain good grooming and personal hygiene. Findings: Review of resident #1's medical record revealed an admission date of 07/14/2022 and diagnoses which included, in part, rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints. Review of resident #1's most recent quarterly MDS (Minimum Data Set) dated 12/20/2024 revealed resident #1 had a BIMS (brief interview for mental status) score of 13 indicating moderate cognitive impairment. Further review of quarterly MDS dated [DATE] revealed resident #1 required two plus persons for physical assist with bed mobility and toileting use. Observation on 04/07/2025 at 12:30 p.m. revealed resident #1's fingernails were jagged,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-30 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (#53, #57, #221) of 4 (#5, #53, #57, #221) residents reviewed for ADLs (activities of daily living). The facility failed to ensure nail care was provided. Findings: Resident #53 Review of resident #53's medical record revealed an admit date of 11/03/2023 with a diagnoses of, but not limited to, unspecified dementia, major depressive disorder, recurrent, severe with psychotic symptoms, unspecified dementia, mild, with mood disturbance, unsteadiness on feet, and cognitive communication deficit. Review of resident #53's quarterly MDS (minimum data set) dated 05/10/2024 revealed a BIMS (brief interview mental status) of 4 indicating severely impaired cognition. Review of resident #53's comprehensive plan of care revealed resident #53 had a self-care deficit, was totally dependent 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview the facility failed to ensure residents' environment remained free of accident hazards on the locked memory unit by failing to ensure all rooms had a door handle. This had the potential to effect 14 residents residing on the memory care unit. Findings: Observation on 07/28/2024 at 8:00 a.m. on the locked memory unit revealed room A failed to have a door handle in place, exposing a sharp edge. Observation on 07/29/2024 at 8:15 a.m. with S8 Maintenance Supervisor on the memory unit revealed room A failed to have a door handle in place, exposing a sharp edge. During an interview on 07/29/2024 at 8:15 a.m. S8 Maintenance Supervisor reported the door handle to room A had been off since the unit was established and confirmed the door handle should have been repaired.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 2 (#20, #67) of 2 (#20, #67) residents reviewed for respiratory services. The facility failed to ensure resident's hand held nebulizer (HHN) masks and tubing were dated and stored in a plastic bag. Findings: Review of the facility's Departmental Respiratory Therapy Policy (revised November 2021) revealed: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection control considerations related to medication nebulizers/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. Resident #20 Review of Resident #20's medical record revealed an admit date of 06/15/2021 with the following diagnoses, in part: chronic obstructive pulmonary disease/unspecified, acute and chronic respiratory failure with hypoxia, panlobular…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-30 · tag F0851 — pattern
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 2 2024 (January 1 - March 31). Findings: Review of the facility Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 2 2024 (January 1 - March 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. Review of the facility's weekend staffing pattern forms for FY Quarter 2 2024 revealed hours of direct care provided exceeded the hours of care required. During an interview on 07/29/2024 at 8:05 a.m. S3 Director of Nursing reported she did not understand why the facility triggered for low staffing and did not know why the data entered would be incorrect because the facility always overstaffs. During an interview on 07/30/2024 at 10:45 a.m. S2 Corporate Nurse reported she did not know why the PBJ Staffing Data Report for FY Quarter 2 2024 to CMS shows low weekend staffing.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure a resident was cared for with respect and dignity by failing to provide a privacy covering for a urinary catheter bag for 1 resident (#221) out of 4 (#35, #38, #42, #221) residents reviewed for dignity out of a total of 31 sampled residents. Findings: Review of resident #221's medical record revealed an admit date of 03/12/2024 with a diagnoses of, but not limited to, unspecified conversion disorder with seizures, bladder-neck obstruction, urinary tract infection and schizoaffective disorder bipolar type. Review of resident #221's Quarterly MDS (Minimum Data Set) dated 01/14/2024 revealed resident #221 had a BIMS (Brief Interview Mental Status) score of 10 indicating moderately impaired cognition. Review of resident #221's July Physician's Orders revealed an order for: Catheter: Urinary Catheter ensure tubing anchor and privacy bag is intact and secure every shift. Observation on 07/28/2024 at 8:00 a.m. revealed resident #221 was up in his room in the wheelchair. Resident #221's door was open 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-30 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview the facility failed to accommodate the needs of 1 (#57) resident out of 4 (#20, #55, #57, #67) residents reviewed for environment. The facility failed to ensure resident #57's call device was within reach. Findings: Review of resident #57's medical record revealed an admit date of 10/25/2023 with a diagnoses of, but not limited to, Alzheimer's disease, unspecified need for assistance with personal care, essential hypertension, Parkinson's disease and anxiety disorder. Review of resident #57's quarterly MDS (minimum data set) dated 05/07/2024 revealed resident #57 did not have a BIMS (brief interveiw mental status) score because resident #57 was rarely or never understood. Review of resident #57's comprehensive plan of care revealed resident #57 had a self-care deficit and required assistance with bathing, bed mobility, dressing, eating, transferring and personal hygiene. Observation on 07/28/2024 at 7:45 a.m. revealed resident #57 in bed with his breakfast tray in front of him. Further observation revealed resident #57's call device was on the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview the facility failed to ensure the most current survey results were posted in a place readily accessible to the residents, family members or anyone to review. Findings: Observation on 07/28/2024 at 11:45 a.m. failed to reveal the most recent survey results were posted in a place that was readily accessible for review. Observation on 07/28/2024 at 11:45 a.m. with S1 Administrator revealed the most recent survey results were not posted in a place that was readily available for review. During an interview on 07/28/2024 at 11:45 a.m. S1 Administrator confirmed the most recent survey results should have been posted for residents, family and anyone to review.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews and interviews the facility failed to ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#35) of 2 (#5, #35) residents reviewed for position and mobility. The facility failed to ensure Resident #35's splint was in place to treat a contracture. Findings: Review of Resident #35's medical record revealed an admit date of 09/20/2019 with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, direct infection of unspecified hand in infectious and parasitic diseases classified elsewhere, need for assistance with personal care, contracture/right hand and unspecified lack of coordination. Review of Resident #35's comprehensive care plan revealed at risk for complications due to right hand decreased strengthening and positioning - 06/26/2024 right palm pressure ulcer treat as ordered per medical director. Review of Resident #35's physician's orders revealed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews, the facility failed to maintain a clean, comfortable, homelike environment for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents investigated for resident rights. This deficient practice had the potential to affect all the residents residing in the facility. The facility's census was 73. Findings: Review of Resident #4's clinical record revealed an initial admission dated of 11/17/2023. Review of Resident #4's Quarterly MDS (Minimum Data Set) dated 04/19/2024 revealed the following diagnoses: Heart failure, unsteady on feet, abnormalities of gait and mobility, inflammatory disease of prostate, muscle wasting and atrophy. Review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11, indicating resident's cognition was mildly impaired. An observation on 07/01/2024 at 11:56 a.m. revealed a soiled gown at the door opening of the Resident #4's room. Resident #4 was out of his bed and in his wheelchair and a strong…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident's Physician/Physician's Representative and Responsible Party (RP) were notified after a fall for 1 (Resident #3) of 3 (Resident #1, #2, and #3) sampled residents. Findings: Review of facility's Assessing Falls and Their Causes policy with a revision date of March 2018 revealed in part: The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After a fall: 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall occurs, or when the fall results in a significant injury or condition change, prompt notification of the physician by phone is indicated. Documentation: When a resident falls, the following information should be recorded in the resident's electronic medical record: 4. Notification of physician and family. Resident #3 was admitted to the facility on [DATE] with diagnoses including in part,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-09 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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, video footage review, and interviews the facility failed to ensure the nursing staff possessed the competency to assess a resident after an unwitnessed fall and complete an internal report in a timely manner for 1 (Resident #3) of 3 (Resident #1, #2, and #3) sampled residents. Findings: Review of facility's Assessing Falls and Their Causes policy with a revision date of March 2018 revealed in part: The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After a fall: 1. If a resident has just fallen, or is on the floor without a witness to the event, evaluate for possible injuries to the head, neck spine and extremities. 5. b. All unwitnessed falls regardless of orientation will require neurological checks using the approved neurological check forms. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-09 · tag F0836 — isolated
    Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, video footage review and interviews, the facility failed to ensure it operated and provided services in compliance with Federal, State, and local laws by not ensuring a resident's RP (Responsible Party) installed surveillance camera was not hampered with and/or obstructed for 1 (Resident #3) of 3 (Resident #1, #2, and #3) sampled residents. Findings: The current Nursing Home Virtual Visitation Act 596 revealed in part: Prohibited Acts Under the Nursing Home Virtual Visitation Act: 2. No person shall intentionally hamper, obstruct, tamper with, or destroy a monitoring device or a recording made by a monitoring device installed in a nursing home; this does not apply to the resident. Resident #3 was admitted to the facility on [DATE] with diagnoses including in part, severe dementia with other behavioral disturbances, persistent mood disorders, major depressive disorder, schizoaffective disorder, and Alzheimer's disease. Review of Resident #3's MDS (Minimum Data Set) dated 01/30/2024…

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

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PRIORITY MANAGEMENT — 38 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.9-1.9 vs chain
Health inspection 2 of 53.2-1.2 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 3 of 53.4-0.4 vs chain
The other 37 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Alpine Skilled Nursing and RehabilitationRuston, LA 1 of 5Bridgeport Medical LodgeBridgeport, TX 1 of 5Camelot Rehabilitation At Magnolia ParkLafayette, LA 1 of 5Colonial Oaks Skilled Nursing and RehabilitationBossier City, LA 1 of 5Hilltop Park Rehabilitation And Care CenterWeatherford, TX 1 of 5Pilgrim Manor Skilled Nursing and RehabilitationBossier City, LA 1 of 5St Joseph Skilled Nursing and RehabilitationMonroe, LA 1 of 5The Bradford Skilled Nursing And RehabilitationShreveport, LA 1 of 5The Guest House Skilled Nursing and RehabilitationShreveport, LA 2 of 5Booker T. Washington Skilled Nursing and RehabilitShreveport, LA 2 of 5Decatur Medical LodgeDecatur, TX 2 of 5Resthaven Living CenterBogalusa, LA 2 of 5Ridgmar Medical LodgeFort Worth, TX 3 of 5Broadmoor Medical LodgeRockwall, TX 3 of 5Camelot Of BroussardBroussard, LA 3 of 5Chateau St. James Rehab And RetirementLutcher, LA 3 of 5Louisiana Extended Care Hospital Of LafayetteLafayette, LA 3 of 5Mabank Nursing CenterMabank, TX 3 of 5Royse City Medical LodgeRoyse City, TX 3 of 5The Homestead of DenisonDenison, TX 3 of 5The Woodlands Healthcare CenterLeesville, LA 3 of 5Timber Springs Rehab and RetirementSpringhill, LA 4 of 5Belterra Health & RehabMcKinney, TX 4 of 5College Park Rehabilitation And Care CenterWeatherford, TX 4 of 5Jo Ellen Smith Convalescent CenterNew Orleans, LA 4 of 5Mansfield Medical LodgeMansfield, TX 4 of 5The Parks at Garland Healthcare and RehabGarland, TX 4 of 5Victoria Gardens Of AllenAllen, TX 4 of 5Victoria Gardens of FriscoFrisco, TX 4 of 5Vista Ridge Nursing & Rehabilitation CenterLewisville, TX 4 of 5Windmill Village Rehabilitation & Care CenterLubbock, TX 5 of 5Camelot BrooksideJennings, LA 5 of 5Chateau D'Ville Rehab and RetirementDonaldsonville, LA 5 of 5Chateau Terrebonne Health Care CenterHouma, LA 5 of 5Grapevine Medical LodgeGrapevine, TX 5 of 5Spring Lake Skilled Nursing And RehabilitationShreveport, LA 5 of 5Springtown Park Rehabilitation And Care CenterSpringtown, TX

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
SDB HOLDINGSOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/01/2019
BAUDER, WILLIAMIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2019
BOULWARE, DOUGLASIndividualINDIRECT OWNERSHIP INTERESTsince 04/01/2019
BOULWARE, STEVENIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/01/2019
PRIORITY MANAGEMENT GROUP, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2019
BASS, PATIndividualADP OF THE SNFsince 04/18/2025
STARR, CHRISTINAIndividualADP OF THE SNFsince 10/31/2022
WILLIAMS, JAMESIndividualADP OF THE SNFsince 04/18/2025

CMS files one row per role, so the 11 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.5M
Net patient revenuemost recent cost report
-13.9%
Operating marginrevenue minus expenses
$1.1M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 13%Other / private 16%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$370per resident / day
operating cost
$11,262per month
≈ monthly operating cost
$325per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.

Typical monthly cost in Louisiana
$7,604/mo
Nursing home (semi-private)
$8,076/mo
Nursing home (private)
$5,163/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195515. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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