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Village Health Care at The Glen

403 E. Flournoy Lucas, Shreveport, LA 71115 · Non profit - Corporation · 126 certified beds · (318) 213-3500 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$12,735 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,735 in federal fines (most recent 2026-03-16)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (1/5)

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

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
471 Ashley Ridge Blvd · (318) 861-4009 · Call to confirm hours
Pharmacy
9510 Ellerbe Rd · (318) 797-3272 · Call to confirm hours
Grocery
9535 Ellerbe Rd · (318) 795-9006 · Call to confirm hours
Park
7140 Colquitt Rd · (318) 294-1040 · 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 3 of 5
Short-stay residentsrehab / post-hospital 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased30.0%17.8%15.4%worse
Long-stay residents who lose too much weight3.2%5.2%5.4%better
Long-stay residents with a catheter left in their bladder1.3%1.2%0.9%worse
Long-stay residents with a urinary tract infection2.2%2.1%2.0%worse
Long-stay residents with depressive symptoms1.2%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 injury2.4%3.5%3.3%better
Long-stay residents whose ability to walk worsened35.1%17.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication23.7%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine88.4%94.9%95.3%typical
Long-stay residents with pressure ulcers4.5%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control12.1%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.0%22.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.2%3.1%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine52.3%76.3%79.4%worse
Short-stay residents rehospitalized after admission26.0%28.0%22.6%worse
Short-stay residents with an outpatient ER visit9.6%14.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.102.561.67better
Long-stay outpatient ER visits per 1,000 resident days0.592.741.80better

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.

39.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 185 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.6%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
58.1%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 58.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 74 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

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

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF39.6%CMS range 32.8–45.951.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 9.1–16.210.7%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 discharge58.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge59.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.4%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.1%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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%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 worsened1.6%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 hospitalization7.9%CMS range 5.1–11.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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
1.05
LPN hours/ resident / day
2.91
Aide hours/ resident / day
4.19
Total nurse hours/ resident / day
0.15
RN hoursweekends
33.6%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 126 beds and averages 100.1 residents a day — about 79% occupied, or roughly 26 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.19 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 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 3.97 hrs/resident/day on weekends vs 4.29 on weekdays — 7% thinner on weekends. RN hours go from 0.27 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

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

Inspection trend

8
deficiencies at the latest standard inspection (2025-05-15)
3
at the previous standard inspection (2024-04-11)

Deficiencies are more than at the previous inspection — worsening. 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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2026-03-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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, surveillance video review, observation, and interviews, the facility failed to protect the resident's right to be free from physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for Resident #1, who was cognitively impaired, on 01/09/2026 at approximately 7:58 a.m. when S4 CNA was observed on surveillance video physically abusing Resident #1. S4 CNA was observed to forcibly lift Resident #1 from a sitting to standing position three times by gripping Resident #1's left upper arm while yelling at Resident #1 Get up! resulting in multiple areas of bright purple purpura (bruising) to posterior left upper arm. S4 CNA further picked up Resident #1 by her underarms and S4 CNA dropped Resident #1 in wheelchair at the time of transfer. Because this type of inappropriate, unwanted physical abuse and being yelled at would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in Resident #1'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-06-24 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews the facility failed to ensure residents maintained acceptable parameters of nutritional status by failing to ensure weights were obtained monthly for 2 (#2, #9) of 3 (#2, #3, #9) residents reviewed for nutrition. Findings:Review of undated Policy titled Weighing and Measuring the Resident revealed:PurposeThe purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident.Preparation1. Review the resident's care plan to assess for any special needs of the resident.4. Weight is usually measured upon admission and monthly during the resident's stay. (Note: Weight is measured in pounds [16 ounces=1 pound]) .DocumentationThe following information should be recorded in the resident's medical record:1. The date and time the procedure was performed.3. The height and weight of the resident.6. If 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Ecited before2026-06-24 · 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 record review, observations and interview, the facility failed to ensure residents who required respiratory care received the care and services consistent with professional standards of practice for 1 (#4) of 3 (#4, #61, #80) residents reviewed for respiratory care. The facility failed to ensure Resident #4's oxygen tubing was changed weekly, nebulizer tubing was dated, and nebulizer mouthpiece was stored properly when not in use. Findings:Review of undated policy titled Departmental (Respiratory Therapy) - Prevention of Infection revealed:PurposeThe purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.Preparation1. Review the resident's care plan to assess for any special circumstances or precautions related to the resident.Infection Control Considerations Related to Oxygen Administration .7. Change the oxygen cannulae and tubing every seven (7) days, or as needed.8. Keep the oxygen cannulae and tubing used prn (as needed) in a plastic bag when not in…

    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 plan of correction
  • Potential for harm · D2026-06-24 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to ensure resident's medical records reflected the resident's advance directive wishes for 1 (#92) of 1 resident reviewed for advance directives. The facility failed to ensure resident #92's medical records were consistent with the resident's wishes. Findings:Review of resident #92's records revealed an admit date to this facility 05/05/2026.Review of resident #92's records revealed diagnoses that include unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified pain, muscle wasting and atrophy, not elsewhere classified, multiple sites, and unspecified heart failure.Review of resident #92's Physician Orders revealed an order dated 05/05/2026 for a Full Code.Review of resident #92's Face Sheet revealed the Advance Directive section indicated Full Code.Review of resident #92's records with S7 LPN (license practical nurse) revealed resident #92 as a Full Code.Review of the resident #92's records on 06/24/2026 at 2:30 p.m. with S3 ADON (assistant director of nursing) revealed…

    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 plan of correction
  • Potential for harm · Dcited before2026-03-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interviews, the provider failed to develop and implement a comprehensive person centered care plan for each resident as evidenced by failing to implement care plan intervention for falls for 1 (#1) Resident out of 3 residents reviewed for falls.Findings: Review of Resident #1's medical record revealed an admission date of 07/03/2025 to the facility. Further review of Resident #1's medical record revealed diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other lack of coordination, Alzheimer's disease, and muscle weakness.Review of Resident #1's comprehensive care plan revealed Resident #1 was a fall risk with approach dated 10/22/2025 fall mat to each side of bed when in bed.An observation on 03/09/2026 at 8:27 a.m. revealed Resident #1 was resting in bed with eyes closed. Further observation failed to reveal a fall mat in place to both sided of the bed.An observation on 03/09/2026 at 2:20 p.m. in Resident #1's room with S5 CNA failed to reveal fall mats in place in Resident #1'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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure a resident's environment remained free of accident hazards by failing to ensure a resident's room floor maintained non-skid traction for 1 (Resident #3) of 3 residents reviewed for falls. Findings: Review of the facility's Falls and Fall Risk, Managing policy dated March 2018 revealed in part: Policy Statement: Based 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.Policy Interpretation and Implementation:DefinitionAccording to the MDS, a fall is defined as:Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught…

    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 before2025-05-15 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#30, #52, and #78) of 5 (#9, #30, #41, #52, and #78) residents reviewed for restraints. The facility failed to ensure: 1) Consent was obtained for the use of a gerichair with lap tray for Resident #30; 2) The facility failed to have documented evidence of monitoring of resident condition when lap trays were in use for Resident #30 and Resident #78; 3) Resident care plans were developed with problems and approaches related to the use of a gerichair with lap tray for Resident #30 and Resident #78 and; 4) Quarterly restraint assessments were conducted for the use of bed and chair alarms for Resident #52. Findings: Review of the facility's Physical Restraints policy dated reviewed/revised July 2024 revealed in part: Policy and Purpose: The facility is committed to maintaining a restraint-free environment. Physical restraints will…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-15 · tag F0605 — failed to not use drugs as a restraint — pattern
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interview, the facility failed to ensure residents receiving a psychotropic medication had a Gradual Dose Review (GDR) attempted for 1 (#30) of 5 (#4, #5, #30, #51, #77) residents reviewed for unnecessary medications. Findings: Review of Resident #30's medical records revealed an admit date of 12/21/2021 with the following diagnoses, including in part: Alzheimer's disease with late onset, wandering in diseases classified elsewhere, depression unspecified, unspecified dementia moderate with mood disturbance, MDD (major depressive disorder) recurrent in partial remission, and generalized anxiety disorder. Review of Resident #30's Physician's Orders revealed an order dated 10/19/2023 for Trazadone 50mg (milligram) tablet by mouth at bedtime for MDD. Review of Resident #30's GDR dated 11/24/2024 failed to reveal Trazadone 50mg was reviewed for an attempted GDR and a rationale was provided for continuing psychoactive medication at current dose by the Physician/Nurse Practitioner. During an interview on 05/14/2025 at 2:15 p.m. S2 DON (Director of Nursing)…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-15 · tag F0656 — failed to write and follow a full care plan — pattern
    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 resident's comprehensive person-centered care plans by: 1. The facility failed to develop a care plan with a focus and appropriate approaches on bed rails/side rails for 2 (#9, #41) of 5 (#9, #30, #41, #52, #78) residents reviewed for restraints. 2. The facility failed to implement 1 (#24) of 3 (#19, #24, #90) residents reviewed for nutrition. The facility failed to ensure Resident #24 was weighed weekly as per the physician order. Findings: Resident #9 Review of Resident #9's May 2025 physician orders dated 09/17/2024 revealed 1/3 length assist rail up times one on left when in bed to facilitate bed mobility. Review of Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview on Mental Status) of 12 out of 15 indicating moderately impaired cognition. Review of Resident #9's care plan failed to reveal a care plan had been developed with a focus and appropriate approaches for use of bed rails/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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, observation and interviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#6) of 2 (#6, #24) residents reviewed for pressure ulcers. The facility failed to identify, assess, and treat pressure wounds for Resident #6. Findings: Review of Resident #6's medical records revealed an admit date of 10/02/2020 with the following diagnoses, including in part: moderate protein-calorie malnutrition, muscle wasting and atrophy multiple sites, Alzheimer's disease unspecified, neuromuscular dysfunction of bladder unspecified and cognitive communication deficit. Review of Resident #6's Comprehensive Care Plan revealed problems and approaches for: at increased risk for pressure ulcer - investigate causes of injury/bruise/skin tear, treatment as ordered .has fragile skin with history of prone to bruising and/or skin tear - assess new areas for size and injury .Further review failed to reveal current wounds on right foot and right heel 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-15 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews the facility failed to provide respiratory care consistent with professional standards for 1 (#72) of 1 resident reviewed for respiratory care. The facility failed to ensure Resident #72's nebulizer mask and tubing were labeled, dated and stored properly when not in use, and failed to develop a care plan for respiratory treatments with appropriate approaches. Findings: Review of Facility's Policy on Administering Medications through a small volume (handheld) nebulizer with a revision date October 2010 revealed: Purpose: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Preparation: 2. Review the resident's care plan, current orders, and diagnoses to determine resident needs. Steps in Procedure: 29. when equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. Change equipment and tubing every seven days, or according to facility…

    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
Show the remaining 15 citations
  • Potential for harm · E2025-05-15 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews the facility failed to ensure medications (inhalations vials) for nebulizer treatments were stored properly for 1 (#72) of 1 resident reviewed for respiratory. Findings: Review of Facility's Resident Rights Policy with a revision date of November 2016 revealed in part: Policy and Purpose: Each and every resident in this facility has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. To meet this requirement residents have rights guaranteed to them under State and Federal Law. Resident of the facility have the right to: Procedures: 24. Self-administer medications when the interdisciplinary team has determined this practice is clinically appropriate. Medications, including over-the-counter medications, should be provided to the nursing staff and are not to be stored in the resident's room unless the requirements are met. Review of Resident #72's May 2025 Physician…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-05-15 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to ensure equipment was in safe operating condition. The facility failed to perform glucometer control checks for 2 Households (X and Z) according to the facility's policy and procedures.This deficiency has the potential to effect 6 residents (#74, #43, #5, #31, #7, #41) residing in Household X and 3 residents (#14, #21, #346) residing in Household Z. Findings: Household X Review of Facility's Glucometer-Disinfecting and Quality Control Procedures Policy with an effective date of November 1, 2019 revealed: Policy and Purpose - To ensure proper disinfection and operation of glucometers in use by facility staff. Procedure: 3. At a minimum quality control checks on the glucometer will be performed daily. Results of quality control checks will be recorded on the glucometer log. Review of Facility's Blood Glucose Monitoring System Daily Quality Control Record for Household X failed to reveal glucometer controls were checked during the month of May 2025. During an interview on 05/14/2025 at 10:20 a.m. S8LPN (Licensed Practical…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure MDS (Minimum Data Set) assessments accurately reflected the resident's status for 1 (#24) of 20 (#3, #5, #6, #9, #19, #24, #26, #28, #30, #41, #51, #52, #58, #59, #72, #77, #78, #90, #94, #95) sampled residents reviewed. The facility failed to ensure for Resident #24's most recent MDS assessment dated [DATE] accurately reflected Resident #24's functional ability. Findings: Review of Resident #24's medical record revealed an admit date of 01/16/2023 with diagnoses that included, in part, hemiplegia following cerebral infarction affecting right dominate side, hemiplegia following cerebral infarction affecting left non-dominate side, and generalized muscle weakness. Review of Resident #24's May 2025 physician orders revealed an order dated 09/04/2024 for full range of motion performed to all extremities with morning and bedtime care for hemiplegia. Review of Resident #24's most recent MDS assessment dated [DATE] revealed no functional impairment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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 review and interview, the facility failed to ensure residents' environment was as free of accident hazards as possible by failing to evaluate residents' fall risk and implement interventions to reduce fall risk for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents. Findings: Review of Resident #4's medical record revealed an admission date of 01/31/2025 with diagnoses that included, in part, coronary artery disease, atherosclerotic heart disease of the native coronary artery without angina pectoris, unspecified anemia, hypertension, macular degeneration, hyperlipidemia, and major depressive disorder. Review of Resident #4's medical record revealed a Fall Risk Assessment had been conducted on 02/10/2025 with a total score of 23. The Fall Risk Assessment form indicated a score of 10 or more indicates a high risk for falls. Further review of Resident #4's medical record failed to reveal any Fall Risk Assessment had been conducted on admission or prior to the 02/10/2025 Fall Risk Assessment. Review of Incident Logs revealed Resident #4 had unwitnessed falls on 02/01/2025,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-04 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, observations and interview the facility failed to ensure each resident received the care and treatment in accordance with professional standards of practice for 2 (#1, #3) of 3 sampled residents. The facility failed to ensure medications were administered for Resident's #1 and #3 in accordance with the physician's orders and /or within their liberalized medication time blocks. Findings: Review of the facility's Medication Administration Schedule Healthcare Policy and Procedures revealed in part, the following. Effective Date: 03/01/2012. Reviewed /Revised: 06/12/2023. Policy and Purpose: To administer medications and treatments in a liberalized manner in accordance with resident preferences. To facilitate medications compliance, schedule medical care around natural life patterns, and promote continued quality of life through honoring principals of natural awakenings and resident choice. Procedures: 1. Liberalized medication time blocks have been established. Liberalized Time Code Blocks: AM medications administered (7AM - 10:30AM) 7. Medications/treatments…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review the facility failed to ensure 1 (#3) of 3 sampled resident's environment remains as free of accident hazards as possible. The facility failed to have Resident #3's fall mats in place as ordered to prevent injuries. Findings: Observation on 09/04/2024 at 9:00 a.m. revealed 1 fall mat positioned along the floor on the right side of Resident #3's bed. Observation on 09/04/2024 at 10:30 a.m. revealed 1 fall mat positioned along the floor on the right side of Resident #3's bed. During an interview on 09/04/2024 at 10:30 a.m. S2 CNA (Certified Nurse Assistant) reported there should have been 2 fall mats on the floor along each side of Resident #3's bed. Review of Resident #3's Physician's Orders revealed an order dated 08/31/2024 for a low bed with fall mats times 2 to be applied when in bed. Review of Resident #3's Medical Records revealed an admit date of 04/25/2024. Diagnoses include Alzheimer's disease, impaired balance, impaired mobility, muscle weakness,…

    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 · D2024-08-06 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 interview, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were assessed for the risk of entrapment from bed rails, obtaining a written order from the physician for bed rails and an informed consent from resident or resident representative prior to installation for 2 (#1, #2) out of 3 (#1, #2, #3) residents reviewed for falls. Findings: Resident #1 Review of Resident #1's medical record revealed an admit date of 03/13/2023 with the following diagnoses, including but not limited to: Parkinson's disease without dyskinesia/without mention of fluctuations, dementia in other disease classified elsewhere/unspecified severity without behavior/psychosis/mood/anxiety, schizoaffective disorder, weakness, unspecified lack of coordination, muscle weakness (generalized), and cognitive communication deficit. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 06…

    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 before2024-06-24 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility failed to ensure Resident #1 had a written consent for a self-releasing seatbelt and was able to intentionally remove the self-releasing seatbelt in the same manner as it was applied by the staff. Findings: Review of Facility's Chemical & Physical Restraints Policy and Procedure (Reviewed/revised April 2017) revealed: - Policy and purpose: It is the policy of the ___Retirement System to maintain a restraint free environment . - Procedure: 1. Physical restraints are defines as any manual method or physical or mechanical device attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-08 · tag F0697 — failed to manage pain — pattern
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews the facility failed to ensure pain management is provided to residents who may require such services consistent with professional standards of practice for 1 (#1) of 3 (#1, #2, and #3) sample residents reviewed for pain management after a fall/injury. The facility failed to ensure an initial assessment for pain was completed for resident #1 after a fall/injury. Findings: Review of the facility's Fall - Clinical Protocol (Revised March, 2018) presented by S3 Director of Quality and Compliance RN (Registered Nurse) revealed in part the following: Assessment and Recognition 2. In addition, the nurse shall assess and document/report the following: f. Pain; Review of resident #1's ID (Interdisciplinary) Notes dated 04/15/2024 S5 LPN (Licensed Practical Nurse) documented at 5:20 a.m. writer on hall during morning med pass hear resident calling out for help. Writer entered room resident noted awake and alert lying on back on floor next to bathroom. Left side quarter size knot to back of head. Right hand thumb cut, left knee side cut, left skin tear to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-11 · tag F0637 — pattern
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, the facility failed to ensure that 1 (#82) resident out of 35 sampled residents reviewed for a significant change in status was comprehensively assessed using the CMS (Center for Medicare & Medicaid Services) specified Resident Assessment Instrument after Resident #82 was hospitalized following a cerebral infarction and right femoral head fracture on 02/10/2024. Findings: Review of Resident #82's diagnosis revealed hemiplegia following cerebral infarction affecting left non-dominant side, right femoral head fracture. Review of Resident #82's nurse's note dated 02/10/2024 revealed Resident #82 was found lying supine on the floor with no movement to her right lower extremity and tremors to the left side of her body. Resident #82 was assessed by the nurse and 3 staff members assisted Resident #82 into her wheelchair. The Nurse Practitioner was notified and Resident #82 was transferred to the emergency room for evaluation. Review of Resident #82's hospital records revealed the following, in part: Hospital admit date of 02/10/2024 and discharge…

    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 · E2024-04-11 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure resident assessments were transmitted within the required timeframe for 10 (#3, #41, #47, #61, #76, #50, #51, #72, #34, #62) of 10 residents reviewed for assessments out of a total of 35 sampled residents. Findings: Review of Resident #3's MDS (Minimum Data Set) assessments revealed an Other State Assessment MDS dated [DATE] with a status of completed on 02/15/2024 and submitted and accepted on 03/21/2024. Further review of Resident #3's MDS revealed a Quarterly MDS dated [DATE] with a status of completed 02/15/2024 and submitted 03/20/2024 and not accepted. Review of Resident #41's MDS assessments revealed a Quarterly MDS dated [DATE] with a status of not completed, not submitted, and not accepted. Review of Resident #47's MDS assessments revealed an Other State Assessment MDS dated [DATE] with a status of completed on 02/22/2024 and submitted and accepted on 03/21/2024. Further review of Resident #47's MDS revealed a 5-Day MDS dated [DATE]…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-11 · 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 observations and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions. This had the potential to affect 12 residents who received trays out of the main kitchen on 04/08/2024. Findings: Review of the facility's Basic Standards-Food Services -Health Care Policy (revised March 2022) revealed the following: Sanitation: 7. Effective methods of cleaning all equipment and work areas are followed as outlined in individual assignment procedures. 9. Food is stored following sanitary code. All open containers are dated and labeled with first use date and discarded prior to expiration. All food items removed from original containers are properly packaged, dated and labeled prior to being stored. Observation on 04/08/2024 at 8:30 a.m. of the main kitchen revealed the following: 1. Meat covered in ice with frost bitten appearance inside a plastic bag without a label inside the freezer. 2. An opened, unlabeled jar of jalapenos, tartar sauce, and pepperoncini's and lime juice inside the walk in refrigerator. 3. Stand Mixer was unclean 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-19 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey agency for 1 (#1) of 3 (#1, #2, & #3) residents reviewed for abuse. Findings: Review of facility's Resident Abuse and Neglect Prevention and Detection policy with a revision date of November 2022 revealed in part: G. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injures of unknown origin and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made or discovered, to the administrator of the facility and to other officials . if the events that caused the allegation involve abuse or result in a serious bodily injury . Resident #1 was admitted to the facility on [DATE] with diagnoses including in part, Alzheimer's disease, dementia, anxiety disorder, cognitive communication deficit 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-10 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, observation and interviews, the facility failed to provide services that met professional standards for 1 (#371) of 24 sampled residents reviewed. The facility failed to ensure safe medication administration practices by leaving medication at the bedside. Findings: Review of facility policy and procedure with subject line of Pharmaceutical Services and a revision date of February 2018 revealed in part, Provision for Medications: 5. Self-administration of medication by residents is permitted only on order of the residents' physician and with the approval of the interdisciplinary team. Review of facility policy and procedure entitled Self-Administration of Medications with revision date of February 2021, revealed in part: 8. Self-administered medications are stored in a safe & secure place, which is not accessible by other residents. Review of Resident #371's medical record revealed an admit date of 04/18/2023 with diagnoses including, but not limited to, chronic respiratory failure with hypoxia and pneumonitis. Review of Resident #371's admit MDS (Minimum…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-10 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 ensure resident's medical records reflected the resident's wishes for 1 (#36) of 1 (#36) resident reviewed for advanced directives out of a total sample of 29. The facility failed to ensure the physician's orders were consistent with the resident's wishes for Do Not Resuscitate (DNR). Findings: Review of facility's Emergency Procedure - Cardiopulmonary Resuscitation (CPR) revealed in part: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified CPR/BSL (Basic Life Support) shall initiate CPR unless: a. it is known that a Do Not Resuscitate order that specifically prohibits CPR and/or external defibrillation exists for that individual . 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer. Review of Resident #36's LaPOST (Louisiana Physician Orders for Scope of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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

$12,735 in federal fines across 1 penalty.

  • $12,735 — penalty dated 2026-03-16

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.

Who owns this facility

Owner / managerTypeRoleShareSince
THE GLEN RETIREMENT SYSTEMOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/01/1966
BOLTON, MICHAELIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2024
DOCKENDORF, NOREENIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2024
FULLER, JEANNEIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2021
MCGOWEN, CHERYLIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2022
RICE, BARBARAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2024
SIMMONS, MARLAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2018
TERRY, BARBARAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2010
WASHINGTON, ALLISONIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2020
WESTMORELAND, MARTIIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2014
WILLIAMS, CYNTHIAIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2024
WILLIAMS, JOANNIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 05/01/2023
BURNS, DEEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2024
WILLIAMS, DEBRAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/18/2015
GREER, MICHELLEIndividualADP OF THE SNFsince 10/01/2013
HERNANDEZ, ROBERTIndividualADP OF THE SNFsince 01/01/2015

CMS files one row per role, so the 33 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$9.2M
Net patient revenuemost recent cost report
-14.8%
Operating marginrevenue minus expenses
$603K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 29%Medicare 15%Other / private 56%

This home reported $603K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 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

$359per resident / day
operating cost
$10,922per month
≈ monthly operating cost
$313per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in LA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195533. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-15, 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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