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Guest House Nursing and Rehabilitation

109 Guest House Drive, West Monroe, LA 71292 · For profit - Limited Liability company · 140 certified beds · (318) 387-3900 Medicare & Medicaid certified

Call the home — (318) 387-3900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Jul 2025Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Jul 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (27) — 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 facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)
  • about 19% of its spending goes to commonly-owned related companies

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1245 Glenwood Dr · (318) 361-3878 · Call to confirm hours
Pharmacy
115 Smith St · (318) 387-9677 · Call to confirm hours
Grocery
4-WAY2.9 mi
104 Highway 34 · (318) 323-6786 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
824 Highway 3033 · (318) 387-6372

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 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 increased31.9%17.8%15.4%worse
Long-stay residents who lose too much weight9.6%5.2%5.4%worse
Long-stay residents with a catheter left in their bladder3.4%1.2%0.9%worse
Long-stay residents with a urinary tract infection4.2%2.1%2.0%worse
Long-stay residents with depressive symptoms2.1%2.3%6.5%typical for the 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 injury7.2%3.5%3.3%worse
Long-stay residents whose ability to walk worsened27.2%17.9%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.3%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine90.5%94.9%95.3%typical
Long-stay residents with pressure ulcers3.9%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control23.2%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table27.8%22.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.7%3.1%1.4%worse than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine85.8%76.3%79.4%typical
Short-stay residents rehospitalized after admission33.3%28.0%22.6%worse
Short-stay residents with an outpatient ER visit30.2%14.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.562.561.67worse
Long-stay outpatient ER visits per 1,000 resident days4.002.741.80worse

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.

55.3% 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 161 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.3%U.S. median 51.5%
Got home and stayed home
9.2%U.S. median 10.7%
Went back to hospital
47.2%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 47.2% 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 91 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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 SNF55.3%CMS range 47.8–60.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.2%CMS range 6.5–12.410.7%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 discharge47.2%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 discharge70.3%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 discharge40.7%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 identified97.0%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 setting97.3%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 stay2.3%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 worsened2.3%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 hospitalization8.4%CMS range 5.6–13.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 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

0.24
RN hours/ resident / day
1.33
LPN hours/ resident / day
2.36
Aide hours/ resident / day
3.93
Total nurse hours/ resident / day
0.09
RN hoursweekends
64.1%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 140 beds and averages 105.3 residents a day — about 75% occupied, or roughly 35 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 3.93 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 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 3.35 hrs/resident/day on weekends vs 4.16 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.30 to 0.09 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% 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

9
deficiencies at the latest standard inspection (2025-07-30)
5
at the previous standard inspection (2024-07-24)

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · D2026-05-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    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 and interview the facility failed to ensure each resident received the care and treatment in accordance with professional standards of practice for 2 (#1, #2) of 3 sampled residents. The facility failed to assess, monitor, and document edema in accordance with the physician's orders and/or the comprehensive plan of care.Findings: Resident #1Review of resident #1's records revealed diagnoses that include edema, permanent atrial fibrillation, chronic right heart failure, hypertension, restless legs syndrome, disorder of peripheral nervous system and diabetes.Review of resident #1's Physician's Orders revealed an order dated 04/17/2026 for Lasix oral tablet 20 mg (milligrams). Give 1 tablet by mouth every 24 hours as needed for edema.Review resident #1's Comprehensive Plan of Care revealed resident has diagnosis of chronic kidney disease Stage II- risk for excess fluid volume, decreased urine output, and sodium retention. Monitor for generalized edema.Review of resident #1's April 2026 MAR (medication administration record) failed to reveal documentation 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
  • Potential for harm · E2025-07-30 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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 observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#38, #100,) of 2 (#38, #100) sampled residents reviewed for environmental concerns. The facility failed to ensure that residents' wheelchairs were maintained in good repair.Findings:Resident #38 Review of Resident #38's record revealed an admit date of 01/04/2023 with diagnoses including chronic diastolic (congestive) heart failure, left knee primary osteoarthritis and chronic kidney disease. Further review of records revealed a quarterly Minimal Data Set (MDS) assessment dated [DATE] documented Resident #38 utilized a wheelchair for mobility and required moderate assistance with transferring.On 07/28/2025 at 9:53 a.m. and 07/29/2025 at 8:50 a.m., observations of Resident #38's wheelchair revealed the wheelchair arm padding to be cracked and torn.On 07/29/2025 at 9:50 a.m., an observation conducted with S2Director of Nursing (DON) confirmed that Resident #38's wheelchair armrest…

    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 · D2025-07-30 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was free from misappropriation of personal property for 1 (#11) of 1 resident reviewed for personal funds. Findings:Review of the facility's undated Abuse and Neglect Prohibition policy revealed the following in part:Fundamental Information:Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Review of Resident #11's record revealed an admission date of 02/27/2025 with diagnoses including chronic obstructive pulmonary disease, chronic cough, unsheltered homelessness, seizures, personal history of transient ischemic attack, cerebral infarction without residual deficits, chronic respiratory failure with hypoxia, pulmonary fibrosis, chronic kidney disease, other mixed anxiety disorders, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a…

    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 · D2025-07-30 · tag F0604 — failed to not use physical restraints improperly — isolated
    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 1 (#16) of 1 residents reviewed for restraints. The facility failed to have documented evidence of releasing the lap tray every two hours for range of motion. Findings:Use of Restraint Policy dated April 2017Policy Interpretation and ImplementationPhysical Restraints are defined as any manual method or physical or mechanical device, material, or equipment 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.The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-30 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a thorough investigation was completed for an allegation of misappropriation of property/exploitation for 1 (#7) of 1 resident reviewed for personal funds.Findings:Review of the facility's undated Abuse and Neglect Prohibition revealed the following in part:Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Fundamental Information:Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Investigation:1. The facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state law.Review of Resident #11's record revealed an admission date of 02/27/2025 with diagnoses including chronic obstructive pulmonary disease, chronic cough, unsheltered homelessness, other seizures,…

    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 · D2025-07-30 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to notify the state-designated mental health disability authority promptly for a review when a resident with Mental Disorders or Intellectual Disorders experienced a change in mental or physical status for 1 (#7) of 2 (#7 and #8) residents reviewed for Pre-admission Screening and Resident Review (PASARR).Findings: Review of Resident #7's record revealed an admission date of 06/24/2025 with diagnoses including unspecified dementia mild with mood disturbance, bipolar disorder current episode depressed mild or moderate severity unspecified, panic disorder, insomnia due to other mental disorder, post-traumatic stress disorder acute, hypertension, tachycardia, hypothyroidism, personal history of other mental and behavioral disorders. Further review of the record revealed Resident #7 was admitted to the facility from an inpatient psych facility.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status…

    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 before2025-07-30 · 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 a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 (#89) of 2 (#63 & #89) sampled residents reviewed for mood/behavior. Findings: Review of the medical record for Resident #89 revealed an admission date of 10/21/2018 with diagnosis of Parkinson's disease, breast cancer, edema, transient ischemic attack, dementia, Post-Traumatic Stress Disorder (PTSD), major depressive disorder, and atrial fibrillation. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively aware and able to make daily decisions. Further review revealed Resident #89 needed maximal assistance with all activities of daily living. Review of section I…

    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 · D2025-07-30 · 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 and interview, the facility failed to ensure a resident was as free of accident hazards as is possible by failing to ensure an appropriate intervention was attempted for 1 (#71) of 8 (#2, #4, #9, #10, #18, #36, #71, #89) residents reviewed for accidents.Findings:Review of the medical record for Resident #71 revealed an admission date of 01/14/2025 with diagnoses that included vascular dementia, displaced fracture of middle phalanx of left middle finger, repeated falls, history of transient ischemic attack, and hypertension.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment with daily decision making. Resident #71 required substantial/maximal assistance with sit to lying, lying to sitting, and chair/bed-to-chair transfer. Additionally, the April MDS assessment documented the resident as always continent of bowel and bladder. Review of the in-service training…

    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 before2025-07-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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 observations, record review and interview, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 (#61) of 1 (#61) residents reviewed for respiratory care. The facility failed to ensure there was signage indicating oxygen in use was posted outside the entrance of Resident #61's room. Findings:Review of the facilities Oxygen Administration policy, revised date of October 2010, revealed in-part: Place an Oxygen in Use sign on the outside of the room entrance door.On 07/29/2025 at 07:52 a.m. an observation of Resident #61 revealed she was receiving oxygen at 4 liters per minute (LPM) via nasal cannula (NC). Further observation revealed there was no signage posted outside Resident #61's room indicating no smoking oxygen in use. Record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing,…

    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 · D2025-07-30 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for any active bleeding or bruising for a resident who received an anticoagulant for 1 (#1) 3 (#1, #61, #71) reviewed for general concerns.Findings:Review of the medical record for Resident #1 revealed an admission date of 06/25/2025 with diagnoses that included acute on chronic congestive heart failure, chronic pulmonary edema, atrial fibrillation and hypertension.Review of the Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated that Resident #1 was cognitively intact with daily decision making. The MDS indicated that the resident received an anticoagulant which is a high risk medication.Review of the current plan of care documented the resident's risk for abnormal bleeding related to anticoagulant therapy. The plan of care also indicated that Resident #71 should be monitored…

    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
Show the remaining 17 citations
  • Potential for harm · Ecited before2025-03-19 · 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

    Based on observation, review of the policy, and interviews, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an unlocked, open medication room that was not being monitored by licensed nursing staff. Findings: Review of facility's policy and procedure for Administering Medications (no date) revealed the following: Medications and biological are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Observation on 03/18/2025 at 5:02 a.m. revealed the medication room (medication room a) door was unlocked and propped open by a wooden board. No nursing staff were present in the nurse's station or medication room at this time. Interview on 03/18/2025 at 5:05 a.m. with S4 Certified Nursing Assistant (CNA) confirmed that the medication room door was unlocked and propped open and that no nurses were in the room or in view of the medication room. Interview on 03/18/2025 at 5:10 a.m.…

    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 · Ecited before2024-12-30 · tag F0729 — pattern
    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    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 that before allowing an individual to serve as a nurse aide, a facility must receive receive registry verification that the individual has met competency evaluation requirements for 1 Certified Nursing Assistant (S5CNA) of 3 (S5CNA, S6CNA, and S7CNA) personnel files reviewed. The facility allowed an employee to work as a CNA with an expired and out of State certification. Findings: Review of S5CNA's personnel file revealed his date of hire was on [DATE]. Further review revealed that S5CNA received his nurse aide certification in a different state from which he was currently empoyed. Review further revealed the certification had expired on [DATE]. On [DATE] at 8:15 a.m., an interview with S1Administrator confirmed that S5CNA did not have a current nurse aide certification in the state he was currently employed. On [DATE] at 9:53 a.m., an interview with S8CNA Supervisor confirmed that S5CNA had provided services to residents after his nurse aide…

    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 · D2024-12-30 · 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 observations, record reviews, and interviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (#1) of 2 (#1 and #2) resident records reviewed, by assessing that bed rails were not indicated for a resident who was identified as having bed rails in use. Findings: Review of the medical record revealed a recent admission date of 12/18/2024. The resident's diagnoses included in part vascular dementia, moderate with behavioral disturbance and a history of falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a brief interview for mental status score of 03 indicating the resident had severe cognitive impairment with his daily decision making skills. Observation on 12/23/2024 at 10:20 a.m. and 12/26/2024 at approximately 8:40 a.m. revealed resident #1 had ¼ bed rails, one intact to each side of the resident's bed frame. Both rails were upright and in a locked position. Review of the Bed Rail assessment dated [DATE] at…

    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 · D2024-12-30 · 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 observations, record reviews, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation for 2 (#1 and #2) of 2 (#1 and #2) residents reviewed for accident hazards. The facility failed to have documented evidence of an assessment for the risk of entrapment from bed rails for residents identified as having ¼ bed rails in use. Findings: Resident #1 Review of the medical record for resident #1 revealed a recent admission date of 12/18/2024. The resident's diagnoses included in part vascular dementia, moderate with behavioral disturbance and a history of falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 03 indicating the resident had severe cognitive impairment with his daily decision making skills. Observations on 12/23/2024 at 10:20 a.m. and 12/26/2024 at approximately 8:40 a.m. revealed resident ¼ bed rails, one intact to each…

    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 · E2024-08-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure nursing staff was competent in providing nursing and related services to assure resident safety and maintain resident's highest practicable physical, mental, and psychological well-being for each resident. The facility failed to ensure: 1) the Certified Nursing Assistants (CNAs) conducted a walk through round and provided a report on residents during shift change and 2) CNAs rounded on residents every 2 hours for 2 (#1, #2) of 3 (#1, #2, #3) sampled residents. Findings: Resident #1 Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included multiple myeloma not having achieved remission, personal history of Non-Hodgkin's lymphoma, adult failure to thrive, unspecified dementia unspecified severity without behavioral disturbance, depression, history of falling, and acute kidney failure unspecified. Review of Assessment Reference Date (ARD) Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief…

    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 · E2024-07-24 · 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 review and interview the facility failed to electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to Centers for Medicare and Medicaid (CMS) in a timely manner for 3 (#43,#48, and #94) of 3 (#43,#48, and #94) residents reviewed for the completion of a fourteen day discharge assessment. Findings: Record review revealed resident #43 was admitted to the facility on [DATE] and discharged on 04/01/2024. The last transmitted MDS assessment in the electronic health record was an admission assessment completed on 03/19/2024. Record review revealed resident #48 was admitted to the facility on [DATE] and discharged on 04/27/2024. The last transmitted MDS assessment in the electronic health record was an admission assessment completed on 03/05/2024. Record review revealed resident # 94 was admitted to the facility on [DATE] and discharged on 04/05/2024. The last transmitted MDS assessment in the electronic health record was a quarterly assessment completed on 03/06/2024. On…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-24 · 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

    Based on observation, record review, and interview the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#66) of 1 (#66) residents identified with a skin rash. Findings: On 07/22/2024 at 10:48 a.m., observation of resident #66 revealed a dark patchy red rash to the face, back and arms. Interview at that time with resident #66 revealed she did not know the cause of the rash. On 07/24/2024 review of the record for resident #66 revealed diagnoses in part of dermatitis, arthritis, stage 3 chronic kidney disease, mild cognitive impairment and atrial fibrillation. Further review of the record revealed resident #66 had allergies to sulfonamide antibiotics. Review of the record also revealed the initial treatment for the rash began on 06/07/2024 with an order for hydrocortisone 1% ointment apply to areas on the face twice a day (BID) for 10 days- avoid the eyes and for Claritin 10 milligrams (mg) by mouth (po) one time a day for 10 days. Further review of the record revealed the following orders for resident #66's rash: 07/01/2024 Benadryl 25mg every…

    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 before2024-07-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#25, #71) of 2 (#25, #71) sampled residents reviewed for respiratory care. The facility failed to ensure: 1) a resident's oxygen (O2) was administered as ordered, the O2 tubing was dated, and the nebulizer was dated/stored properly (#25); and 2) a resident's O2 concentrator was clean (#71). Findings: Review of the facility Oxygen Administration (Concentrator or Tank) Policy (no date noted) revealed in part: Humidifier bottles, cannulas and O2 tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. Resident #25 On 07/23/2024 at 2:11 p.m., review of the record for resident #25 revealed diagnoses in part of hypothyroidism, vascular dementia, atrial fibrillation, major depressive disorder, chronic obstructive pulmonary disease, chronic viral hepatitis C, and sleep apnea. Review of 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 date of correction
  • Potential for harm · Ecited before2024-07-24 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure that the pharmacist reported any irregularities to the physician and director of nursing for 1 (#15) of 5 (#15, #23, #37, #51, #59) residents reviewed for unnecessary medications. The pharmacist failed to identify that resident #15 was receiving as needed (prn) doses of the psychotropic medication clonazepam beyond 14 days without a documented rationale and duration date for administration. Findings: Record review revealed resident #15 was admitted to the facility 02/09/2019 with diagnoses that included Alzheimer's disease, unspecified dementia, major depressive disorder, essential hypertension, insomnia, anxiety disorder, psychiatric disorder with delusions due to known physiological condition, and Tourette's disorder. Review of the active July 2024 physician orders revealed an order dated 05/23/2024 for clonazepam 0.5 milligram (mg) tablet give one tablet by mouth every day prn for agitation. Further review revealed there was no evidence of a…

    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 · E2024-07-24 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that each resident was free from unnecessary medication use for 1 (#15) of 5 (#15, #23, #37, #51, #59) residents reviewed for unnecessary medications. The facility failed to have a documented rationale in the resident's medical record to indicate the duration of an as needed (prn) psychotropic medication to be extended beyond 14 days of use for resident #15 who received the prn medication clonazepam. Findings: Record review revealed resident #15 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia, major depressive disorder, essential hypertension, insomnia, anxiety disorder, psychiatric disorder with delusions due to known physiological condition, and Tourette's disorder. Review of the active July 2024 physician orders revealed an order dated 05/23/2024 for clonazepam 0.5 milligram(mg) tablet give one tablet by mouth every day prn for agitation. Further review revealed there was no…

    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 · Ecited before2024-05-16 · tag F0729 — pattern
    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    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 the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 4 (S3CNA, S8CNA, S10CNA, and S11CNA) of 5 (S3CNA, S8CNA, S10CNA, S11CNA and S12CNA) personnel files reviewed. Findings: Review of S3CNA's personnel file revealed a hire date of 03/20/2024. Further review of S3CNA's personnel file revealed there was a State Adverse Action check upon hire. Further review of the personnel file revealed there was no documented evidence of State Adverse Action checks obtained monthly. Review of S8CNA's personnel file revealed a hire date of 05/15/2023. Further review of S8CNA's personnel file revealed there was a State Adverse Action check upon hire. Further review of the personnel file revealed there was no documented evidence of State Adverse Action checks obtained monthly. Review of S10CNA's personnel file revealed a hire date of 02/28/2024. Further review of S10CNA's personnel file revealed there was a State Adverse Action check upon hire. Further review of the personnel file…

    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 · E2024-05-16 · tag F0836 — pattern
    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 — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to ensure it was in compliance with state laws by failing to obtain criminal history checks upon hire for 1 (S8Certified Nursing Assistant) (CNA) of 5 (S3CNA, S8CNA, S10CNA, S11CNA and S12CNA) personnel files reviewed. Findings: The current Long Term Minimum Licensing Standards, statute 9759 A. states the nursing facility shall have statewide criminal history checks performed on non-licensed personnel to include CNAs. Review of the personnel file for S8CNA revealed a hire date of 05/15/2023. Further review of S8CNA's personnel file revealed no documented evidence of a criminal history check obtained upon hire. On 05/15/2024 at 3:20 p.m., an interview with S9Clerical confirmed there was no documented evidence of a criminal history background check obtained upon hire for S8CNA.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · 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 all alleged violations involving abuse, neglect, exploitation or mistreatment witnessed by staff are reported immediately to their supervisor or the Director of Nursing for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. Findings: Review of the facility's policy and procedure for Recognizing Signs and Symptoms of Abuse/Neglect with a revised date of January 2011 revealed: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing (DON) Services immediately. Review of the medical record for resident #1 revealed diagnoses of Alzheimer's disease, depression, Tourette's, lumbago with sciatica, osteoporosis, dementia, reflux, anxiety, and psychotic disorder. Review of the current care plan for resident #1 revealed impaired cognitive short and long term memory loss related to the diagnosis…

    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 · Dcited before2024-05-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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 have documented evidence that allegations of verbal abuse were thoroughly investigated for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Investigations policy dated April 2014 revealed: All reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigation by facility management; 3. The individual conducting the investigation will, at a minimum: c. Interview the person (s) reporting the incident; d. Interview any witnesses to the incident; 5. Witness reports will be obtained in writing. Either the staff member will write his/her statement and sign and date it, or the investigator may obtain the staff statement, read it back to the member and have him/her sign and date it. Review of the medical record for resident #1 revealed diagnoses of Alzheimer's disease, depression, Tourette's, lumbago with sciatica, osteoporosis, dementia, reflux, anxiety,…

    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 · E2023-08-02 · tag F0658 — failed to meet professional standards of care — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (#3) of 5 (#1, 2, 3, 4, 5) residents reviewed. The facility failed to ensure resident #3's Calcium-D3 was administered as ordered. Findings: Review of the record for resident #3 revealed diagnoses including type 2 diabetes mellitus, congestive heart failure, vascular dementia, chronic kidney disease stage 5, renal dialysis, paroxysmal atrial fibrillation, and hyperparathyroidism. Review of resident #3's Quarterly Minimal Data Set (MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to compete the interview. Further review revealed she required extensive to total dependence on staff for all activities of daily living. Review of resident #3's June 2023 physician orders revealed an order dated 06/02/2023 for Calcium (Ca) 600 milligrams (mg) -D3 10 micrograms (mcg) 1 by mouth twice daily…

    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 before2023-08-02 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 the pharmacist must report any irregularities to the attending physician, the facility's medical director, and the director of nursing and these reports must be acted upon for 1 (#3) of 5 (#1, 2, 3, 4, 5) residents reviewed. The pharmacist failed to identify that resident #3's Calcium-D3 was not administered as ordered. Findings: Review of the record for resident #3 revealed diagnoses including type 2 diabetes mellitus, congestive heart failure, vascular dementia, chronic kidney disease stage 5, renal dialysis, paroxysmal atrial fibrillation, and hyperparathyroidism. Review of resident #3's Quarterly Minimal Data Set (MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to compete the interview. Further review revealed she required extensive to total dependence on staff for all activities of daily living. Review of resident #3's June 2023 physician 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-22 · 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

    Based on observation and interviews the facility failed to ensure expired medications were not available for use and administered to residents as evidenced by expired medications being stored in the facility's 2 of 2 medication rooms. This deficient practice had the potential to affect any of the facility's 92 residents as listed on the Resident Census and Condition of Residents Report. Findings: Review of the facility's policy titled, Medication Storage in the Facility revealed the following, in part: Policy: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Procedure: 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists. On 06/22/2023 08:40 a.m. S8RN…

    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

“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.

Who owns this facility

Owner / managerTypeRoleShareSince
JEFFREY M ASHBROOK TESTAMENTARY TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST25%since 01/01/2018
RONALD ANTHONY GOUX ESTATEOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 12/29/2020
ASHBROOK, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL26%since 01/01/2011
GOUX, LYNETTEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 01/01/2011
LANDRY, ROBERTIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/08/2024
GOUX, JEREMYIndividualCORPORATE OFFICER; ADP OF THE SNFsince 07/08/2008
ROUNSAVILLE, REBECCAIndividualCORPORATE OFFICERsince 07/08/2008
MAISON HEALTHCARE MANAGEMENT COMPANY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
CASTO, CORTLANDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/07/2023
KRIER, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2013
GOUX, TIMOTHYIndividualADP OF THE SNFsince 01/01/2018

CMS files one row per role, so the 20 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$9.3M
Net patient revenuemost recent cost report
-0.2%
Operating marginrevenue minus expenses
$1.8M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 58%Medicare 25%Other / private 18%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$262per resident / day
operating cost
$7,962per month
≈ monthly operating cost
$261per 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 195551. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-30, 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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