Zachary Manor Nursing and Rehabilitation Center
6161 Main Street, Zachary, LA 70791 · For profit - Corporation · 110 certified beds · (225) 654-6893 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 23% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.8% | 17.8% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.4% | 5.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 1.9% | 1.2% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.0% | 2.1% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 2.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.6% | 3.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 22.0% | 17.9% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.2% | 23.2% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 94.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 10.7% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.5% | 22.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 3.1% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 75.3% | 76.3% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.7% | 28.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 4.6% | 14.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.59 | 2.56 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.43 | 2.74 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.9% 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 21 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.7%CMS range 34.2–63.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.5–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 42.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 38.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 96.8% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 3.2–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 110 beds and averages 70.7 residents a day — about 64% occupied, or roughly 39 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.49 hrs/resident/day on weekends vs 4.18 on weekdays — 16% thinner on weekends. RN hours go from 0.47 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.
- Potential for harm · Dcited before2026-03-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement a person centered care plan by failing to ensure nursing staff followed the physician's order to notify the MD of an elevated blood glucose level for 1 (#2) of 3 residents reviewed with Type 2 Diabetes Mellitus.Findings: Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Other Hypoglycemia, Unspecified Severe Protein-Calorie Malnutrition, and Long-Term Use of Insulin. Review of Resident #2's Quarterly MDS with an ARD of 01/03/2026 revealed a BIMS assessment was not conducted related to the resident was rarely/never understood. Review of Resident #2's current Care Plan revealed the following, in part:Problem: MD orders - need to follow; andInterventions: Humalog KwikPen Subcutaneous Solution 100 unit/mL (Insulin Lispro).Problem: The resident has Diabetes Mellitus; andInterventions: Diabetes medication as ordered by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents' Medication Administration Record (MAR) were accurately documented for 2 (#3 and #4) of 4 sampled residents reviewed for accurate documentation. Review of the facility's undated policy titled Insulin Guidelines revealed the following, in part: Policy: Insulin is utilized to control blood sugar levels in residents with diabetes mellitus. Insulin therapy may include various regimens, which are carried out per doctor's orders. Insulin lowers the blood glucose by decreasing the release of glucose from the liver and increasing the utilization of glucose by muscle and fat cells.Guidelines: Whenever a physician orders Regular insulin on a sliding scale, care must be taken to document finger stick blood sugar and administration of insulin as ordered. Charting on MAR and/or nurses' notes should include the following:a. Date, time, and results of finger stick blood sugar testingb. Dose of insulin administration in accordance with sliding scale…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-02-11 · tag F0641 — patternEnsure 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 interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#37 and #71) out of 28 residents in the final sample. The facility failed to ensure Resident #37 and #71 were coded accurately on the Entry Minimum Data Set (MDS) assessment. Resident #37 Review of Resident #37's Clinical Record revealed she was admitted to the facility on [DATE] with diagnosis which included Schizoaffective Disorder, Bipolar Type, Dementia Psychotic Disturbance, Catatonic Disorder Depressive Disorders, and Mental Disorder. Review of Resident #37's Entry MDS with an ARD of 04/17/2025 revealed the following, in part: Section A1500 Preadmission Screen and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have a serious mental illness and or intellectual disability or a related condition was coded as no. Review of Resident #37's Behavioral Health State Form 142 with a date of 03/18/2025 revealed Resident #37 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 1 (#76) of 29 residents reviewed during the initial pool.Findings: Review of the facility's policy titled, Call Light Systems, undated, revealed the following, in part:Policy: To respond to resident's request and needs. Essential Points: Unless indicated in the care plan, each resident, when in their room or in bed, must have the call light placed within reach at all times. when out of bed, call bell is to be pulled so it is accessible from wheelchair or bedside chair. Review of Resident #76's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unsteadiness On Feet, Parkinson's Disease, and Primary Generalized Osteoarthritis. Review of Resident #76's Entry MDS, with an ARD of 01/28/2026, indicated the resident was assessed by the facility and required substantial assistance for transfers. Review of Resident #76's current Care Plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to protect each residents' right to be free from verbal abuse for 1 (#33) of 29 residents reviewed for abuse in the initial pool. The facility failed to protect Resident #33 from verbal abuse by Resident #11.Findings: Review of facility's policy titled Abuse-Neglect Prevention Manual with a revision date of 04/03/2025 revealed the following:II. Policy: It is the policy of the facility that each resident will be free from abuse.Each resident residing in this facility has the right to be free from verbal abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents.Definitions:Verbal abuse is defined as the use of oral, written, or gestured communication, or sounds to residents within hearing distance, regardless of their age, ability to comprehend, or disability. Resident #33 Review of Resident #33's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to report allegations of physical and verbal abuse to the State Survey Agency immediately, but no later than 2 hours, for 1 (#33) of 29 residents reviewed for abuse in the initial pool. Findings: Review of facility's policy titled Abuse-Neglect Prevention Manual with a revision date of 04/03/2025 revealed the following:6. Reporting and Response: it is the policy of the facility that abuse allegations are reported per Federal and State Law. Reports are to be no later than 2 hours to health standards if the incident or allegation involves abuse with or without serious bodily harm.Definitions:Verbal abuse is defined as the use of oral, written, or gestured communication, or sounds to residents within hearing distance, regardless of their age, ability to comprehend, or disability. Physical Abuse includes hitting, slapping, pinching, biting, and kicking. B. Alleged Violation: is the terminology used when a verbal allegation of resident abuse. has been made…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#24) of 2 residents reviewed for ADL's. The facility failed to trim and clean Resident #24's fingernails.Findings: Review of the facility's undated policy, Nail Management, revealed the following, in part:Policy: Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails.It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Non diabetic residents may have nail care performed by Certified Nursing Assistants (CNA). Review of Resident #24's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Muscle Wasting and Atrophy of Right and Left Shoulder and Need for Assistance with Personal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#68) of 5 residents reviewed on Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing direct care for Resident #68 who was on EBP.Findings: Review of the facility's policy titled, Enhanced Barrier Precautions Policy and Procedure, dated 08/12/2024, revealed the following, in part: Definitions: Precautions involve gown and glove use during high contact resident care activities for residents.at increased risk of multi drug resistant organism acquisition (for example residents with wounds or indwelling medical devices.)High-contact resident activities include:Device care or use: feeding tubeCare and use of indwelling medical devices would mean any dressing changes, injecting or infusing medication or tube feedings with indwelling medical device. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-08 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to have sufficient Certified Nursing Assistant (CNA) staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the facility assessment. This deficiency had the potential to affect the facility's total census of 68 residents. Findings: Review of the facility's Minimum Staffing Requirements assessment revealed the following: Hall A Days: 1-2 CNA Evenings: 1 CNA Nights: 1 CNA Hall B Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Hall C Days: 2 CNA Evenings: 2 CNA Nights: 1 CNA Review of the facility's Staffing Pattern dated 03/04/2025 revealed the following: Staff assigned: Day shift - 7 CNA; Evening shift- 2-CNA; Night shift- 2 CNA On 04/06/2025 at 9:16 a.m. an interview was conducted with S8CNA. She revealed the facility was often short staffed. She further stated it was most often Hall B and Hall C that was short staffed. On 04/06/2025 at 9:35 a.m. an interview was conducted with S7CNA. She revealed the facility was often short…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident's call light was within reach for 1 (#R1) of 7 (#1, #2, #3, #4, #5, #6, and #R1 ) residents reviewed. Findings: A review of the facility's undated policy titled Call Light System, revealed, in part: Unless indicated in the care plan, each resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of resident ability to use it. A review of the medical record for Resident #R1 revealed she was admitted to the facility on [DATE] with diagnoses which included, Muscle Wasting and Atrophy right shoulder, Chronic Pain Syndrome, Unsteadiness on feet, History of falling, Dementia, Lack of Coordination, and Alzheimer's Disease. A review of the current Care Plan for Resident #R1 revealed the resident was at risk for falls related to Gait/balance problems. Interventions included encourage resident to call for assist. On 04/06/2025 at 8:51 a.m., an observation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · F2025-01-08 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect any of the 67 residents residing in the facility. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2024 Quarter 4 (July 1- September 30) revealed the following: -One star staffing rating, triggered. -Excessively low weekend staffing, triggered. -No Registered Nurse hours, triggered. -Failed to have licensed nursing coverage 24 hours/day, triggered. An interview was conducted on 01/08/2025 at 10:40 a.m. with S10CHR. She stated she was responsible for submitting payroll data to a contract company who was hired to submit the facility's payroll data. She stated on 01/08/2025, the contract company identified inaccurately submitted September 2024 payroll data for direct care staffing. She stated all quarters for payroll data submission for direct care staffing should be complete and accurate. An interview was conducted on 01/08/2025 at 10:52 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.
- Potential for harm · Ecited before2025-01-08 · tag F0641 — patternEnsure 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 interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#12, #54 and #66) residents out of a total of 21 sampled residents. The facility failed to ensure: 1. Resident #12 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #54 was coded correctly for vision; and 3. Resident #66 was coded correctly for discharge. Findings: Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #12's OBH-Level II Evaluation Summary & Determination Notice dated 08/02/2024 revealed under recommendations: The individual has a serious mental illness and nursing home admission was recommended. Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024 revealed Section A1500 PASRR: Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure a resident's plan of care was revised by failing to update vision interventions for 1 (#54) of 19 residents reviewed in the final sample for Care Plans. Findings: Review of Resident #54's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Legally Blind. Review of Resident #54's Quarterly MDS, with ARD of 12/09/2024, revealed a BIMS of 12, which indicated she was moderately cognitive impaired. Further review revealed Section B: Hearing, Speech, and Vision, line B100-Vision was coded as Adequate, and Corrective Lenses was coded as No. Review of Resident #54's Care Plan dated 12/22/2023 revealed: Care Plan Description: Visual deficit related to Blindness to Bilateral Eyes Interventions: Assist resident to maintain eyeglasses. Encourage to wear glasses. Ensure adequate lighting for tasks. Keep eyeglasses within reach. Keep pathways clear. Provide assistance with ambulation as needed. On 01/08/2025 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.
- Potential for harm · D2025-01-08 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, interviews, and record review, the facility failed to ensure there was a system in place for facility residents to receive routine dental care by an outside dentist as requested for 1 of 1 (#16) resident reviewed for dental services. This deficient practice had the potential to affect any of the 67 residents residing in the facility. Findings: A review of Resident #16's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Mild Protein-Calorie Malnutrition. A review of Resident #16's Quarterly MDS with an ARD of 12/26/2024 revealed he had a BIMS of 11, which indicated he was moderate cognitively impaired. A review of the In House Facility Dental notes revealed the following: 05/29/2024 Resident #16 refused dental services today. Resident #16 told S11MR he only wants to see an outside dentist. 08/29/2024 Resident #16 refused dental services today. On 01/07/2025 at 2:25 p.m., an observation and interview was conducted with Resident #16. He was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#14 and #65 ) of 2 (#14 and #65 ) residents reviewed for accurate documentation. The facility failed to ensure: 1. The medical record of Resident #65 contained accurate documentation of Coroner Notification with Permission to Release the Body; and 2. The medical record of Resident #14 contained a documented nurse assessment upon return from dialysis. This deficient practice had the potential to affect a current census of 67 residents. Findings: Review of the facility's undated policy, titled Documentation Guidelines: General, revealed the following: Nursing Service documentation will include, but shall not be limited to the following: 4. Baseline data such as weight, vital signs, etc. 5. Follow up care of resident's incidents and accidents Documentation in the nursing record will be made when a change in resident condition occurs. This includes all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of infection for 1 (#167) of 19 resident's reviewed in the final sample. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment (PPE) while providing catheter care; and 2. Staff performed proper hand hygiene while providing catheter care. Findings: Review of Resident #167's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Urinary Tract Infection. Review of Resident #167's current Physician Orders revealed the following, in part: Enhanced Barrier Precautions utilized when performing high-contact resident care activities related to Urinary Catheter; and Catheter care with soap and water. One time every shift. On 01/07/2025 at 9:20 a.m., an observation of the Enhanced Barrier Precautions sign posted on Resident #167's door revealed the following, in part: Providers and Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview, the provider failed to ensure the care plan was implemented for 1 ( #2) of 3 (#1, #2, and #3) residents sampled for ADL care had incontinence care provided with the required amount of staff assistance. Findings: Review of the document titled CNA Skill Acknowledgement of Resident Wall Care Plan Sheet and Turning Schedule revealed the following, in part: Resident Wall Care Plan Sheets and Turning Schedules are used by this facility to relay important individualized information about the residents to the CNA caring for that person. Each resident should have a Resident Wall Care Plan Sheet located in their room either above the bed, on the bulletin board or in another prominent location easily seen by direct care staff . The Resident Wall Care Plan Sheet should include information including but not limited to: Transfer status (including use of lift (type) and size of sling, if lift is used) . It is the responsibility of the CNA to read and follow the wall care plan instructions to care for each resident. Review of the undated policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure residents remained free of accident hazards by failing to ensure residents were transferred with proper transfer assistance and devices for 2 (#2 and #3) of 3 (#1, #2, and #3) residents reviewed for transfer assistance. The facility failed to ensure: 1. Resident #2 was transferred with 2 person assistance; and 2. Resident #3 was transferred with a mechanical lift. Findings: Review of the document titled CNA Skill Acknowledgement of Resident Wall Care Plan Sheet and Turning Schedule revealed the following, in part: Resident Wall Care Plan Sheets and Turning Schedules are used by this facility to relay important individualized information about the residents to the CNA caring for that person. Each resident should have a Resident Wall Care Plan Sheet located in their room either above the bed, on the bulletin board or in another prominent location easily seen by direct care staff. The Resident Wall Care Plan Sheet should include information including but not limited to: Transfer status (including use of lift (type)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure the oxygen tubing and humidification bottles were properly labeled for 3 (#23, #266, and #267) of 3 (#23, #266, and #267) residents reviewed for oxygen therapy. Findings: Resident #23 Review of the Clinical Record for Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses which included Shortness of Breath. Review of Resident #23's Quarterly MDS with an ARD of 11/08/2023 revealed she had a BIMS of 10, which indicated she had moderate cognitive impairment. Further review revealed she received oxygen therapy. Review of the current Physician Orders for Resident #23 revealed the following, in part: Start date: 03/06/2022 Oxygen at 2 Liters via nasal cannula continuously Start date: 11/01/2022 Change 02 tubing/humidifier bottle and clean filter q week on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-21 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was properly sealed and dated after opening; and 2. Dietary staff wore a hair restraint while the kitchen. There were a total of 56 out of 60 facility residents who were provided meals and beverages from the facility's kitchen. Findings: 1. Review of the facility's Appearance and Dress Code Policy revealed, in part, the following: Each employee will be expected to adhere to the dress code established by this facility. Dietary Personnel must wear a hairnet large enough to cover all the hair. On 02/19/2024 at 8:35 a.m., an initial tour of the facility's kitchen was conducted with the following observations made within the facility's refrigerator: -1 package of deli sliced white American cheese opened and undated; and -1 package of deli sliced cheddar American cheese opened, undated, and unsealed. On 02/19/2024 at 8:40 a.m., an interview was conducted with S3PM. She verified the above observations and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-21 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
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 resident rights by failing to initiate resident grievances received during monthly resident council meetings for 1 (#53) of 8 (#31, #46, #51, #52, #53, #58, #61, and #62) residents present for the resident council meeting. Findings: Review of the facility's policy titled Resident Council revealed, in part, the following: Policy: It is the policy of this facility that a Resident Council be supported by the administration. Procedure: 7. Written follow-up to resident concerns identified at each meeting will be identified in writing regardless of whether or not the issue is resolved. 9. Minutes of the Meetings: a. Documentation of meetings, findings and recommendations shall be maintained by the committee and are to be filed in the Administrator's office. c. Minutes of Meetings shall contain at least the following information: 4. Findings, recommendation and corrective action taken. 10. Responsibilities: h. Maintaining minutes of all meetings and submitting a copy to the Administrator for his/her review. 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.
- No harm found · Bcited before2024-02-21 · tag F0641 — patternEnsure 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 interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#14) of 4 (#14, #22, #28, and #35) residents reviewed for falls. Findings: Review of Resident #14's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Lack of Coordination and Unsteadiness on Feet. Review of Resident #14's Quarterly MDS with an ARD of 01/22/2024 revealed a BIMS of 4, which indicated she was severely cognitively impaired. Further review revealed the following: Section J-Health Conditions: Fall since admit/reentry/prior asmt: any falls - 0. No; and Falls since admit/reentry/prior asmt: no injury- Blank. Review of the Facility's Incident Log revealed Resident #14 had falls on 12/27/2023 and 12/28/2023. On 02/20/2024 at 1:38 p.m., an interview was conducted with S4MDS. She stated she was responsible for completing Resident #14's MDS assessments. She verified Resident #14 was not coded for falls on the last…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CENTRAL MANAGEMENT COMPANY — 21 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.6 | +0.4 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 4 of 5 | 3.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 2.4 | +0.6 vs chain |
The other 20 homes this chain runs (chain average 2.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| KISTACHIE HEALTH, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 52% | since 01/01/2005 |
| PRICO, INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 48% | since 01/01/2005 |
| MAUMALANGA, HOLLY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 6% | since 03/31/2025 |
| ZIMMERMAN, FREDA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 12% | since 03/31/2025 |
| CENTRAL MANAGEMENT COMPANY, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2005 |
| PRICE, TEDDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | — | since 03/01/2025 |
| BOLWAHNN, SHEILA | Individual | ADP OF THE SNF | — | since 12/01/2008 |
| CANTRELL, JEFFREY LEE | Individual | ADP OF THE SNF | — | since 10/01/2013 |
| ROGERS, DAWN | Individual | ADP OF THE SNF | — | since 01/01/2005 |
| SHELTON, JAMES | Individual | ADP OF THE SNF | — | since 01/01/2005 |
CMS files one row per role, so the 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in LA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Louisiana Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 195362. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.