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Lakeview Nursing Center

16411 Robinson Road, Gulfport, MS 39503 · For profit - Corporation · 105 certified beds · (228) 831-3001 Medicare & Medicaid certified

Call the home — (228) 831-3001 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations$12,183 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $12,183 in federal fines (most recent 2024-02-28)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Urgent care / clinic
12261 Highway 49 N, Suite 11 · (228) 867-5185 · Call to confirm hours
Pharmacy
12261 US-49 · (228) 284-1450 · Call to confirm hours
Grocery
12057 US-49 · (228) 831-8187 · Call to confirm hours
Park
17481 Orange Grove Rd · (228) 832-2828 · Typically dawn to dusk
Place of worship
16148 Robinson Rd · (228) 832-7907

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 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.

Overall rating3★
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 increased17.3%20.5%15.4%worse
Long-stay residents who lose too much weight7.9%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.5%1.4%0.9%worse
Long-stay residents with a urinary tract infection0.7%2.5%2.0%better
Long-stay residents with depressive symptoms0.0%1.6%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.2%3.1%3.3%worse
Long-stay residents whose ability to walk worsened17.9%19.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.9%23.8%18.9%better
Long-stay residents given the seasonal flu vaccine96.4%97.0%95.3%typical
Long-stay residents with pressure ulcers5.3%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control24.6%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.2%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.5%1.4%better
Short-stay residents given the seasonal flu vaccine94.7%84.6%79.4%better
Short-stay residents rehospitalized after admission28.4%27.7%22.6%worse
Short-stay residents with an outpatient ER visit22.1%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.902.431.67worse
Long-stay outpatient ER visits per 1,000 resident days4.452.861.80worse

* 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.

§ 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.

37.8% 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 95 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.8%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
61.8%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 61.8% 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 34 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 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF37.8%CMS range 27.9–51.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 6.7–16.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.8%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 discharge38.2%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 discharge58.8%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 identified72.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%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 hospitalization8.9%CMS range 5.5–13.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 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

0.58
RN hours/ resident / day
1.54
LPN hours/ resident / day
2.05
Aide hours/ resident / day
4.16
Total nurse hours/ resident / day
0.43
RN hoursweekends
56.9%
Total nursing turnover
13.3%
RN turnover

How full it usually is: this home is certified for 105 beds and averages 76.1 residents a day — about 72% occupied, or roughly 29 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.16 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 3.43 hrs/resident/day on weekends vs 4.46 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% 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

3
deficiencies at the latest standard inspection (2025-09-18)
8
at the previous standard inspection (2025-04-02)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · Gcited before2024-02-28 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews, and facility policy reviews, the facility failed to implement care plan approaches related to prohibiting the use of oxygen in the smoking area for one (1) of four (4) sampled resident's care plans. Resident #1. Findings Include: Record review of the facility's Comprehensive Care Plans policy date implemented 4/3/20, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . A record review of the Care Plan with a problem onset date of 11/6/23 revealed Problem/Need: SMOKING I am a smoker and requires supervision .Approaches .Supervise all smoking .Prohibition of oxygen use in the smoking area . A record review of the facility investigation revealed on 2/21/24, the Activities Director (AD) was assisting with the smoke break at the facility with her back turned and heard a popping/clicking sound. Upon turning, she observed sparks coming from Resident #1's nasal cannula. She immediately removed the cannula and turned his oxygen off. Record review of the Physician Orders for…

    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
  • Actual harm · Gcited before2024-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and facility policy review, the facility failed to provide a safe smoking environment when the facility staff did not remove an oxygen (O2) canister from Resident #1 prior to entering the smoking area and did not secure a cigarette lighter to prevent Resident #1 from lighting a cigarette. This failure resulted in Resident #1 receiving burns to his face. This was for one (1) of three (3) sampled residents reviewed for smoking. Findings Include: Review of the facility's policy, Accidents and Supervision, dated 12/9/2020, revealed, Policy: The resident environment will remain as free of accident hazards as is possible .This includes .3. Implementing interventions to reduce hazard(s) and risk(s) . Policy Explanation and Compliance Guidelines .3. Implementation of Interventions .i. Resident-directed approaches may include .supervising .residents . Review of the facility's policy, Resident Smoking, Smokeless Tobacco, and Vaping Policy, dated 3/29/22, revealed, Policy: This facility provides a safe and healthy environment for residents,…

    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 before2025-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and facility policy review, the facility failed to ensure oxygen cautionary signage was posted on a resident's door for one (1) of 20 sampled residents (Resident #59).Findings include:A review of the facility's policy, Oxygen Administration, dated 7/24/23, revealed, .Oxygen is administered to residents who need it, consistent with professional standards of practice.Policy Explanation and Compliance Guidelines.6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use.On 9/15/25 at 12:05 PM, an observation revealed no oxygen signage was posted on the door of Resident #59, where an oxygen concentrator was noted inside the room.On 9/16/25 at 9:00 AM, during an observation and interview, Resident #59 was observed with an oxygen concentrator in his room and there was no cautionary signage on the door. The resident stated he uses the oxygen sometimes, particularly after dialysis, when he feels tired. On 9/16/25 at 1:45 PM, during an interview with Licensed Practical Nurse (LPN) #1, she stated that…

    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 before2025-09-18 · tag F0761 — failed to label and store drugs safely — isolated
    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, interviews, record review, and facility policy review, the facility failed to ensure medications were stored securely and in accordance with professional standards of practice by allowing a resident to have medications stored at the bedside without an assessment for safe self-administration, for one (1) of 20 sampled residents. Resident #86Findings include:A review of the facility's policy, Resident Self-Administration of Medication, dated 8/2024, revealed, .Policy Explanation and Compliance Guidelines.7. Bedside medication storage is permitted only when it does not present a risk to confused residents.The following conditions are met for bedside storage to occur- a. The manner of storage prevents access by other residents.8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage.On 9/15/25 at 2:45 PM, during an observation, Resident #86 had eye drops in the room on the overbed table in plain view.On 9/16/25 at 9:00 AM, during an observation, Resident #86 had two (2) small…

    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 · D2025-09-18 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to provide residents with an alternative meal choice of equal nutritive value for one (1) of 22 sampled residents (Resident #62).Findings included:On 9/17/25 at 11:00 AM, during an observation, the posted menu consisted of barbecue chicken, baked beans, and mixed vegetables, with no alternative entree listed.On 9/17/25 at 11:30 AM, during an observation and interview with the Dietary Manager (DM), there was no alternative entree or vegetables on the steam table. The DM stated that residents were provided with a Between Meal dining sheet, which included choices of hamburger with chips, grilled cheese with chips, cream of chicken soup with crackers, chicken noodle soup with crackers, peanut butter and jelly sandwich, or deli sandwich. She further explained that salad and chicken tenders were also available but verified the facility did not prepare any readily available alternative entrees. She stated residents requested an item from the Between Meal menu, and staff submitted the request using the sheet.On 9/17/25…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-02 · 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

    Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, homelike environment for two (2) of four (4) days of survey. Findings included: A review of the facility's policy titled, Safe and Homelike Environment, revised 07/24/2023, revealed, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . Policy Explanation and Compliance Guidelines: . 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment . A review of the facility's document related to Housekeeping, undated, revealed, . Duties and Responsibilities: Ensures the provision of a clean environment for our residents and staff, providing high quality services and high standards of cleanliness .Functions .2. Ensures that daily and deep cleaning schedules are adhered to .14. Clean floors, to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfecting .22. Moves furniture and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-02 · 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, interview, record review, and facility policy review, the facility failed to implement a care-planned intervention related to falls for one (1) of eighteen (18) sampled residents. Resident #13. Findings included: A review of the facility's policy, Comprehensive Care Plans, dated 3/5/2025, revealed, .It is the policy of this facility to . implement a comprehensive person-centered care plan for each resident . that includes measurable objectives .and meet professional standards of quality .Policy Explanation and Compliance Guidelines .8. Qualified staff responsible for carrying out interventions specified in the care plan will be of their roles and responsibilities for carrying out the interventions, initially and when changes are made . During an observation on 03/30/25 at 11:16 AM, Resident #13 was lying in bed with a fall mat folded at the head of the bed and not unfolded on the floor positioned in a way to prevent injury in the event the resident fell from the bed. During an observation and interview on 04/01/25 at 11:01 AM, Licensed Practical Nurse (LPN) #1…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-02 · tag F0851 — pattern
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day. Findings included: A record review of the Payroll Based Journal (PBJ) Staffing Data Report for the fourth (4th) quarter (July 1-September 30, 2024) revealed the facility triggered for Excessively Low Weekend Staffing, No RN Hours, and Failed to Have Licensed Nursing Coverage 24 Hours/Day. Further review revealed the Infraction Dates for No RN Hours and Failure to Have Licensed Nursing Coverage 24 Hours/Day were 7/6, 7/7, 7/13, and 7/14 of 2024. A record review of the Staffing Grid completed by the Director of Nursing (DON) revealed the facility had RN and nursing coverage on 7/6/24, 7/7/24, 7/13/24 and 7/14/24. On 03/31/25 at 1:30 PM, during an interview with the Administrator,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-02 · tag F0646 — isolated
    Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
    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, record review, and facility policy review, the facility failed to complete a Change in Status Form to generate a request for a Preadmission Screening and Resident Review (PASRR) Level Two (II) Assessment, for a resident with a mental status change, for one (1) of 18 residents reviewed for PASRR. Resident #37. Findings include: A record review of the facility's policy Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, dated 01/10/25 revealed .This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . Policy Explanation and Guidelines .9. Any residents who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state…

    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 before2025-04-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident environment remained free of accident hazards when a fall mat intended to prevent injury during falls was not properly placed for one (1) of three (3) residents reviewed for accidents/hazards, Resident #13. Findings included: A review of the facility's policy titled Accidents and Supervision, dated 2/19/2019 and revised 12/9/2020, revealed, .The resident environment will remain free of accidents hazards as is possible .this includes .3. Implementing interventions to reduce hazard(s) and risk(s) . On 03/30/25 at 11:16 AM, during an observation, Resident #13 was lying in bed with a fall mat folded at the head of the bed and not unfolded on the floor positioned in a way to prevent injury in the event the resident fell from the bed. On 04/01/25 at 11:01 AM, during an observation and interview, Licensed Practical Nurse (LPN) #1 confirmed that Resident #13 was in bed and the fall mat was folded on the left side of the bed, instead of being unfolded on the floor bedside…

    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 · D2025-04-02 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and facility policy review, the facility failed to store food using sanitary methods to prevent cross-contamination, as evidenced by a plastic cup used as a scoop stored directly inside a container of cornmeal for one (1) of four (4) days of kitchen observations. Findings included: A review of the facility's document ServeSafe Manager, undated, revealed, .Preventing Cross-Contamination .Food, equipment, utensils .must be stored in ways that prevent cross-contamination .Storing .you need to store items in a way that prevents cross-contamination . On 03/30/25 at 10:34 AM, during an observation of the kitchen and interview with the Dietary Manager, there was a clear plastic cup inside the fish fry/corn meal container dry goods container. The Dietary Manager confirmed the clear plastic cup was being used as a scoop and acknowledged this constituted cross-contamination. On 04/01/25 at 12:25 PM, during an interview with the Registered Dietitian (RD), she explained the dietary department uses Serve Safe guidelines for policy and procedures related to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-02 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain a clean environment and implement comprehensive care plan interventions during an annual recertification survey on 7/20/2023 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of eight (8) deficiencies cited. F584 and F656. Findings Include: Record review of the facility's policy, Quality Assessment and Performance Improvement, dated 2/24/2021, revealed, .It is the policy of this facility to .maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .Policy Explanation and Compliance Guidelines .2. The QA Committee shall .c. Develop and implement appropriate plans of action to correct…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2025-04-02 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, record review, and facility policy review, the facility failed to ensure timely administration of pneumonia vaccinations for one (1) of five (5) residents reviewed for immunizations (Residents #70). Findings include: A record review of the facility's policy, Pneumococcal Vaccine (Series), dated 6/19/23, revealed .It is our policy to offer residents .immunizations against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations. Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .2 .Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders . A record review of the admission Record revealed the facility admitted Resident #70 on 2/3/25 with diagnoses including Encounter for Surgical Aftercare following surgery on the Digestive System. A record review of the admission Minimum Data…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection, for one (1) of four (4) observations of staff entering and exiting residents' rooms. Findings include: Record review of the facility's policy titled, Hand Hygiene: Clean Hands Save Lives, with date implemented 1/21/21 revealed, . It is the policy of this facility that hand hygiene will be handled as follows: . Hand hygiene is a way of cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands . Facts to Consider: .Germs can spread from .surfaces when you .touch a contaminated surface or objects .Washing hands can keep you healthy and prevent the spread of .infections from one person to the next . Record review of the facility's policy titled, Perineal Care Policy, revised 2/21 revealed, .Policy: Peri care is to be performed following this procedure to ensure . cross contamination if avoided remove gloves .wash hands with soap 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review and facility policy review the facility failed to provide a privacy bag for a resident with an indwelling catheter for one (1) of five (5) residents with urinary catheters. Resident #235. Findings Include: Record review of the facility's policy titled Catheter Care, undated, revealed Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation .2. Privacy bags will be available and catheter drainage bag will be covered at all times while in use . On 07/17/2023 at 11:00 AM, during an observation, Resident #235 was lying in bed and had an indwelling catheter drainage bag that had yellow urine visible from the doorway and hallway. On 07/19/2023 at 01:15 PM, during an observation, Resident #235 was lying in bed talking to a visitor. The visitor was at the bedside of the resident and the indwelling catheter drainage bag was not covered and urine was visible in his room and hallway.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-20 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review and facility policy review the facility failed to maintain a clean environment for two (2) of 20 resident rooms. Resident #54 and Resident #76 Findings Include: Review of the facility's policy, Routine Cleaning and Disinfection, dated 5/12/23, revealed, Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .Policy Explanation and Compliance Guidelines .13. Cleaning of walls .will be conducted when visibly soiled. 14. Privacy curtains in resident rooms will be changed when visibly dirty . Resident #54 On 7/17/23 at 12:20 PM, in an observation and interview with Resident #54, the privacy curtain facing the resident had large visible stains and was soiled. The resident stated that the curtain had been in that condition for a while and no one had said anything to him about replacing it. He said he was sure staff had noticed it but had not done anything about it. On 07/18/23 at 01:53 PM, in an interview and observation with Certified 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to a medication for one (1) of (20) care plans reviewed. Resident #54 Findings Include: Review of the facility's policy, Comprehensive Care Plans, undated, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . In an observation and interview on 7/17/23 at 12:20 PM, with Resident #54 he was lying in the bed and there was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54 and was labeled as Triamcinolone Acetonide. Resident #54 stated he had gotten the cream when he went to the doctor several months ago for eczema and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review and facility policy review the facility failed to provide nail care for a resident who was unable to carry out Activities of Daily Living (ADLs) for one (1) of (20) sampled residents. Resident #76. Findings include: Record review of the facility's policy, Activities of Daily Living (ADLs), dated 10/28/2021, revealed, .The staff will provide care on a timely basis to promote and prevent avoidable changes in care. This includes the residents ability to: 1. Bathe, dress, and groom .Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal oral hygiene as documented in the resident's care plan . During an observation on 07/17/23 at 11:49 AM, Resident # 76 was in bed, and he had fingernails on both hands that were thick, jagged, and had a dark discoloration. The middle three fingernails on both hands were curved beyond the nail bed. During an interview on 7/18/23 at 4:15 PM, with Certified 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-20 · 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 observation, interviews, record review, and facility policy review, the facility failed to ensure a resident had been assessed for safe self-administration of medication and failed to ensure a physician's order was transcribed accurately for one (1) of (20) sampled residents. Resident #54 Findings Include: Record review of the facility's policy, Resident Self-Administration of Medication dated 6/23/2023, revealed, Policy .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . Record review of the facility's policy, Medication Orders, undated, revealed, .Policy Explanation and Compliance Guidelines . 4. Documentation of Medication Orders .f. Transcribe newly prescribed medications on the .treatment record . During an observation on 7/17/23 at 12:20 PM, Resident #54, was lying in the bed and there was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54 and was labeled as…

    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 · D2023-07-20 · 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

    Based on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewed for respiratory conditions. Resident #26 Findings Include: Review of the facility's policy, Oxygen Administration, dated 6/23/23, revealed, .Policy Explanation and Compliance Guidelines .6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use . On 07/17/23 at 11:12 AM, Resident #26 was sitting in a wheelchair next to his bed. There was an oxygen (O2) concentrator in the corner of the room, with a nasal cannula stored on the back of the concentrator. Resident #26 was not wearing the nasal cannula and was unable to communicate if he had removed the cannula himself. There was no cautionary signage on the door of the room indicating that oxygen was being administered. Record review of the Physician's Order Sheet' revealed a Physician's Order dated 7/9/23 for Oxygen at 2L (liters) continuous r/t (related to) hypoxia. Record 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 · Dcited before2023-07-20 · tag F0761 — failed to label and store drugs safely — isolated
    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, interviews, record review and facility policy review, the facility failed to properly secure a medication for one (1) of (20) sampled residents. Resident #54 Findings Include: Review of the facility's policy, Medication Storage, reviewed/revised 6/20/23, revealed, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the .medication rooms .Policy Explanation and Compliance Guidelines 1. General Guidelines a. All drugs and biologicals will be stored in locked compartments . Review of the facility's policy, Resident Self-Administration of Medication, dated 6/23/23, revealed, .Policy Explanation and Compliance Guidelines .7. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage . On 7/17/23 at 12:20 PM, Resident #54 was observed lying in the bed. There was a container of medication on his overbed table in front of him. The container of cream, which had a pharmacy label, was prescribed to Resident #54, and was labeled as…

    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 · D2023-07-20 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained and interventions were monitored for effectiveness for one (1) repeated deficiency related to Physician Order transcription errors that was cited in May 2022 and October 2022. The facility's continued failure during three surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for three (3) of (3) previous surveys reviewed. Findings Include: Record review of the facility's policy, Quality Assurance Performance Improvement, dated 2/24/2021, revealed, Policy: It is the policy of this facility to .maintain an effective .QAPI program . During this recertification survey, the facility was cited F684 (Quality of Care). The facility failed to ensure a physician's order was transcribed accurately. In May 2022, the facility was cited F684 for failure to ensure a physician's order was transcribed accurately. In October 2022, the facility was again cited F684 for failure to ensure 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-07-20 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review, the facility failed to provide written notification to the resident and the resident's representative, in a language they could understand, the reason a resident was transferred to the hospital for one (1) of one (1) resident records reviewed for hospitalizations. Resident #12 Findings include: Review of the facility's policy, Transfer and Discharge (including AMA), revised 6/23/23, revealed, Policy: It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Policy Explanation and Compliance Guidelines: . 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location . to which the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$12,183 in federal fines across 2 penalties.

  • $6,091 — penalty dated 2024-02-28
  • $6,092 — penalty dated 2024-02-28

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
LAKEVIEW CORPORATIONOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/1998
CARPENTER, DIANEIndividualW-2 MANAGING EMPLOYEEsince 02/29/2008
CAIN, BRIANIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 01/01/1998

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$8.5M
Net patient revenuemost recent cost report
+0.5%
Operating marginrevenue minus expenses
$935K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 7%Other / private 25%

This home reported $935K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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

$269per resident / day
operating cost
$8,182per month
≈ monthly operating cost
$271per 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 MS

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 Mississippi Medicaid page.

Typical monthly cost in Mississippi
$9,581/mo
Nursing home (semi-private)
$9,885/mo
Nursing home (private)
$4,369/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 255182. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-18, 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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