Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Louisburg Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including food debris and dried substances on carts, a refrigerator with spills and dirty dressing containers, and a prep table with food debris. Dietary staff acknowledged these areas were not on the cleaning schedule, and no kitchen cleanliness policy was provided.
Surveyors found that the laundry area had flaking paint above clean linens, cluttered counters with non-laundry items, and dirty laundry blocking essential sinks and stations. Staff interviews confirmed awareness of these issues, and a backlog of laundry was reported due to equipment failure. The facility's maintenance policy assigned responsibility for upkeep, but these deficiencies were not addressed.
Several residents and/or their representatives were not fully informed about the specific names, dosages, and reasons for their prescribed psychotropic medications, as consent forms only listed medication classes and general side effects. Although staff reported verbally educating residents, this was not documented in the medical record, resulting in incomplete compliance with facility policy.
A resident with severe cognitive impairment and incontinence was provided peri-care by staff who failed to close the window blinds, exposing the resident to the front parking lot. Staff acknowledged the oversight, and facility policy requires residents to be treated with respect and dignity.
A resident with dementia and moderate cognitive impairment did not have a complete Minimum Data Set (MDS) assessment, as staff failed to analyze findings for triggered Care Area Assessments (CAA). The resident was frequently incontinent and dependent on staff for toileting, but the required analysis was missing from documentation, as confirmed by staff interviews and record review.
Staff did not follow Enhanced Barrier Precautions when accessing a resident's G-tube, using only gloves instead of the required gown and gloves, despite an active order and facility policy. Additionally, the laundry area was found to be unsanitary, with flaking paint above clean linens, cluttered counters with non-laundry items, and dirty laundry blocking essential areas due to equipment issues and lack of awareness among staff.
The facility did not consistently post daily nurse staffing sheets with the actual hours worked by licensed and unlicensed staff, as required. On several observed days, the posted sheets lacked this information, and administrative staff confirmed that actual hours were omitted if they matched scheduled hours, contrary to facility policy.
The facility did not accurately submit hourly staffing data for all weekend personnel through the PBJ system, despite having sufficient staff coverage according to internal schedules and payroll records. Administrative staff confirmed that inaccuracies in reported time were due to automatic lunch deductions and discrepancies between scheduled and reported hours.
Failure to Maintain Sanitary Food Preparation and Service Conditions
Penalty
Summary
Surveyors observed multiple sanitation deficiencies in the facility's kitchen and food service areas during an initial tour. Specifically, several carts used for holding and delivering food and beverages were found with food debris and dried-on sticky substances. The inside of a two-doored reach-in refrigerator contained a dried-on red liquid and food debris, and three one-gallon containers of dressings inside the refrigerator had dried-on dressing around the tops and sides. Additionally, a prep table had food debris on its bottom shelf. Dietary staff confirmed that these areas of concern were not currently included in the kitchen's cleaning schedules. The facility was unable to provide a policy regarding the cleanliness of the kitchen.
Deficient Laundry Area Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry area, as evidenced by multiple observations and staff interviews. In the clean linen processing room, the ceiling had flaking and missing paint directly above residents' clean laundry, and the clean linen folding counter was cluttered with non-laundry items such as a staff purse, a laptop, and a desk organizer. In the dirty laundry washing area, resident linen and clothes in bags were stacked on the floor, causing clutter and blocking access to the staff hand-washing sink, the eye-wash station, and the washer laundry-soap refill. Additionally, both the ceiling and walls in the laundry areas had chipped and missing paint. Staff interviews confirmed awareness of the inappropriate conditions. Administrative staff acknowledged that paint flaking and chipping near clean laundry presented an infection concern and that only clean laundry should be on the folding counter. Maintenance staff were unaware of the missing paint in the laundry areas, and housekeeping staff reported that a washer had been out of service, leading to a backlog of laundry. Housekeeping staff also stated they were unaware that non-laundry items should not be on the folding counter. The facility's preventive maintenance policy assigned responsibility to the maintenance director for ensuring the building and equipment were maintained in a safe and operable manner.
Failure to Provide and Document Complete Psychotropic Medication Information
Penalty
Summary
The facility failed to adequately inform several residents and/or their representatives about the specific risks, benefits, and alternatives associated with their prescribed psychotropic medications. In multiple cases, the consent forms provided to residents only listed the general class of medication (such as antidepressant, antipsychotic, or antianxiety) and potential side effects for the class, but did not include the names of the individual medications, their prescribed dosages, or the specific reasons for their use. This lack of detailed information was observed in the records of residents with varying degrees of cognitive function, including those with intact cognition and those with moderate to severe cognitive impairment. For example, one resident with diagnoses including altered mental status, metabolic encephalopathy, and anxiety disorder had a consent form that omitted the names and dosages of prescribed medications such as Buspar and Cymbalta. Another resident with borderline personality disorder, cerebral palsy, and major depressive disorder was prescribed multiple psychotropic medications, but the consent form again lacked specific medication names and dosages. In both cases, administrative staff confirmed that while residents were verbally informed about their medications, this education was not documented in the medical record as required by facility policy. Additional residents with diagnoses such as schizophrenia, alcohol-induced dementia, and depression were also found to have incomplete psychotropic consent documentation. In some instances, residents expressed confusion or dissatisfaction regarding their medications, with one resident stating they were told an antidepressant would help with pain, but it was not effective. The facility's policy required that residents and/or their representatives be informed and that this communication be documented, but this was not consistently done, leading to the deficiency.
Failure to Ensure Resident Dignity During Personal Care
Penalty
Summary
Staff failed to maintain a resident's dignity during personal care by not closing the window blinds before beginning peri-care. The resident, who had a diagnosis of dementia with severe cognitive impairment and was always incontinent of bowel and bladder, was dependent on staff for toileting and wore incontinent products. During the care, staff removed the resident's cover and incontinent brief and turned her toward a window that faced the front parking lot, with the blinds raised approximately 12 inches. One staff member requested that the blinds be closed before continuing, at which point the administrative nurse acknowledged that the blinds should have been closed prior to starting care. Another staff member admitted to not thinking about closing the blinds before initiating care. Facility policy states that residents have the right to be treated with respect and dignity, and staff interviews confirmed that the expectation was to close blinds before providing care.
Incomplete MDS and CAA Documentation for Resident with Dementia
Penalty
Summary
The facility failed to complete a thorough Minimum Data Set (MDS) assessment for one resident with a diagnosis of dementia and moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The resident was frequently incontinent of bowel and bladder and required staff assistance for toileting. The Care Area Assessments (CAA) triggered by the MDS were not fully analyzed, as the analysis of findings was missing from the documentation. This incomplete assessment was confirmed through review of the resident's electronic medical record and interviews with facility staff, who acknowledged the expectation to thoroughly complete the MDS and associated CAAs according to the RAI manual.
Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Laundry Environment
Penalty
Summary
Facility staff failed to implement adequate Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (G-tube) during a flushing procedure. Although the resident had an active order for EBP requiring gown and gloves for all cares due to the feeding tube, two licensed nurses accessed and flushed the G-tube using only gloves, omitting the required gown. Both nurses performed proper hand hygiene before and after the procedure, but did not follow the full PPE protocol as outlined in the facility's EBP policy. Interviews confirmed that staff were aware of the correct PPE requirements but did not adhere to them during the observed care. Additionally, the facility failed to maintain a sanitary environment in the laundry area. Observations revealed flaking and missing paint on the ceiling above clean laundry, clutter on the clean linen folding counter including non-laundry items, and a dirty laundry area that was cluttered and backed up with bags of resident linen and clothes stacked on the floor. This clutter blocked access to the staff hand-washing sink, eye-wash station, and laundry-soap refill. Maintenance and housekeeping staff were unaware of the extent of the issues, and one washer being out of service contributed to the laundry backlog.
Failure to Accurately Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing sheets included accurate and identifiable information, specifically the actual hours worked by licensed and unlicensed staff. Observations on multiple dates revealed that the posted staffing sheets did not list the actual number of hours worked, and this issue was found on several days throughout the month. During an interview, an administrative staff member stated that if the actual hours worked matched the total number of hours scheduled, she did not rewrite it on the daily staffing sheet. The facility's policy required accurate and timely posting of staffing information, as well as submission of staffing data through the CMS Payroll-Based Journal (PBJ) system.
Failure to Accurately Submit Weekend Staffing Data via PBJ
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Federal regulatory agency through the Payroll-Based Journal (PBJ) system. Specifically, the facility did not accurately report hourly staffing data for all weekend personnel for multiple fiscal quarters. Although the PBJ Staffing Data Report indicated insufficient weekend staffing, a review of the nursing schedule and payroll data sheets for the same periods showed that the facility actually had sufficient staff coverage on weekends. During an interview, administrative staff confirmed that reported time was not accurately recorded in relation to staff scheduling, and that a half-hour was automatically deducted from each staff member's worked time for lunch by corporate policy. The facility's own policy requires timely and accurate submission of staffing data to CMS, but this was not followed, resulting in incomplete and inaccurate reporting for weekend staffing.
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Illustrative
What surveyors actually found near you
We read the 384 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Louisburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Paola | 10.1 mi | ★★★★★ | 8 | 0 |
| North Point Skilled Nursing Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Spring Hill Care And Rehab | 11.9 mi | ★★★★★ | 1 | 1 |
| Beautiful Savior Home | 15.3 mi | ★★★★★ | 2 | 0 |
| Carnegie Village Rehabilitation & Health Care Cent | 16.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.