Average — CMS composite of the measures below.
The next survey window likely opens 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 Calcasieu Community Care Center during CMS and state inspections, most recent first.
MDS assessments were inaccurately coded for two residents. One resident’s quarterly MDS indicated opioid use even though the MAR showed no opioid doses during the look-back period, and another resident’s admission MDS indicated weight loss even though the record and weight review showed no documented weight loss. An LPN and the Clinical Coordinator verified both coding errors.
Food service staff failed to maintain proper steam table temperatures, document meal temperatures, use clean serving bowls, and fully cover hair during meal service. A Homemaker served hot and cold foods that were outside required temperature ranges without corrective action, used a bowl with dried particles, and another Homemaker served residents with braids exposed outside the hair net; the DON confirmed the temperature documentation and hair restraint expectations.
The facility failed to maintain an effective antibiotic stewardship program, lacking proper surveillance, tracking, and trending of antibiotic use. The Infection Preventionist confirmed the absence of a certified Infection Control Preventionist since April, and the previous DON lacked certification. Multiple infections were reported, with insufficient documentation for residents on antibiotics. The facility did not provide evidence of an effective program by the survey exit.
The facility did not ensure that the designated Infection Preventionist had completed specialized training in infection prevention and control, as required by their policy. The Assistant Director of Nursing, who held the role, lacked documented evidence of such training. The Director of Nursing confirmed the absence of a certified Infection Preventionist since April, obtaining her certification only when surveyors were present. This deficiency potentially affected 115 residents.
The facility failed to maintain nutritional standards for residents on pureed diets, leading to significant weight loss in four residents. Kitchen staff did not use recommended liquid additives, using water instead, which did not meet nutritional requirements. Residents experienced severe weight loss, with low meal intake percentages and missing menu items. The registered dietitian had previously in-serviced staff on proper preparation, but oversight was lacking.
The facility failed to adhere to pureed diet guidelines, affecting eight residents. Kitchen staff used water instead of broth or milk to puree foods and omitted pureed bread from a meal. The dietary manager confirmed the error, and the registered dietician had previously trained staff on proper procedures.
The facility failed to implement and maintain an effective QAPI program, lacking evidence of measuring success, data collection, and staff in-services. This deficiency, confirmed by the DON, potentially affected 115 residents.
A facility failed to assess a resident's ability to self-administer medication, as required by their policy. The resident, with conditions including COPD and Mild Cognitive Impairment, had a nasal spray and inhaler at their bedside, which they used without documented assessment. An LPN confirmed the lack of assessment, highlighting a potential risk to other residents.
A facility failed to complete and submit a Minimum Data Set (MDS) assessment in a timely manner for a resident who was readmitted after a hospital discharge. The resident's medical record lacked evidence of a reentry assessment being opened, completed, or transmitted, which was confirmed by the Clinical Coordinator.
A resident with Cerebrovascular Disease and Unspecified Dementia was not accurately coded in the MDS for hospice care and significant weight changes. Despite having a physician's order for hospice care and experiencing a 7.4% weight gain in the last 30 days, the MDS assessment did not reflect these conditions. The Clinical Coordinator confirmed the omissions during a review.
A facility failed to refer a resident with newly diagnosed mental disorders for a Level II PASARR evaluation, as required by policy. The resident, initially admitted with Major Depressive Disorder and PTSD, was later diagnosed with Schizophrenia, Bipolar Disorder, and Anxiety Disorder. Despite these new diagnoses, no Level II PASARR was submitted, which was confirmed by the Social Services Director.
The facility failed to ensure accurate PASARR screenings for two residents with mental disorders. One resident with Bipolar Disorder and another with Obsessive-Compulsive Disorder had screenings that did not reflect their diagnoses. The Social Services Director admitted to not updating the screenings and could not locate the necessary documentation for one resident.
A facility failed to properly label an enteral feeding administration set for a resident, as required by policy. During an observation, it was found that the set lacked the resident's name, date, time of initiation, and the initials of the person who initiated the feeding. An LPN confirmed the labeling omission. The resident had a history of cerebral infarction, dysphasia, and aphasia, with specific physician's orders for enteral feeding. This deficiency potentially affected four residents receiving enteral feedings.
The facility failed to properly store respiratory equipment for two residents, leading to a deficiency in infection control practices. A resident's nebulizer tubing and mouthpiece were left exposed to air, and another resident's oxygen nasal cannula was found on the floor. Both instances were confirmed by LPNs to be against the facility's infection prevention policy.
The facility did not follow professional standards for food service safety by failing to label opened refrigerated food items with the date they were opened. During an observation, a gallon of ranch dressing and a bag of sliced cucumbers were found opened and undated in the kitchen refrigerator. The Dietary Manager confirmed the oversight, which could potentially impact the 115 residents consuming food from the kitchen.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage II Pressure Ulcer, as required by their infection control policy. Despite the policy's mandate for gown and glove use during wound care, there was no signage or PPE available near the resident's room. Two wound care nurses confirmed their lack of awareness regarding the EBP requirement for residents with pressure ulcers, highlighting a lapse in policy adherence.
MDS Assessments Were Coded Incorrectly for Medication Use and Weight Loss
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for 2 of 37 sampled residents. For Resident #26, the Quarterly MDS with an ARD of 10/29/2025 was coded in Section N to indicate the resident was taking an opioid during the last 7 days. However, review of the electronic MAR for 10/23/2025 through 10/29/2025 showed no doses of opioid medication were administered. During interview and record review, the LPN Clinical Coordinator verified the MDS was coded as receiving opioid medication and confirmed the MAR did not show any opioid doses. For Resident #88, the admission MDS with an ARD of 11/12/2025 was coded in Section K0300 to indicate a weight loss of 5% or more in the last month or 10% or more in the last 6 months. Review of the electronic medical record did not reveal documentation that the resident had lost weight from admission to the MDS assessment date. During interview and record review, the Clinical Coordinator verified the admission MDS was coded for weight loss, reviewed the resident’s weights, and acknowledged there was no weight loss. The LPN who completed the MDS confirmed the assessment was coded incorrectly and needed to be modified.
Food Service Temperature, Sanitation, and Hair Restraint Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when steam table temperatures were not maintained and food was served without required temperature checks being documented. On 12/08/2025 at 11:45 a.m., a Homemaker measured foods on the steam table at House D and found the pureed seasoned greens at 77 degrees Fahrenheit, the gelatin fruited pear at 59 degrees Fahrenheit, and the pureed gelatin fruited pear at 75 degrees Fahrenheit. Although she stated the foods would be sent back to the kitchen when temperatures were not in the appropriate range, she served the foods to residents without any corrective measures. A review of the House D Kitchen Daily Temperature Log also showed no documented temperatures for pureed lunch and dinner meals on 12/03/2025 and no documented temperatures for the pureed dinner meal on 12/05/2025. The deficiency also involved food service sanitation and staff presentation. During the same observation, the Homemaker attempted to serve gelatin fruited pear in a dessert bowl with dried particles inside, and she stated the bowl was not clean and should not have been used; 6 of 13 bowls had dried particles noted inside. On House C, another Homemaker was observed serving residents with a hair net on while two braids of hair hung outside the hair net on her face. The Dietary Manager confirmed that the hair should have been completely covered without exposed hair and also confirmed that temperatures should be documented prior to serving on each household for every meal and that soiled dishes should not be used to serve residents.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of surveillance, tracking, and trending of antibiotic use. The policy titled 'Antibiotic Stewardship' was not effectively implemented, as it required the Infection Preventionist (IP) or designee to review all clinical infections treated with antibiotics and document them on a surveillance tracking form. However, the facility did not provide evidence of such documentation or an effective program in place. The Infection Preventionist confirmed that the facility had not had a certified Infection Control Preventionist since April 2024, and the previous Director of Nursing (DON) who was handling infection control did not have the necessary certification. The report highlighted that there were multiple infections reported from July to October 2024, with several infections remaining open and unresolved. During the review period from September to October 2024, five residents were on antibiotics, but documentation was insufficient, with only one progress note for two residents receiving antibiotics. The facility's DON, who was also the Infection Preventionist, acknowledged the absence of an effective antibiotic stewardship program and confirmed that floor nurses were responsible for daily documentation, which was not adequately performed. The facility did not provide evidence of an antibiotic stewardship program by the time of the survey exit.
Infection Preventionist Lacked Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had completed specialized training in infection prevention and control. The facility's policy required that the Infection Preventionist have professional training in a related field and obtain specialized ICP training beyond initial professional training. However, a review of the facility's infection control records revealed no documented evidence that the Assistant Director of Nursing, who was the designated Infection Preventionist, had completed such specialized training. During an interview, the Director of Nursing confirmed that the facility had not had an Infection Preventionist with a certification since April 2024. She also stated that she obtained her certification on October 8, 2024, when the surveyors were present at the facility. This deficiency had the potential to affect a census of 115 residents.
Failure to Maintain Nutritional Standards for Residents on Pureed Diets
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for residents on mechanically altered therapeutic diets, leading to significant weight loss in four residents. The deficiency was identified through observations, interviews, and record reviews, revealing that the kitchen staff did not consistently use the recommended liquid additives when preparing pureed foods. Instead of using broth or milk as specified in the facility's Pureed Foods Guideline, water was used, which is not recommended. This failure to adhere to the guidelines resulted in meals not meeting the nutritional requirements as planned by the registered dietitian. Resident #52 experienced a severe weight loss of 9.17% in three months and 17.86% in less than six months. The resident's care plan indicated a focus on nutritional problems, with interventions to provide and serve the diet as ordered. However, meal intake records showed low consumption percentages, with many meals consumed at 0-25%. Resident #88 also suffered a severe weight loss of 12.13% in one month and 22.76% in six months, with observations confirming the absence of pureed bread on the meal tray, which was part of the planned menu. Resident #93 had a weight loss of 7.63% in three months, with a care plan focusing on returning to baseline weight. The resident was observed refusing meals, indicating a potential issue with meal acceptance. Resident #106 experienced a weight loss of 10.40% in less than three months, with fluctuating meal intake and reliance on PEG feedings for nutrition. The registered dietitian confirmed that she had previously in-serviced the kitchen staff on proper pureed diet preparation but did not observe the preparation process during her rounds. The dietary manager was responsible for overseeing the kitchen staff, but the deficiency in following the guidelines persisted.
Failure to Follow Pureed Diet Guidelines
Penalty
Summary
The facility failed to ensure that recipes for pureed foods and menus were followed for residents receiving pureed diets. This deficiency affected eight residents who were prescribed pureed diets. During an observation, it was noted that the kitchen staff, S7KS, used water instead of the recommended liquids such as broth or milk to puree chicken and potato salad. Additionally, the pureed diet tray prepared for a resident lacked pureed bread or a substitute, deviating from the facility's lunch menu which included chicken thighs with barbecue sauce, baked beans, Texas toast, and vanilla dessert. The dietary manager, S5DM, confirmed that water should not have been used as a liquid for pureeing foods and that the bread should have been pureed as part of the meal. The registered dietician, S8RD, who conducts monthly kitchen inspections, was informed of the improper use of water and confirmed that she had previously trained the kitchen staff on the correct preparation of pureed diets. Despite this training, the guidelines were not followed, leading to the deficiency in meal preparation for residents on pureed diets.
Deficiency in QAPI Program Implementation
Penalty
Summary
The facility failed to effectively implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through a review of the facility's undated QAPI policy and an interview with the Director of Nursing (S2DON). The facility did not provide documented evidence of measuring or tracking the success of actions implemented, nor did it show evidence of data collection and analysis. Additionally, there was no documentation of in-services conducted with clinical and non-clinical support staff. The Director of Nursing confirmed the absence of documentation related to data collection, analysis, monitoring, performance tracking, and staff in-services. This lack of evidence had the potential to affect the care of 115 residents.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to assess whether it was clinically appropriate for a resident to self-administer medication, which is a requirement according to their policy. The policy mandates that an interdisciplinary team must evaluate each resident's cognitive and physical abilities to determine the safety and appropriateness of self-administering medications. However, for one resident with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Mild Cognitive Impairment, there was no documented evidence of such an assessment in the resident's electronic medical record. During an observation and interview, it was found that the resident had a prescription nasal spray and inhaler on their bedside table, which they confirmed they used to self-administer medication. A Licensed Practical Nurse (LPN) also confirmed the presence of these medications at the bedside and acknowledged that there was no assessment documented for the resident's ability to self-administer medication. This oversight in following the facility's policy had the potential to affect a significant number of residents.
Failure to Complete and Submit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was completed and submitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for a resident who was readmitted. The deficiency was identified during a review of the medical record of a resident who had been discharged to the hospital and subsequently readmitted. The resident's medical record showed no documented evidence that a reentry assessment was opened, completed, or transmitted after the readmission. This oversight was confirmed during an interview with the Clinical Coordinator, who acknowledged that the reentry assessment had not been initiated or submitted as required.
Inaccurate MDS Coding for Hospice Care and Weight Changes
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of a resident, specifically in the areas of weight gain and hospice care. The resident, who was admitted with diagnoses including Cerebrovascular Disease and Unspecified Dementia, had a physician's order for hospice care and a care plan indicating end-stage cardiovascular disease. Despite these details, the resident's MDS assessment did not reflect the hospice care status, as Section O, which pertains to special treatments and programs, was not coded for hospice care. Additionally, the resident experienced a significant weight change, with a 7.4% weight gain in the last 30 days and an 18.4% weight loss in the last 90 days. However, the MDS assessment failed to capture this information, as Sections K0300 and K0310, which address weight loss and gain, were not assessed and were left with a dash, indicating they were not evaluated. The Clinical Coordinator confirmed these omissions during a record review and interview, acknowledging that the MDS should have been coded to reflect the resident's weight gain and hospice care status.
Failure to Refer for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with newly diagnosed mental disorders to the appropriate state-designated authority for a Level II PASARR evaluation. The deficiency was identified during a review of the facility's policy and the resident's electronic health record (EHR). The policy stated that any resident with newly evident or possible serious mental disorder (MD) or intellectual disability (ID) must be referred for a Level II PASARR evaluation. However, the facility did not adhere to this policy for one resident who was diagnosed with Schizophrenia, Bipolar Disorder, and Anxiety Disorder on 08/16/2024. The resident in question was initially admitted with diagnoses including Major Depressive Disorder and Post-Traumatic Stress Disorder. Despite the new diagnoses of Schizophrenia, Bipolar Disorder, and Anxiety Disorder, there was no evidence that a Level II PASARR had been submitted after these diagnoses. The Social Services Director confirmed that the resident's PASARR from 2020 indicated a Level II was not required and acknowledged the oversight in not submitting a new Level II evaluation after the new diagnoses.
Inaccurate PASARR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that residents with mental disorders or intellectual disabilities had accurately completed PASARR Level I and/or Level II screenings. Specifically, two residents, identified as #11 and #49, were found to have discrepancies in their PASARR screenings. Resident #11 was admitted with a diagnosis of Bipolar Disorder, but the Level I PASARR screening did not indicate this mental illness. Similarly, Resident #49, who was admitted with a diagnosis of Obsessive-Compulsive Disorder, also had a Level I PASARR screening that failed to reflect this condition. The screenings were not updated to include these qualifying diagnoses. During a concurrent records review and interview, the Social Services Director (S4SSD) acknowledged responsibility for completing and reviewing PASARRs upon resident admission. However, she admitted that she did not resubmit the PASARR screenings to reflect the qualifying diagnoses for both residents. Additionally, the Level I PASARR screening form for Resident #49 could not be located in the electronic medical record, and S4SSD was unable to confirm if the qualifying diagnosis had been accurately indicated. This oversight resulted in the facility's non-compliance with PASARR requirements for these residents.
Failure to Label Enteral Feeding Administration Set
Penalty
Summary
The facility failed to ensure proper labeling of a resident's enteral feeding administration set, which is a requirement according to their policy. During an observation, it was noted that the administration set for a resident receiving tube feeding did not have the resident's name, date, time of initiation, or the initials of the person who initiated the feeding. This observation was confirmed by an LPN present at the time, who acknowledged that the set should have been labeled with this information. The resident involved had a medical history including cerebral infarction, dysphasia, and aphasia, and had specific physician's orders for enteral feeding that were not properly documented on the feeding set. This deficiency had the potential to affect a total of four residents receiving enteral feedings in the facility.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment for two residents, leading to a deficiency in infection control practices. Resident #10, who was admitted with diagnoses including Osteoporosis and Major Depressive Disorder, had a physician's order for Ipratropium-Albuterol Inhalation solution to be administered three times a day for pneumonia. During an observation, it was noted that Resident #10's nebulizer tubing and mouthpiece were left on top of a drawer unit, exposed to air, and not stored in a plastic bag as required by the facility's infection prevention policy. This was confirmed by an LPN who acknowledged that the equipment should have been stored in a bag when not in use. Similarly, Resident #96, who was admitted with Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension, and Chronic Cough, had an order for oxygen to be applied as needed for dyspnea. An observation revealed that the resident's oxygen nasal cannula was found on the floor, which was confirmed by another LPN to be inappropriate as it should have been stored in a bag. These findings indicate a failure to adhere to the facility's policy on the proper storage of respiratory equipment, potentially compromising infection control measures.
Failure to Label Opened Refrigerated Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling refrigerated food items with the date they were opened. During an observation and interview with the Dietary Manager, it was noted that a gallon of ranch dressing and a zip-locked bag of sliced cucumbers in the kitchen's free-standing refrigerator were opened and used without being labeled with the date of opening. The Dietary Manager confirmed these findings and acknowledged that the opened food items should have been labeled with the date they were opened, but they were not. This oversight had the potential to affect the 115 residents who consumed food prepared in the kitchen.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage II Pressure Ulcer, as required by their infection prevention and control policy. The policy, revised in April 2024, mandates the use of gown and gloves during high-contact resident care activities, such as wound care, to prevent the spread of multi-drug resistant organisms. Despite this, there was no signage indicating the need for EBP on or near the resident's room, nor was there any personal protective equipment (PPE) available in the immediate area. During an observation and interview with two wound care nurses, it was confirmed that they were unaware of the requirement for EBP for residents with pressure ulcers. The resident in question had a pressure ulcer on her left gluteus, which required daily wound care. The absence of EBP signage and PPE availability indicates a lapse in adherence to the facility's infection control policy, potentially compromising the safety and care of the resident.
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What surveyors actually found near you
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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.
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Nursing homes near Lake Charles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Lake Charles | 1.5 mi | ★★★★★ | 6 | 0 |
| Rosewood Nursing Center | 2.8 mi | ★★★★★ | 1 | 0 |
| Lake Charles Care Center | 3 mi | ★★★★★ | 0 | 0 |
| Resthaven Nursing & Rehab Center, Llc | 3.4 mi | ★★★★★ | 4 | 0 |
| The Gardens And Guardian | 3.7 mi | ★★★★★ | 0 | 0 |
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