Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Grand Cove Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and hypertensive heart disease had an EMR progress note documenting Multaq 400 mg as 2 tablets BID for paroxysmal atrial fibrillation, a regimen exceeding the usual and maximum recommended single dose. Review of the MAR showed no corresponding physician order for Multaq, current or discontinued. The DON confirmed the absence of any Multaq order, and a later progress note indicated the Multaq order had been entered as 2 tablets BID instead of 1 tablet BID. The medical director confirmed this entry was incorrectly documented in the resident’s medical record, demonstrating incomplete and inaccurate medical record documentation.
Incomplete wound care documentation was found for two residents. One resident had ordered tx for a diabetic ulcer, but the TAR did not show the care was completed. Another resident had multiple wound orders, including pressure ulcers and a later stage 3 wound, but the TAR and MR did not document wound care on multiple occasions; the DON confirmed one missed entry and stated she provided care without documenting it.
A resident with multiple mental health diagnoses repeatedly refused hygiene and nail care over several months. Despite staff and hospice documentation of these refusals and notifications to nursing staff, the care plan was not updated to reflect the refusals or include interventions. Staff interviews confirmed awareness of the refusals but acknowledged the care plan did not address them.
A resident's care plan was not revised to reflect her current ability to perform activities of daily living independently, except for showering, despite updated assessments and interviews confirming her improved status. The care plan continued to indicate a need for assistance in multiple areas, which was not consistent with the resident's actual needs.
Several residents did not receive their prescribed medications within the required timeframes, as medications scheduled for specific times were administered significantly late. Staff, including LPNs and the DON, confirmed the late administration of both morning and evening medications, which did not comply with the facility's medication administration policy.
A resident's quarterly MDS assessment was not completed and submitted to CMS within the required 14-day timeframe. Review of records and staff interview confirmed the assessment was finalized after the deadline.
A resident's MDS assessment was incorrectly coded to indicate use of an anticoagulant but not an antiplatelet, despite the resident receiving Plavix, an antiplatelet medication, during the assessment period. This error was confirmed through EMAR review and staff interview.
Two residents with hemiplegia and diabetes who required significant assistance with personal hygiene were observed with unkempt facial hair and long, curling fingernails. Staff confirmed frequent refusals of ADL care by one resident, but these refusals and related needs were not addressed in the care plans for either resident.
A resident prescribed Carbidopa-Levodopa for Parkinson's disease experienced a discrepancy between the physician's order, which called for one 50-200 mg tablet three times daily, and the medication blister pack, which contained 25-100 mg tablets labeled to give two tablets three times daily. An LPN identified the inconsistency during medication pass, flagged the medication, and administered only one tablet, while the DON confirmed the mismatch between the order and packaging. The eMAR did not document the irregularity.
Dietary staff did not consistently use gloves, hair restraints, or proper sanitary procedures during food preparation and service. A cook prepared pureed food without gloves or a facial hair restraint, another staff member measured food temperatures without gloves, and a dietary aide used an uncleaned ice scoop after it contacted a drink. These actions were confirmed by the dietary manager and were not in accordance with facility policy, potentially affecting all residents receiving food and beverages.
A facility failed to complete a timely reentry MDS assessment for a resident who was readmitted after a hospital stay. The resident, diagnosed with a UTI and Vascular Dementia, returned to the facility without the required assessment being initiated. A nurse confirmed the oversight during a review, highlighting a deficiency in the assessment process.
A provider failed to ensure an accurate assessment for a resident with Schizophrenia and Bipolar Disorder. The resident's EMR indicated a PASRR Level II determination, recommending specialized services, but this was not reflected in the SC MDS assessment. The staff member responsible was unaware of the PASRR Level II status.
The facility failed to securely store and discard expired medications, as evidenced by an expired container of Gavilyte G found in an unlocked refrigerator meant for resident food. The Assistant Director of Nursing confirmed that the medication, prescribed to a resident, should not have been accessible in this manner and should have been discarded.
A facility failed to maintain effective infection control when an LPN did not follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols during a nephrostomy tube dressing change for a resident. The LPN entered the room without a gown or gloves and did not change gloves or perform hand hygiene between dressing changes on the resident's bilateral nephrostomy tubes. This breach was confirmed by the LPN, the Assistant Director of Nursing/Infection Preventionist, and the Director of Nursing.
Inaccurate Medication Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident, as required by its own medical records policy and accepted professional standards. The facility’s policy states that each resident must have an electronic clinical record that is complete, accurate, readily accessible, and systematically organized, including assessments, care plans, services provided, and diagnostic information. For one resident with dementia and hypertensive heart disease without heart failure, the electronic medical record contained a progress note dated 02/10/2026 documenting a dosing regimen for Multaq 400 mg as 2 tablets by mouth twice daily for paroxysmal atrial fibrillation. This documented regimen exceeded the usual dosing of 1 tablet twice daily and the maximum recommended single dose of 1 tablet, as indicated by an FDA black box warning. Further review of the resident’s February 2026 MAR showed no evidence of any physician’s order for Multaq, either current or discontinued, despite the progress note describing Multaq dosing. During interviews, the DON confirmed that the resident did not have a physician’s order for Multaq in the EMR. The DON also reviewed a subsequent progress note dated 02/12/2026 that stated an order review had identified Multaq as entered as 2 tablets/400 mg BID instead of the correct 1 tablet/400 mg BID, and that the order was immediately changed. The medical director later confirmed that this documentation had been entered incorrectly in the resident’s medical record, demonstrating that the resident’s EMR contained inaccurate and incomplete medication documentation.
Incomplete Wound Care Documentation in Resident Records
Penalty
Summary
Medical records were not accurately documented and maintained in accordance with professional standards for 2 residents whose wound care was being reviewed. For one resident, the record showed an order for treatment of a diabetic ulcer to the left lateral malleolus with normal saline, moist hydrofera blue, border gauze dressing, and a prevalon off-loading boot, but the October TAR did not document that the treatment was completed on 10/25/2025. The DON reviewed the record and confirmed the wound care was not documented on the TAR and could not confirm or deny whether it had been completed. For another resident with multiple pressure ulcers and other wounds, physician orders included treatments for a DTI to the left lateral malleolus, stage 4 pressure ulcers to the left trochanter and right ischial tuberosity, an unstageable pressure ulcer to the left lower back, a stage 2 pressure ulcer to the right malleolus, and later a stage 3 pressure ulcer to the left scapula. The October TAR did not document wound treatments completed on 10/24/2025, and the November TAR did not document treatments completed on 11/17/2025. The DON confirmed the 10/24/2025 wound care was not documented on the TAR and stated she had provided wound care on 11/17/2025 but did not document it; the corporate RN also confirmed the wound care was not documented on the TAR or in the medical record on 11/17/2025.
Failure to Address and Care Plan for Repeated Refusals of Hygiene and Nail Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's repeated refusals of hygiene and nail care. Record reviews showed that the resident, who had diagnoses including schizoaffective disorder, unspecified dementia, anxiety disorder, and major depressive disorder, consistently refused hygiene care daily over a two-month period and refused nail care on multiple occasions. Hospice aide visit notes also documented refusals of nail care, with notifications made to nursing staff. Despite these ongoing refusals, the resident's care plan did not include any identification of the refusal of care or interventions to address it. Interviews with facility staff, including LPNs and the nurse responsible for MDS and care plan updates, confirmed that the refusals were known and occurred frequently, yet were not reflected in the care plan. The staff acknowledged that the care plan should have included these issues and interventions but did not.
Failure to Update Care Plan Following Change in ADL Status
Penalty
Summary
The facility failed to revise the comprehensive, person-centered care plan for one resident following changes in her activities of daily living (ADL) status. Record review showed that the resident was admitted with diagnoses including congestive heart failure, anxiety, and depression, and her most recent assessment indicated she was independent in most ADLs except for requiring some assistance with bathing. However, the care plan continued to list her as needing partial or moderate assistance with bathing, supervision for transfers, and assistance with toileting, despite her current ability to perform most tasks independently except for showering. Interviews with the resident and a corporate registered nurse confirmed that the care plan had not been updated to reflect the resident's current ADL abilities.
Failure to Administer Medications on Time as Ordered
Penalty
Summary
The facility failed to provide services that meet professional standards of quality by not administering medications on time as ordered for three out of eleven sampled residents. According to the facility's policy, medications are to be administered no more than one hour before or after the scheduled time. For one resident with diagnoses including congestive heart failure, anxiety, and depression, evening medications scheduled for 8:00 p.m. and 9:00 p.m. were administered significantly late, at 10:14 p.m. and 10:25 p.m. The resident confirmed not receiving medications at the expected times, and the Director of Nursing verified the late administration upon review of the medication administration record. Additionally, another resident was observed receiving multiple morning medications due at 9:00 a.m. at 11:36 a.m., with the LPN confirming the late administration. A third resident's medications, due at 8:00 a.m. and 9:00 a.m., were also administered late, as confirmed by both observation and staff interview. These findings demonstrate that the facility did not adhere to its own medication administration policy, resulting in late delivery of prescribed medications for multiple residents.
Failure to Complete and Submit Quarterly MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a resident's quarterly Minimum Data Set (MDS) assessment was completed and submitted to CMS within the required timeframe. Record review showed that the assessment for one resident had an Assessment Reference Date (ARD) of 05/06/2025, but the assessment was not completed and signed until 06/05/2025, exceeding the 14-day completion requirement. During an interview, the staff member responsible for MDS assessments confirmed that the assessment was not completed within the CMS-mandated period.
Inaccurate MDS Coding for Antiplatelet Medication
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment regarding the use of antiplatelet medication. Specifically, the quarterly MDS for a resident with an Assessment Reference Date (ARD) of 02/12/2025 indicated that the resident was taking an anticoagulant but not an antiplatelet medication. However, review of the electronic medication administration record (EMAR) for February 2025 showed that the resident had been administered Plavix, which is an antiplatelet medication, during the MDS lookback period. This discrepancy was confirmed during an interview and record review with the staff member responsible for MDS coding, who acknowledged the incorrect coding on the assessment.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with significant care needs. One resident, admitted with hemiplegia, type 2 diabetes mellitus, and morbid obesity, was documented as being dependent on staff for personal hygiene. Observations revealed the resident was unshaven with long, unkempt facial hair and fingernails that were long, curling, and had brown debris underneath. Staff interviews confirmed that the resident frequently refused ADL care, and this issue had been reported to administration. However, a review of the resident's care plan showed that these refusals and the need to address them were not included in the care plan. Another resident, also with hemiplegia and type 2 diabetes mellitus, required substantial to maximal assistance for personal hygiene. Observation showed this resident had long, curling fingernails. The report documents that the care plans for both residents did not address their specific needs related to personal hygiene and refusals of care, as identified through record reviews, staff interviews, and direct observation.
Failure to Ensure Consistent Medication Orders and Packaging
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) identified a discrepancy between the physician's order and the instructions on the medication blister pack for a resident prescribed Carbidopa-Levodopa for Parkinson's disease. The physician's order and the electronic Medication Administration Record (eMAR) both specified to administer one 50-200 mg extended-release tablet by mouth three times daily. However, the blister pack available in the medication cart contained 25-100 mg tablets and was labeled to administer two tablets by mouth three times daily, which would match the total prescribed dose but differed in tablet strength and instructions. During medication administration, the LPN noticed the inconsistency and flagged the medication pack with a sticker indicating a direction change, while also confirming that only one 25-100 mg tablet was administered to the resident at that time. The Director of Nursing (DON) reviewed the orders, eMAR, and blister pack, confirming the mismatch between the physician's order and the medication packaging. There was no documentation in the eMAR to indicate the irregularity or conflict between the orders and the medication available for administration.
Failure to Follow Food Safety Standards in Dietary Services
Penalty
Summary
Dietary staff failed to adhere to professional standards for food service safety in several observed instances. One dietary cook was seen preparing pureed food without wearing gloves and without a facial hair restraint, despite facility policy requiring hair restraints to prevent hair from contacting food. Another dietary staff member was observed measuring food temperatures at the steam table without wearing gloves. Additionally, a dietary aide was seen scooping ice into glasses and tapping the ice with the back of the scoop, causing the drink to drip onto the scoop, and then returning the uncleaned scoop to the ice bin for further use. These actions were confirmed by the dietary manager, who acknowledged that all staff should use appropriate hair restraints, gloves, and sanitary procedures as outlined in facility policy. These deficiencies were observed during food preparation and service, with the potential to affect all 80 residents who consumed food and beverages prepared in the kitchen. The facility's policies on employee work practices and hand sanitation were reviewed and found to require the use of hair restraints, gloves, and proper sanitary procedures, which were not followed during the observed incidents.
Failure to Complete Timely Reentry MDS Assessment
Penalty
Summary
The facility failed to complete a reentry Minimum Data Set (MDS) assessment in a timely manner for Resident #14, who was part of a sample of 25 residents. This deficiency had the potential to affect the entire census of 73 residents. Resident #14 was initially admitted to the facility with diagnoses including a Urinary Tract Infection and Vascular Dementia. The resident was hospitalized on May 27, 2024, and returned to the facility on May 30, 2024. However, a review of the resident's MDS assessments revealed that a reentry assessment had not been initiated following the readmission from the hospital. During an interview and record review on June 5, 2024, a Registered Nurse (S7RN) confirmed that Resident #14 had a recent hospital stay and was readmitted to the facility. The nurse verified that the reentry assessment was overdue and had not been initiated, confirming the deficiency in the facility's assessment process.
Inaccurate Resident Assessment Due to PASRR Omission
Penalty
Summary
The provider failed to ensure that a resident's assessment accurately reflected the resident's status, specifically for one resident out of three reviewed in a sample of 25. The deficiency had the potential to affect a census of 73 residents. The resident in question was admitted with diagnoses including Schizophrenia and Bipolar Disorder. A review of the resident's electronic medical record (EMR) showed a PASRR Level II determination, indicating a serious mental illness and recommending nursing home admission with specialized services. However, the resident's Significant Change (SC) Minimum Data Set (MDS) assessment did not reflect the PASRR evaluation. During an interview, the staff member responsible for completing the SC MDS confirmed that the PASRR was not identified in the assessment and was unaware of the resident's PASRR Level II status.
Expired Medication Found in Unlocked Resident Refrigerator
Penalty
Summary
The facility failed to ensure that medications were stored securely and discarded upon expiration, as evidenced by an expired medication being found in an unlocked refrigerator designated for resident food storage. The policy review indicated that the facility's medication storage policy required a lock and key system to secure medications and a separate area for storing discontinued, expired, or unusable medications. However, during an observation, it was found that the facility did not adhere to this policy. An observation conducted with the Assistant Director of Nursing (S3ADON) revealed that a refrigerator labeled 'Resident Refrigerator' was unlocked and centrally located on Hall A. This refrigerator was intended for resident food items and was accessible to residents and their families at any time. Inside this refrigerator, a half-full container of Gavilyte G, a laxative prescribed to a resident, was found. The prescription label indicated that the medication had expired. S3ADON confirmed that the medication belonged to a resident and acknowledged that it should not have been stored in the resident food refrigerator and should have been discarded due to its expiration.
Infection Control Breach During Nephrostomy Tube Dressing Change
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by a Licensed Practical Nurse (LPN) not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols during a nephrostomy tube dressing change for a resident. The resident, who was on EBP due to bilateral nephrostomy tubes, required the use of gown and gloves for high-contact care activities. However, the LPN entered the resident's room without wearing a gown or gloves, despite the presence of an EBP sign and available PPE outside the room. During the dressing change, the LPN did not change gloves or perform hand hygiene after removing the soiled dressing and before cleaning the wound site. Additionally, the LPN failed to change gloves or perform hand hygiene between the dressing changes on the left and right nephrostomy tubes. These actions were confirmed by the LPN, the Assistant Director of Nursing/Infection Preventionist, and the Director of Nursing, all acknowledging the failure to follow the facility's infection control policies and procedures.
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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) |
|---|---|---|---|---|
| Resthaven Nursing & Rehab Center, Llc | 0.5 mi | ★★★★★ | 4 | 0 |
| The Gardens And Guardian | 0.6 mi | ★★★★★ | 0 | 0 |
| Lake Charles Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Rosewood Nursing Center | 2.9 mi | ★★★★★ | 1 | 0 |
| Calcasieu Community Care Center | 3.9 mi | ★★★★★ | 3 | 0 |
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