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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gueydan Memorial Guest Home during CMS and state inspections, most recent first.
MDS assessments did not accurately reflect resident status for three residents. One resident’s MDS failed to code hypoglycemic use despite insulin administration, another resident’s MDS failed to code bed and chair alarms despite an order for a clip alarm and documentation that the alarm was in place, and a third resident’s MDS failed to code depression and hypoglycemic use despite MAR documentation of Sertraline, Glimepiride, and Pioglitazone. The MDS staff member confirmed the coding errors during interview and record review.
Unlabeled Enteral Feeding Bag: A resident with dysphagia and gastrostomy status had an enteral feeding order for Osmolite at 45 ml/hr, but the tube feeding bag was observed without a label. An LPN stated the bag should have included the resident's name, date, time, rate, and nurse's initials, and confirmed it was not labeled.
Oxygen Delivered at Incorrect Ordered Rate: A resident with COPD and pneumonia had an order for O2 at 2 L via NC QHS and PRN, but was observed with the oxygen set at 4 L. An LPN/Treatment Nurse reviewed the order and confirmed the setting was incorrect, and the resident stated she does not touch the machine.
Failure to Assess Entrapment Risk and Obtain Consent for Assist Bars: A resident with dementia, repeated falls, and osteoarthritis was observed in bed with both upper assist bars raised. The chart showed the resident needed extensive help with bed mobility and could use assist bars as needed, but there was no documented entrapment risk assessment or informed consent from the resident or representative before the assist bars were used; the DON confirmed both omissions.
Controlled medication documentation was inaccurate for one resident in Med Cart 1. A resident with Anxiety Disorder had an order for PRN lorazepam, and the EHR showed the dose was given, but the narcotic record did not reflect the administration. During a controlled drug count, an LPN stated she gave the medication and forgot to sign it on the narcotic log, and the DON confirmed controlled meds are to be documented immediately after administration.
Expired medications were found in a med cart and the med room, including Linzess, Trazadone, and Mirtazapine, and an LPN confirmed they should have been discarded. Surveyors also found orange juice stored in the medication-only refrigerator, and both the LPN and DON confirmed food should not be stored with medications.
A resident receiving hospice services did not have the most recent hospice plan of care or physician recertification of terminal illness in the facility record. The resident had diagnoses including CAD, CHF, and AKI, and the MDS noted a chronic disease with a life expectancy of less than 6 months. The LPN/Treatment Nurse confirmed the documents were missing, and the DON acknowledged she was responsible for obtaining them and that they should have been available.
The facility did not ensure residents' personal funds were accessible during non-banking hours, affecting 51 residents. During a resident council meeting, residents reported they could not access petty cash on weekends, as it was only available when the business office was open. The Social Services Director confirmed this practice and was unaware that petty cash needed to be accessible at all times.
The facility did not deliver mail to residents on Saturdays, affecting 49 residents. During a resident council meeting, several residents reported not receiving their unopened mail on Saturdays, with mail only being delivered when the office was open from Monday to Friday. The Secretary/Transportation Supervisor/Medical Record confirmed that no staff was available on Saturdays to deliver mail, resulting in Saturday mail being delivered on Monday morning.
The facility failed to follow its grievance policy, resulting in unresolved grievances and residents unaware of the grievance process. Only five grievances were filed over a year, with two unresolved. Residents reported not knowing how to file grievances, and the Social Services Director admitted to not understanding what should be filed as a grievance.
The facility failed to maintain a clean and sanitary kitchen, affecting 44 residents. Observations revealed food residue in the fryer, build-up on the deep freezer, and debris in the oven. Unlabeled and spoiled food items were found, and a staff member was seen without a beard restraint. The Dietary Manager confirmed these issues, acknowledging non-compliance with cleaning and labeling policies.
The facility failed to ensure accurate MDS assessments for three residents. A resident with End Stage Renal Disease did not have dialysis treatment reflected in their MDS. Another resident was incorrectly identified as using physical restraints, despite no evidence or orders for such. Additionally, a resident receiving continuous oxygen therapy was not documented as such in their MDS. These inaccuracies were confirmed during record reviews and interviews.
The facility failed to implement its smoking safety policy for residents identified as unsafe smokers. Despite the policy requiring smoking aprons and supervision, three residents with conditions like Alzheimer's and dementia were observed smoking without aprons. Staff interviews confirmed the policy was not followed, leading to a deficiency in accident hazard prevention.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy during hospital transfers. Despite multiple transfers, there was no evidence of notification, and interviews confirmed the facility's practice of not sending bed-hold letters due to available open beds.
The facility failed to ensure proper oxygen delivery and care planning for two residents. One resident received oxygen at an incorrect rate, while another's care plan lacked focus on pneumonia management and continuous oxygen use, as confirmed by staff reviews.
The facility did not maintain RN coverage for 8 consecutive hours daily, as required. Time card reviews from January to March 2024 revealed insufficient RN hours on specific days in February and March. Interviews confirmed the lack of coverage, with the DON acknowledging the issue and a secretary unable to provide documentation for claimed RN hours.
A resident with dysphagia and other conditions was not provided a mechanically altered diet as ordered by the physician. The resident's meal tray included whole slices of meatloaf and garlic bread, contrary to the finely chopped texture specified in the dietary order. This was confirmed by an RN during an observation.
The facility did not maintain an effective infection control program by failing to conduct an annual review of its policies and procedures. The policy was last updated in 2018, and the DON/IP could not provide documentation of a recent review, admitting unawareness of the annual review requirement.
MDS Assessments Did Not Match Resident Status
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 3 sampled residents. For Resident #2, the Quarterly MDS with an assessment reference date of 07/01/2025 coded Section N0415(J) Hypoglycemic as no, even though the MAR showed Lantus and Novolog were administered from 06/25/2025 through 07/01/2025. During interview and record review on 08/26/2025, the MDS staff member confirmed that yes should have been coded for the hypoglycemic item and was not. For Resident #13, the Quarterly MDS with an assessment reference date of 07/25/2025 coded bed alarm and chair alarm as not used, despite a physician order dated 01/24/2024 for a clip alarm at all times due to poor safety awareness and q1 hour checks, and the July 2025 MAR showing the clip alarm was in place at all times for the entire month. The MDS staff member confirmed the resident used a chair alarm and a bed alarm for the month of July 2025 and that both items should have been coded as used. For Resident #42, the significant change MDS with an assessment reference date of 05/28/2025 coded depression and hypoglycemic as no, although the MAR showed Sertraline was administered for depression and Glimepiride and Pioglitazone were administered as hypoglycemics during the look-back period. The MDS staff member confirmed both items should have been coded yes.
Unlabeled Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident's enteral feeding was properly labeled for Resident #5, who had diagnoses including muscle wasting and atrophy, dysphagia, and gastrostomy status. The resident had a physician's order for enteral feeding with Osmolite at 45 ml per hour. During an observation of the resident's tube feeding bag and administration set, the formula bag was found to have no label. The facility's policy for continuous pump enteral tube feeding stated that the formula label should document initials, the date and time the formula was hung or administered, and initials that the label was checked against the order. During interview and observation, an LPN stated that tube feeding bags should be labeled with the resident's name, date, time, rate, and nurse's initial, and confirmed that the resident's tube feeding bag was not labeled and should have been.
Oxygen Delivered at Incorrect Ordered Rate
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards of practice by not ensuring that oxygen was delivered at the ordered rate for Resident #18. The resident was admitted with diagnoses including chronic obstructive pulmonary disease and pneumonia, and her annual MDS showed a BIMS score of 15, indicating she was cognitively intact. Her physician's order dated 03/24/2025 directed oxygen at 2 liters per nasal cannula every night and as needed. During observation on 08/25/2025, Resident #18 was seen in the dining room with oxygen in place by nasal cannula, and the oxygen setting was observed at 4 liters. A Licensed Practical Nurse/Treatment Nurse later observed the same setting and reviewed the physician's orders, confirming that the oxygen should have been set at 2 liters and was incorrectly set at 4 liters. When interviewed, Resident #18 stated that she does not touch the machine at all.
Failure to Assess Entrapment Risk and Obtain Consent for Assist Bars
Penalty
Summary
The facility failed to ensure that Resident #13 was assessed for the risk of entrapment from assist bars and failed to obtain informed consent before the assist bars were used. The facility policy on Bed Safety and Bed Rails stated that a resident assessment for entrapment risk should include factors such as diagnosis, size and weight, sleep habits, medications, cognition, mobility, and fall risk, and that staff must inform the resident or representative about the benefits and potential hazards of bed rails and obtain informed consent before use. Resident #13 was admitted with diagnoses including dementia with behavioral disturbance, repeated falls, and osteoarthritis. The resident's MDS showed a BIMS score of 2, indicating severely impaired cognition, and the resident required substantial to maximal assistance with bed turning and was dependent for chair-to-bed transfers. The care plan stated that the resident needed assistance of 2 staff for repositioning in bed and that assist bars x 2 could be used as needed for bed mobility. During observation, the resident was in bed with both left and right upper assist bars raised. Record review showed no evidence of an entrapment risk assessment or consent from the resident or responsible party, and the DON confirmed that the side rail assessment did not include entrapment risk and that informed consent had not been obtained.
Controlled Medication Administration Not Documented
Penalty
Summary
The facility failed to provide pharmaceutical services by not accurately documenting controlled medication reconciliation for one resident in Med Cart 1. Resident #43 was admitted with a diagnosis that included Anxiety Disorder and had a physician order for Lorazepam Oral Tablet 1 mg, a controlled drug, to be given every 4 hours as needed for anxiety. The resident’s EHR showed the medication was administered at 8:34 a.m. on 08/27/2025, but the facility’s Individual Resident’s Narcotic Record did not show that administration. During a controlled drug count and interview, the LPN stated she had administered the Lorazepam that morning and forgot to sign it on the resident’s narcotic record. Review of the blister pack showed 29 tablets remaining when 30 tablets were supposed to be present, matching the documented administration in the EHR but not the narcotic log. The DON confirmed that after a narcotic or controlled medication is administered, it is to be documented immediately on the resident’s Individual Resident’s Narcotic Log.
Expired Medications and Food Stored With Medications
Penalty
Summary
The facility failed to ensure medications were stored properly in accordance with currently accepted professional principles. During observation of Med Cart 1, surveyors found one bottle of Linzess 72 mcg with an expiration date of 06/05/2025 still stored in the cart. The LPN observed with the cart confirmed the medication was expired and should have been discarded and not kept in the med cart. Surveyors also observed the Med Room and found two expired medications, including one Trazadone 100 mg blister packet with an expiration date of 04/29/2025 and one Mirtazapine 15 mg blister packet with an expiration date of 06/14/2025. In the same medication-only refrigerator, surveyors found a bottle of orange juice stored with medications. The LPN confirmed both medications were expired and should have been discarded and not kept in the med room, and confirmed that food items should not be stored in the same refrigerator as medications. The DON also confirmed that no expired medications should be in med carts or the med room and that food items should not be stored with medications.
Missing Current Hospice Certification and Plan of Care
Penalty
Summary
The facility failed to ensure the designated interdisciplinary team member obtained the most recent hospice plan of care and physician recertification of terminal illness for a resident receiving hospice services. The facility policy titled Hospice Program stated that the DON was responsible for coordinating care with hospice staff and obtaining the most recent hospice plan of care and physician certification and recertification for each resident. Resident #9 was admitted with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, chronic diastolic congestive heart failure, and acute kidney failure. The quarterly MDS indicated the resident had a chronic disease that may result in a life expectancy of less than 6 months, and a physician order dated 01/20/2025 admitted the resident to hospice services with no order to discharge from hospice. Review of the medical record showed no current hospice certification or plan of care; the last available certification period and plan of care were dated 04/10/2025 to 07/18/2025. During interview, the LPN/Treatment Nurse confirmed the resident did not have a current certification and plan of care in the record, and the DON stated she was responsible for obtaining them and confirmed they should have been in the facility.
Inaccessibility of Residents' Personal Funds During Non-Banking Hours
Penalty
Summary
The facility failed to ensure that residents' personal funds were accessible during non-banking hours, affecting 51 residents who had deposited funds in the residents' trust fund. During a resident council meeting, several residents reported that they could not access petty cash on weekends, as it was only available when the business office was open during weekdays. The Social Services Director confirmed that petty cash was not available to residents on weekends and was unaware that it needed to be accessible at all times.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, which affected 49 residents. During a resident council meeting, three residents reported that they did not receive their unopened mail on Saturdays. Two of these residents stated that they only received their mail when the office was open from Monday through Friday. An interview with the Secretary/Transportation Supervisor/Medical Record (S4SEC) confirmed that there was no staff available in the business office on Saturdays to deliver mail to residents. As a result, mail received on Saturdays was not delivered to residents until the following Monday morning.
Failure to Follow Grievance Policy
Penalty
Summary
The facility failed to adhere to its grievance policy and procedure, which resulted in a deficiency. The policy, last revised in April 2017 and reviewed in April 2023, mandates that all grievances and complaints be investigated, recorded, and resolved promptly. However, the facility's grievance records from July 2023 to July 2024 showed only five grievances filed, with only three resolved. Two grievances lacked resolution and were not signed by the Administrator within the required five days. This indicates a failure to follow the established grievance process. Interviews with residents during a council meeting revealed that several residents were unaware of how to file grievances or whom to contact. One resident expressed that they were not informed if grievances were filed or resolved. The Social Services Director (S3SSD), responsible for handling grievances, admitted to being unsure about what should be filed as a grievance. She mentioned that the Activities Director (S9ACT) usually received complaints informally during morning coffee sessions, and these were discussed in staff meetings without formal grievance documentation. This lack of awareness and formal procedure adherence contributed to the deficiency.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect the 44 residents who consumed food from the kitchen. During an inspection, several deficiencies were observed, including food residue and dark black grease in the kitchen fryer, a build-up of brown substance on the outside of the deep freezer, and debris inside the conventional oven. Additionally, the facility's policies regarding food storage and labeling were not followed, as evidenced by unlabeled chicken base, spoiled cheese, dented canned goods, and unlabeled pasta, soda, vanilla flavoring, and cream potatoes. Furthermore, the facility did not adhere to its policy on personal hygiene, as a staff member was observed in the kitchen without a beard restraint. The walk-in refrigerator had food residue and debris on the floor, and a scoop was improperly stored inside a cereal container. The Dietary Manager confirmed these findings and acknowledged that the fryer should have been cleaned, the grease drained, and the conventional oven and deep freezer cleaned. The manager also confirmed that food items should be labeled with the date they were opened or prepped, and dented cans and discolored food should be discarded immediately.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The provider failed to ensure accurate assessments for three residents, leading to deficiencies in the Minimum Data Set (MDS) documentation. Resident #14, who was diagnosed with End Stage Renal Disease and dependent on renal dialysis, had an MDS assessment that did not reflect the dialysis treatment received three times a week, as confirmed by the S5MDS during a record review and interview. Similarly, Resident #28, with diagnoses including Cognitive Communication Deficit and Dementia, was incorrectly identified as using physical restraints in the MDS assessment, despite no evidence or orders for such restraints being found in the resident's records or observed during room checks. Additionally, Resident #102, who had diagnoses of Pneumonia, Hypoxia, and Heart Failure, was receiving continuous oxygen therapy as per physician's orders. However, the MDS assessment failed to indicate the use of oxygen, which was confirmed by the S5MDS during a review of the resident's records. These inaccuracies in the MDS assessments highlight the provider's failure to ensure that the residents' assessments accurately reflected their current medical treatments and conditions.
Failure to Implement Smoking Safety Policy for Unsafe Smokers
Penalty
Summary
The facility failed to ensure the safety of residents who were identified as unsafe smokers by not implementing its own smoking policy. The policy required that residents deemed unsafe smokers be provided with a smoking apron and be supervised while smoking. However, during observations, three residents identified as unsafe smokers were seen smoking without wearing the required smoking aprons. These residents had various diagnoses, including Alzheimer's disease, dementia, major depressive disorder, anxiety disorder, and other conditions that could potentially affect their safety while smoking. Interviews with facility staff, including the Director of Nursing/Infection Preventionist and a Certified Nursing Assistant/Smoke Aide, revealed a lack of adherence to the facility's smoking policy. Despite acknowledging that the residents were unsafe smokers, staff members stated that the residents did not require a smoking apron. This was in direct contradiction to the facility's policy, which was confirmed by the Director of Nursing/Infection Preventionist during the review of the policy. The failure to provide smoking aprons as required by the policy resulted in a deficiency related to accident hazards and inadequate supervision.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide a written notice to a resident and their representative regarding the duration of the bed-hold policy during hospital transfers. This deficiency was identified during a review of the facility's policy titled 'Bed-Holds and Returns,' which mandates that residents and their representatives receive written information about bed-hold policies both in advance of any transfer and at the time of transfer. The review of Resident #102's electronic medical record and the Ombudsman Notification of Transfer logs revealed multiple hospital transfers without evidence of written notification being sent to the resident or their responsible party. Interviews conducted with the resident and the Director of Nursing/Infection Preventionist (S2DON/IP) confirmed the lack of written notification. The resident did not recall receiving any notice regarding bed-hold during hospital transfers. The S2DON/IP reported that the facility did not send out bed-hold letters because the Administrator believed it was unnecessary due to the availability of open beds. This practice was confirmed as no letter was sent to Resident #102 or their responsible party during the hospital transfers.
Oxygen Delivery and Care Plan Deficiencies
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards of practice by not ensuring that oxygen was delivered at the ordered rate for two residents. Resident #2, who was admitted with diagnoses including Pneumonia, Sepsis, and Dementia, had a physician's order for oxygen at 2 liters per nasal cannula continuously. However, observations on two separate occasions revealed that the oxygen was set at 3 liters, contrary to the physician's orders. This discrepancy was confirmed by a Licensed Practical Nurse who reviewed the resident's orders and observed the incorrect oxygen setting. Resident #102, admitted with diagnoses including Pneumonia, Edema, Heart Failure, Tachycardia, and Anxiety, had a physician's order for continuous oxygen at 3 liters per nasal cannula due to pneumonia. Despite this, the resident's care plan did not include a focus or goal related to managing pneumonia symptoms, nor did it mention the continuous use of oxygen. This oversight was confirmed by a Minimum Data Set nurse who reviewed the care plan and acknowledged the absence of the necessary focus and intervention related to the resident's condition and treatment needs.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. This deficiency was identified through a review of time card reports from January 2024 through March 2024. On February 19, 2024, the Director of Nursing/Infection Preventionist (S2DON/IP) worked only 5.5 hours, and no other RN was recorded as working that day. On February 26, 2024, the combined RN coverage was only 7 hours and 48 minutes, with S11RN working 6.35 hours and S2DON/IP working 7 hours and 48 minutes. Additionally, on March 10, 2024, there was no documented RN coverage on the time card report, although a secretary (S4SEC) claimed that an RN (S10RN) worked that day but could not provide documentation to support this claim. Interviews conducted on August 7, 2024, confirmed these findings. S2DON/IP acknowledged the lack of 8 consecutive hours of RN coverage on the specified dates in February. S4SEC reported that S10RN worked on March 10, 2024, but failed to provide time card documentation to verify this information by the time of the exit conference.
Failure to Provide Mechanically Altered Diet as Ordered
Penalty
Summary
The facility failed to ensure that a resident received a mechanically altered diet as ordered by the physician. Resident #35, who was admitted with diagnoses including Non-infective Gastroenteritis, Colitis, and Dysphagia, had a physician's order for a No Added Salt (NAS) diet with finely chopped texture and regular consistency. Despite this order, an observation on 08/05/2024 revealed that the resident's meal tray contained a whole slice of meatloaf and a whole slice of garlic bread, neither of which were finely chopped as required. This discrepancy was confirmed by a registered nurse, S8RN, who acknowledged that the meal did not comply with the physician's dietary order for the resident.
Failure to Conduct Annual Review of Infection Control Policies
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not conducting a yearly review of the infection program policies and procedures. The facility's policy titled 'Infection Prevention and Control Program' was last updated in October 2018, indicating a lapse in the annual review requirement. During an interview, the Director of Nursing/Infection Preventionist (S2DON/IP) acknowledged responsibility for overseeing the infection control program but was unable to provide documentation of the last review of the IPCP policies and procedures. S2DON/IP also admitted to being unaware of the requirement for annual reviews of these 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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kaplan Healthcare Center | 13 mi | ★★★★★ | 14 | 0 |
| Southwind Nursing & Rehabilitation Center | 15.8 mi | ★★★★★ | 9 | 0 |
| Southwest Louisiana War Veterans Home | 16.1 mi | ★★★★★ | 0 | 0 |
| Jeff Davis Living Center, Llc | 16.4 mi | ★★★★★ | 0 | 0 |
| Landmark Of Rayne | 17.2 mi | ★★★★★ | 8 | 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 August 2026) and official state health department websites.