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 Resthaven Nursing & Rehab Center, Llc during CMS and state inspections, most recent first.
Food storage and kitchen sanitation deficiencies were identified when an opened mustard container in the walk-in cooler was not dated, multiple refrigerated items and dry storage milk were expired, the deep fryer had grease and food debris buildup, and two dietary workers were observed with exposed facial hair and mustaches without beard restraints while handling meal trays.
A resident admitted with type 2 DM with diabetic CKD was discharged shortly after admission, but the EMR did not show written notification to the State LTC Ombudsman. During interview, the ADM stated the facility did not notify the Ombudsman of discharges.
Failure to Complete Significant Change MDS Assessments: The facility failed to complete significant change MDS assessments for two residents after documented declines in function, continence, cognition, and other areas. One resident with CHF, hypokalemia, and depression had functional decline, bowel and bladder incontinence decline, and orthopedic fracture repair surgery; another resident with COPD, dementia, and chronic pain syndrome had cognitive decline and functional decline in multiple areas. The MDS nurse confirmed the declines and stated she did not know the criteria for a significant change assessment.
Incorrect MDS Coding for Antipsychotic Use. A resident with delusional disorder and major depressive disorder was ordered Aripiprazole 2 mg daily and received it daily per the eMAR, but the quarterly MDS incorrectly marked antipsychotic use as No in Section N0415. The CCC later verified the resident was receiving the antipsychotic and confirmed the MDS was coded incorrectly.
The facility's kitchen was found to be unsanitary, with excessive food residue, black mildew-like residue, and pest infestations, posing a risk of foodborne illnesses to 110 residents. Equipment and surfaces were not properly cleaned, and food storage practices were inadequate. Additionally, dietary workers lacked proper hair restraints, and used gloves were improperly left in the drink service area. These deficiencies were confirmed by staff and observed during multiple visits.
The facility failed to maintain sanitary conditions in the kitchen, leading to an Immediate Jeopardy situation due to the risk of foodborne illness for 110 residents. Despite awareness of a gnat problem and previous cleanliness issues, the Administrator and Regional Administrator did not conduct thorough inspections, and the Dietary Manager did not report any problems. An email from the Administrator highlighted unresolved cleanliness issues, indicating a lack of effective oversight and communication.
The facility failed to maintain an effective pest control program, resulting in a gnat infestation and the presence of cockroaches in the kitchen. Despite pest control efforts, the issue persisted, affecting the facility's ability to provide a pest-free environment for meal preparation.
The facility failed to follow physician orders and update care plans for three residents. A resident received incorrect water flushes, another was not provided with a prescribed heel protector, and a third resident's care plan was not updated after a fall, despite staff being in-serviced on new interventions. These deficiencies were confirmed by the DON and other staff during observations and interviews.
A facility failed to ensure proper dialysis care for a resident by not assessing the resident's condition before treatments and lacking effective communication with the dialysis center. The resident's communication binder was often incomplete, and staff were unaware of communication procedures. A transporter took the resident to dialysis without a completed pre-dialysis assessment or communication sheet.
A facility failed to ensure proper labeling of a tube feeding container for a resident with Dysphagia and Multiple Sclerosis. The resident was observed receiving Jevity via a feeding pump, but the label lacked the date and time the feeding was hung. An LPN confirmed the omission during an interview and observation.
The facility failed to properly store respiratory equipment for two residents, leading to a deficiency in care. A resident with respiratory conditions had their nebulizer mask left exposed instead of being stored in a bag, as per facility policy. A nurse confirmed the improper storage, and the DON acknowledged the oversight.
The facility failed to maintain adequate staffing levels on weekends, as evidenced by low weekend staffing data. The facility's assessment indicated a need for above 2.35 nursing hours per resident, but on specific weekends, the nursing hours provided were at or just above this minimum requirement. Interviews with the ADON and DON confirmed that staffing levels were insufficient to meet resident needs, resulting in a high resident-to-nurse aide ratio and challenges in providing necessary care.
A nurse in an LTC facility failed to follow medication administration protocols by leaving a medicine cup with 10 pills at a resident's bedside without ensuring they were taken. The resident, who was cognitively intact, had no physician's order or care plan for self-administration. The facility's policy requires that medications be administered at the time they are prepared and that the nurse remains with the resident until all medication is swallowed. This breach was confirmed by the Clinical Care Coordinator and the Director of Nursing.
The facility failed to follow its medication storage policy, resulting in expired and unlabeled medications being found during an inspection. Expired medications were discovered in the refrigerator and on medication carts, and an unlabeled inhaler was found on a cart. The DON confirmed that these practices were against policy, potentially affecting the care of 111 residents.
A facility with 160 licensed beds failed to employ a qualified full-time social worker. The Administrator, lacking the necessary qualifications and experience, was acting as the social worker. The Human Resources representative, who assisted, also lacked the required qualifications. Despite efforts to hire a suitable candidate, the facility had not succeeded.
A facility failed to post required signage outside a COVID-19 positive resident's room, indicating the type of transmission-based precautions and necessary PPE, as per their infection control policy. This oversight was confirmed by a registered nurse and the infection preventionist, potentially affecting six residents on similar precautions.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards and to maintain sanitary kitchen conditions. During a kitchen tour with the Dietary Manager, surveyors observed a large opened container of yellow mustard in the walk-in cooler that was not labeled with the date it was stored or opened. The Dietary Manager confirmed the item should have been labeled. Additional items in the walk-in cooler were observed to be expired, including two large opened containers of cherries, a large opened container of strawberry spread, an opened block of Swiss cheese in a plastic gallon bag, and an opened block of cream cheese in a plastic gallon bag. The Dietary Manager confirmed these items were expired and should have been removed and discarded. Surveyors also observed 10 cans of evaporated milk in the dry storage area with an expiration date of 08/07/2025, and the Dietary Manager confirmed they were expired and should have been removed and discarded. In the kitchen, the deep fryer cover had grease splatter and a thick layer of debris, and when the cover was removed, the cooking oil collection area contained a thick layer of food debris and pieces of fried food material. The Dietary Manager confirmed the deep fryer had not been cleaned after use. Later, two dietary workers were observed placing meal trays on hall food carts while wearing exposed facial hair and mustaches without beard restraints, and the Dietary Manager confirmed their facial hair was not covered as required.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State's Long-Term Care Ombudsman in writing of a resident discharge. Resident #110 was admitted on 06/11/2025 with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, and the EMR showed the resident was discharged on 06/13/2025. Review of the record did not reveal evidence that the Ombudsman was notified in writing of the discharge. During an interview on 08/20/2025, the Administrator stated the Ombudsman had not been notified because this was something the facility did not do.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a significant change MDS within 14 days after determining that a significant change had occurred for 2 residents. The facility policy titled Resident Assessment Instrument (RAI) Policy stated that significant change assessments are to be completed as soon as needed to provide appropriate care, but no later than 14 days after determining a significant change in a resident’s physical or mental condition. Resident #2 was admitted with diagnoses including combined systolic and diastolic heart failure, hypokalemia, and depression. A comparison of MDS assessments with ARD dates of 03/25/2025 and 06/11/2025 showed a decline in functional status in 8 areas, a decline in bowel and bladder continence, and a major orthopedic fracture repair surgery, but the EMR did not show that a significant change assessment had been completed. Resident #4 was admitted with diagnoses including COPD, dementia, and chronic pain syndrome. A comparison of MDS assessments with ARD dates of 05/03/2025 and 08/03/2025 showed a decline in cognitive function/BIMS score and a decline in functional status in 11 areas, and the EMR also did not show that a significant change assessment had been completed. During a concurrent record review and interview, the MDS nurse reviewed both residents’ assessments, confirmed the declines, and stated she did not know the criteria that warranted a significant change assessment and confirmed that one had not been done.
Incorrect MDS Coding for Antipsychotic Use
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the provider failed to accurately code a resident's MDS for use of an antipsychotic medication. Resident #25 had an admit date of 06/18/2015 and diagnoses including delusional disorder and major depressive disorder. The resident's physician orders included Aripiprazole 2 mg daily, and the eMAR for May 2025 through June 2025 showed the medication was administered daily. However, the quarterly MDS with an ARD of 06/03/2025 showed Section N0415, High Risk Drug Classes: Use, Antipsychotic, marked as No for whether the resident was taking an antipsychotic. During an interview and electronic record review on 08/20/2025, the Clinical Care Coordinator verified the resident received Aripiprazole, an antipsychotic medication, and stated the quarterly MDS was coded incorrectly.
Unsanitary Kitchen Conditions and Improper Food Handling
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which posed a risk of cross-contamination and foodborne illnesses to the 110 residents who consumed meals prepared there. During multiple visits, surveyors observed excessive food residue on kitchen equipment, including the stove top, oven, and fryer. There was also black residue under the ice machine's filter, and ice buildup on the floor of the walk-in refrigerator. Additionally, the dish and cookware storage areas were found to have dried food residue, and some clean dishes had food debris. Food storage practices were inadequate, with dented cans, unlabeled bags of cereal, and containers of tuna fish without preparation dates. The kitchen surfaces were also found to be unsanitary, with trash debris and dirt on the floors, black residue resembling mildew on walls and baseboards, and dried food particles on various surfaces. The dishwashing room had significant cleanliness issues, including a large area of black residue behind the dishwasher, dried brown splatter on walls, and a dirty towel hanging on the door. Pests were present, with gnats flying in the dishwashing room and cockroaches found in the kitchen and dry storage areas. Additionally, dietary workers were observed without proper hair and facial hair restraints, further compromising food safety. In another instance, the facility failed to adhere to professional standards for food service safety by leaving used soiled gloves in the residents' drink service area. During lunch service, a pair of used food gloves was found on the counter where residents' drinks were being poured and served. A registered nurse admitted to using the gloves for serving drinks and then placing them on the counter instead of disposing of them in the garbage can. The infection preventionist confirmed that the gloves should have been discarded properly to maintain hygiene standards.
Kitchen Oversight Failure Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to unsanitary and unsafe conditions in the kitchen, which posed a high likelihood of causing foodborne illness to 110 residents. The deficiency was identified as an Immediate Jeopardy situation on 08/18/2024. The Registered Dietician (RD) conducted a quarterly walkthrough of the kitchen on 06/19/2024 and reported no cleanliness issues, although she was aware of a gnat problem for several months. The facility had received a Retail Food Notice of Violations on 06/11/2024, indicating non-critical cleanliness issues, but the Administrator (ADM) believed these had been corrected. Despite being aware of the gnat issue since 08/09/2024, the ADM did not conduct a thorough inspection of the kitchen. The Regional Administrator (RA) and the Dietary Manager (DM) were also involved in the oversight of the kitchen. The RA conducted rounds and observed the kitchen on 08/12/2024, reporting no issues, while the DM was responsible for ensuring daily, weekly, and monthly cleaning tasks were completed. However, the ADM and RA were unaware of the ongoing cleanliness issues, and the DM did not report any problems. An email from the ADM to the DM on 06/05/2024 highlighted several cleanliness issues, but these were not addressed in a meeting. The lack of documentation of kitchen rounds by the ADM and RA further indicates a failure in oversight and communication regarding the kitchen's condition.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects in the kitchen area. During an inspection, a large swarm of gnats was observed in the dishwashing room, and live cockroaches were found behind the stove and in the dry food storage room. Additionally, three dead roaches were discovered in a bucket under the food prep counter. The Dietary Manager acknowledged that a bug light in the kitchen was out of order, which may have contributed to the pest issue. Interviews with facility staff revealed that the pest problem had been ongoing for several months. The Registered Dietician confirmed awareness of the gnat issue during her quarterly kitchen walkthrough. The Administrator was informed of the gnat problem and contacted pest control, but the treatment was ineffective. Both the Regional Administrator and the Administrator acknowledged the persistence of pest control issues despite previous treatments.
Failure to Follow Physician Orders and Update Care Plans
Penalty
Summary
The facility failed to adhere to physician's orders and update care plans for three residents, leading to deficiencies in care. For Resident #1, the facility did not follow the physician's order for water flushes at 45ml/hr, instead administering them at 40ml/hr, as confirmed by the Director of Nursing during observations. Resident #4 was not provided with the prescribed Prevalon heel protector for her right foot during multiple observations, despite the physician's order for it to be worn at all times. The Director of Nursing confirmed the absence of the heel protector during an observation. Resident #5 experienced a fall on 05/07/2024, but the care plan was not updated with new interventions to prevent further falls, such as toileting every two hours, until after a subsequent fall on 06/08/2024. The Assistant Director of Nursing and the Minimum Data Set coordinator confirmed that the care plan was not updated following the initial fall, despite staff being in-serviced on the new toileting schedule. This oversight in updating the care plan contributed to the resident's continued risk of falling.
Failure in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident who required such services. Specifically, the facility did not ensure the assessment of the resident's condition before dialysis treatments and failed to maintain an effective communication system between the facility and the dialysis center. The resident, who was dependent on renal dialysis, was admitted with diagnoses including surgical aftercare following circulatory system surgery and vitamin deficiency. The resident was scheduled for dialysis three times a week at an offsite center. However, the facility's communication binder, which was supposed to contain information communicated to the dialysis center, was found lacking entries on multiple dates. During the investigation, it was revealed that the communication binder was often misplaced, and the facility staff, including the LPN and the Director of Nursing, were unaware of a specific communication procedure with the dialysis center. The facility's policy on post-dialysis care did not address communication, and the corporate nurse was unfamiliar with any regulations regarding dialysis communication. Additionally, a transporter was observed taking the resident to dialysis without a completed pre-dialysis assessment or communication sheet, which was confirmed by an LPN who admitted to not assessing the resident or communicating with the dialysis center.
Failure to Label Tube Feeding Container
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a feeding tube by not ensuring the tube feeding container was properly labeled. Resident #4, who was admitted with diagnoses including Dysphagia and Multiple Sclerosis, was observed receiving Jevity via a feeding pump. However, the label on the tube feeding formula did not include the date and time it was hung, as required. This deficiency was confirmed during an interview and observation with an LPN, who acknowledged the omission of the necessary labeling information.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for two residents, leading to a deficiency in respiratory care. Resident #31, who was admitted with diagnoses including Respiratory Failure and Chronic Obstructive Pulmonary Disease, had physician orders for multiple inhalation solutions to be administered via nebulizer. Observations on two separate occasions revealed that Resident #31's nebulizer mask was left exposed on top of the nebulizer machine and not stored in a closed plastic bag as required by the facility's policy. A registered nurse confirmed the mask should have been bagged and noted the absence of a storage bag in the resident's room. Similarly, Resident #27, admitted with conditions such as Shortness of Breath and Wheezing, had orders for inhalation solutions to be used as needed. An observation found Resident #27's nebulizer mask lying exposed on a nightstand without a storage bag. The registered nurse confirmed the mask was not stored properly. The Director of Nursing also acknowledged that the nebulizer masks should be stored in bags when not in use, confirming the facility's failure to adhere to its own policy.
Inadequate Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels of skilled licensed nurses, nurse aides, and other nursing personnel on weekends, as evidenced by excessively low weekend staffing data. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2 of 2024 showed that the facility's weekend staffing was below the required levels. The facility's assessment indicated an average daily census of 117-125 residents, with a staffing plan aiming to provide above 2.35 nursing hours per resident. However, on specific weekends, the nursing hours provided were at or just above the minimum requirement, with a census of 122 to 124 residents. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the staffing levels were inadequate to meet the needs of the residents. The ADON stated that a minimum of 21 nurse aides per day was necessary, but on certain weekends, only 20 nurse aides were available, with one being an orientation nurse aide. This resulted in a high resident-to-nurse aide ratio, making it challenging to provide necessary care such as baths, showers, and meal services. The facility administrator acknowledged the low weekend staffing data and confirmed that the nursing hours provided were the minimum required, which did not meet the facility's assessment goals.
Medication Administration Protocol Breach
Penalty
Summary
The facility failed to ensure that nursing staff adhered to its policies and procedures for medication administration, as evidenced by a nurse leaving medications at a resident's bedside. The facility's policy mandates that medications be administered as prescribed and that the person administering the medication must remain with the resident until all medication has been swallowed. However, on the morning of August 18, 2024, a nurse prepared and left a medicine cup containing 10 pills on a resident's dresser without ensuring the medications were taken. This action was contrary to the facility's policy, which requires that medications be administered at the time they are prepared and that the nurse remains with the resident during administration. The resident involved, who was cognitively intact with a BIMS score of 15, had no physician's order or care plan for self-administration of medication. Despite this, the nurse left the medications unattended in the resident's room. The Clinical Care Coordinator and the Director of Nursing confirmed that the resident did not have an interdisciplinary team assessment for self-administration of medications and that the nurse should not have left the medications in the room. This incident highlights a lapse in following established medication administration protocols, potentially compromising the resident's care.
Medication Storage Deficiencies
Penalty
Summary
The facility's staff failed to adhere to the policy for medication storage, resulting in several deficiencies. During an inspection, expired medications were found in the refrigerator in Med Room A and on two medication carts. Specifically, an expired Bisacodyl suppository for a resident was found in the refrigerator, and expired medications, including Tamsulosin and Albuterol Sulfate Inhalation Aerosol, were found on the medication carts. Additionally, an unlabeled inhaler was discovered on one of the carts, with the LPN unable to identify the resident it belonged to. These findings indicate a failure to remove expired medications and ensure proper labeling, as required by the facility's policy. The facility's policy mandates that medications be stored safely and securely, with expired or unlabeled medications removed and destroyed according to procedures. However, the inspection revealed that these procedures were not followed, as evidenced by the presence of expired and unlabeled medications. The Director of Nursing confirmed that expired medications should not be stored on medication carts or in refrigerators, and that inhalers should be properly labeled. This oversight had the potential to affect the care of the facility's 111 residents.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility, which has 160 licensed beds and a census of 111 residents, failed to employ a qualified full-time social worker. The Director of Nursing (S2DON) revealed that the facility's Administrator (S1ADM) had been acting as the social worker for over a month. Despite efforts to hire a qualified social worker, the facility had not succeeded in finding a suitable candidate. A review of S1ADM's resume showed that she did not possess a bachelor's degree in social work or a related human services field, nor did she have the required one year of supervised social work experience in a healthcare setting. Additionally, the Regional Administrator (S3RA) mentioned that the Human Resources representative (S4HR) assisted the Administrator in social work duties. However, S4HR's resume indicated a Bachelor of Science in Mass Communication with a concentration in Journalism, lacking the necessary qualifications for a social worker role. S4HR confirmed her educational background and stated that she had no prior experience working with the geriatric population. This situation led to the facility's failure to meet the requirement of having a qualified full-time social worker.
Failure to Post Required Isolation Signage for COVID-19 Positive Resident
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not posting proper signage outside a resident's room to indicate the type of transmission-based precautions and the appropriate PPE required. This deficiency was observed in the case of a resident who was COVID-19 positive and on contact/droplet isolation. The facility's policy, last reviewed on February 14, 2024, required isolation rooms to have proper signage indicating the type of isolation. However, on August 18, 2024, it was observed that the resident's room door lacked any signage indicating the necessary precautions or PPE. The deficiency was confirmed during an observation with a registered nurse, who acknowledged the absence of the required signage. Further confirmation came from the facility's infection preventionist, who stated that the resident should have had a sign on the door as per the facility's policy. This oversight had the potential to affect six residents in the facility who were on transmission-based precautions, as it failed to communicate necessary infection control measures to staff and visitors.
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Illustrative
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.
Illustrative
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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) |
|---|---|---|---|---|
| Grand Cove Nursing & Rehabilitation Center | 0.5 mi | ★★★★★ | 5 | 0 |
| The Gardens And Guardian | 0.6 mi | ★★★★★ | 0 | 0 |
| Lake Charles Care Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Rosewood Nursing Center | 2.6 mi | ★★★★★ | 1 | 0 |
| Calcasieu Community Care Center | 3.4 mi | ★★★★★ | 3 | 0 |
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