Cycle 1
Health 2024-07-10 · Fire 2024-07-10
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lake Charles, LA
The Gardens And Guardian
5-star overall rating with 5-star inspections with 3 recent health deficiencies
1401 Country Club Road, Lake Charles, LA
(337) 480-1550
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
43
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-03-21
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.32 · national 0.68
LPN hours / resident day
1.85
Licensed practical nurse staffing · state 1.18 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.28
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
2.22
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
4.34
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.22 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
4.87
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,738
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.11% · Performance 27.16% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.67% · Performance 10.17% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.81
Baseline 5.17 hours · Performance 5.02 hours · Measure score 6.81 · Achievement 6.81 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 210 · Observed rate 11.9% · Lower 95% interval 8.45% |
| Discharge to community | 50.12% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 233 · Observed rate 42.49% · Lower 95% interval 44.03% |
| Medicare spending per beneficiary | 1.44 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 99.43% |
95.27%
4.2 pts better
|
Numerator 174 · Denominator 175 |
| Falls with major injury | 0.57% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 175 |
| Discharge self-care score | 71.29% |
53.69%
17.6 pts better
|
Numerator 72 · Denominator 101 |
| Discharge mobility score | 77.23% |
50.94%
26.3 pts better
|
Numerator 78 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 5.14% |
2.29%
2.8 pts worse
|
Numerator 9 · Denominator 175 · Adjusted rate 4.53% |
| Healthcare-associated infections requiring hospitalization | 10.17% |
7.12%
3 pts worse
|
Worse than the National Rate · Eligible stays 156 · Observed rate 12.18% · Lower 95% interval 7.38% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 2.5% |
42%
39.5 pts worse
|
Numerator 3 · Denominator 120 |
| Discharge function score | 70.3% |
56.45%
13.8 pts better
|
Numerator 71 · Denominator 101 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 76 · Denominator 76 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 80 · Denominator 80 |
| Resident COVID-19 vaccinations up to date | 7.29% |
25.2%
17.9 pts worse
|
Numerator 7 · Denominator 96 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.7 |
2.6
1.1 pts worse
|
1.9
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 4.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.8
2.2 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.0%
8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
94.9%
3.2 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.4%
3.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
1.8%
1.6 pts worse
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.2%
2.9 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
23.1%
7.1 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.1% |
24.4%
0.3 pts better
|
16.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
20.1%
2.8 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.6%
0.2 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 17.2% |
2.6%
14.6 pts worse
|
1.7%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
16.9%
4.3 pts worse
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
6.2%
2.9 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 5.7% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
83.6%
14.7 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 96.9% · Q3 99.3% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
14.7%
2.9 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 17.6% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
3.3%
0.1 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.1% · Q3 1.3% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.8% |
76.2%
7.6 pts better
|
79.7%
4.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.7% |
27.8%
3.9 pts worse
|
23.9%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.7% · Observed 29.6% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-21 · Fire 2023-06-21
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-06-29 · Fire 2022-06-29
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-07-10
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-08-24
D · Potential for more than minimal harm
2024-07-10
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-08-24
E · Potential for more than minimal harm
2024-01-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-08
D · Potential for more than minimal harm
2023-06-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-06-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-03
E · Potential for more than minimal harm
2022-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-06-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-08-12
C · Minimal harm
2022-06-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-08-12
Penalties and ownership
What sits behind the stars
$0
2025-03-05
Payment Denial
Payment Denial · denial start 2025-03-27 · 1 days
1 day denial
Ownership
Joubert, James
5% Or Greater Direct Ownership Interest · Individual
Joubert, Kimberly
5% Or Greater Direct Ownership Interest · Individual
Joubert, James
Corporate Director · Individual
Wilcoxon, Justin
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Resthaven Nursing & Rehab Center, LLC
Lake Charles, LA
1-star overall rating with 1-star inspections with $34,369 in total fines with 11 recent health deficiencies
#2
Grand Cove Nursing & Rehabilitation Center
Lake Charles, LA
4-star overall rating with 4-star inspections with $29,042 in total fines with 9 recent health deficiencies
#3
Lake Charles Care Center
Lake Charles, LA
3-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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