MAISON DU MONDE LIVING CENTER
For profit - Limited Liability company
128 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
9/100
#225 of 264 in LA
Photo by Maison du Monde Living Center
Photo by Maison du Monde Living Center
Photo by Maison du Monde Living Center
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Maison du Monde Living Center has a Trust Grade of F, indicating poor performance with significant concerns about care quality. It ranks #225 out of 264 facilities in Louisiana, placing it in the bottom half overall, and also #6 out of 6 in Vermilion County, meaning there are no better local options available. Although the facility is improving, as it reduced its issues from 17 to 13 over the past year, it still has a troubling history with 36 total deficiencies, including two critical incidents. Staffing is a weakness, with a low rating of 1 out of 5 stars and a turnover rate of 55%, which is average for the state but suggests instability. Specific incidents include staff failing to wash their hands after performing personal care for residents, which raises concerns about infection control and patient safety.
- Trust Score
- F
- In Louisiana
- #225/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $5,600 in fines. Higher than 77% of Louisiana facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
9/100
Bottom 15%
Review needed
17 → 13 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 17 issues
2024: 13 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $5,600
Below median ($33,413)
Minor penalties assessed
Staff turnover is elevated (55%)
7 points above Louisiana average of 48%
The Ugly 36 deficiencies on record
2 life-threatening
Dec 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure 1 (#49) of 35 sampled residents was safe to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure 1 (#49) of 35 sampled residents was safe to perform self-administration of medication.
Findings:
On 12/18/2024, a review of the facility's policy titled Self- Administration of Medications which was last reviewed on 10/09/2024, read in part, Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; Policy Interpretation and Implementation: 1. As part of their overall evaluation, the staff and/or practitioner will assess each resident's mental and physical, abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and/or practitioner will perform a more specific skill assessment, 3. If the team determines that a resident cannot safely self-administer, the nursing staff will administer the resident's medications. 4. The staff will document their findings and the choices of residents who are able to self-administer medications.
Review of Resident #49's health record revealed she was admitted to the facility on [DATE] with a diagnosis of Gastro-Esophageal Reflux Disease.
Review of Resident #49's physician orders revealed an order dated 11/17/2023, Aluminum-Magnesium-Simethicone Oral Suspension 200-200-20 mg(milligrams)/5ml(milliliters) (Alum (Aluminum) & Mag (Magnesium) Hydrox(Hydroxide)-Simethicone). Give 30ml by mouth with meals related to Gastro-Esophageal Reflux Disease without Esophagitis.
Review of Resident #49's Minimum Date Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/17/2024, revealed she had a BIMS (Brief Interview for Mental Status) score of 10, indicating moderate cognitive impairment.
Review of Resident #49's record revealed no assessment, physician's orders, or careplan for self-administration of medication.
On 12/16/2024 at 9:40 a.m., an observation and interview was conducted with Resident #49. A medicine cup containing a thick, white substance was observed on the bedside table. Resident #49 stated that she had not taken her Maalox yet, but intended to take it, referring to the medicine cup with the thick liquid.
During an observation and interview on 12/16/2024 at 9:51 a.m. with S18LPN (Licensed Practical Nurse), she confirmed she had left the medicine cup on the resident's bedside table. She stated the medication was Mylanta, and the resident preferred to drink it in intervals. She further stated that she should not have left the resident's medication at her bedside.
During an interview and record review on 12/18/2024 at 9:03 a.m. with S2DON (Director of nursing), she confirmed that Resident #49's record did not contain an assessment or a physician's order for Resident #49 to self- administer her own medications. She also confirmed that self- administration of medication was not included in her the resident's plan of care. S2DON also confirmed Resident #49 did not have the appropriate documentation to prove the resident could safely self-administer her medications and the nurse should not have been left Mylanta at the resident's bedside.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an alleged injury of unknown source was reported immediatel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an alleged injury of unknown source was reported immediately, but not later than two (2) hours after the allegation was made to the State Survey Agency for 2 (#84, #113) out of 3 (#7, #84, #113) sampled residents investigated for falls. The deficient practice had the potential to affect a total census of 112 residents.
Findings:
On 12/17/2024, a review of the facility's policy titled, Abuse Investigation and Reporting with a last reviewed date of 10/09/2024 revealed the following in part .Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing of facility .2. All alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury
Resident #84
Review of Resident #84's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle wasting and atrophy.
Review of Resident #84's Quarterly Minimum Date Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/11/2024 revealed she had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment.
Review of Resident #84's electronic health record revealed a nurse note dated 10/15/2024 at 5:44 a.m., that read in part .resident found outside of room door in hallway on the floor. Urine and feces noted on the floor. Barefoot, without a brief on. Resident c/o (complained of) pain to left arm and sob (shortness of breath) .
Review of Resident #84's Fall Report revealed the incident occurred 10/15/2024 at 5:00 a.m., that read in part .resident was found outside of room door in hallway on the floor. Urine and feces noted on the floor. Barefoot, without a brief on. Resident c/o pain to left arm and sob. Scheduled transfer to ER (emergency room) .
Review of Resident #84's Radiology Interpretation for XR (x-ray) Forearm 2 views left on 10/15/2024 read in part: impacted non-displaced fracture of the distal radius with minimal cortical deformity.
Further review of Resident #84's electronic health record revealed a nurse note dated 10/15/2024 at 10:46 a.m., that read in part .Resident returned from ER via van. DX (diagnosis) UTI (urinary tract infection and left radial fracture .
On 12/17/2024 at 11:36 a.m., attempted interview with Resident #84 regarding incident on 10/15/24. Resident unable to recall events of incident.
Resident #113
Review of Resident #113's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, depression, anxiety disorder, unspecified psychosis, and muscle wasting and atrophy.
Review of Resident #113's Significant Change Minimum Date Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/25/2024 revealed he had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severe cognitive impairment.
Review of Resident #113's electronic health record revealed a nurse note dated 10/12/2024 at 6:01 a.m., that read in part .staff came out of MCU (memory care unit) while nurses were giving report and stated that resident was sitting on the floor. Resident stated that his feet just left from under him. ROM (range of motion) done. Resident stated that he hit his head. Small bruises noted to top of head. Resident complains of left wrist pain .
Review of Resident #113's Fall Report revealed the incident occurred 10/12/2024 at 6:00 a.m., that read in part . staff came out of MCU (memory care unit) while nurses were giving report and stated that resident was sitting on the floor. Resident stated that his feet just left from under him. ROM (range of motion) done. Resident stated that he hit his head. Small bruises noted to top of head. Resident complains of left wrist pain. Notified NP. Will call son. Sending to ER for eval (evaluation). Neuros initiated .
Review of Resident #113's Radiology Interpretation for XR Wrist 3 views Lt (left) on 10/12/2024 read in part: acute fracture of the ulnar styloid and distal radial metaphysis.
Review of Resident #113's electronic health record revealed a nurse note dated 10/12/2024 at 10:50 a.m., that read in part .Resident returned to facility with transport. Resident in stable condition. Resident has colles splint to left hand, wrist, and forearm. Resident has an acute minimally displaced fracture to left ulnar styloid.
On 12/17/2024 at 11:24 a.m., attempted interview with Resident #113 regarding incident on 10/12/24. Resident unable to recall events of incident.
On 12/18/2024 at 10:27 a.m., an interview and record review was conducted with S2DON (Director of Nursing). S2DON confirmed Resident #84 had an unwitnessed fall with a fracture on 10/15/2024 and the resident had severe cognitive impairement and unable to state how the incident occured . S2DON also confirmed the incident was not reported to the state agency and should have been. S2DON also confirmed Resident #113 had an unwitnessed fall with a fracture on 10/12/2024 and the resident had severe cognitive impairement and uable to state how the incident occured. S2DON also confirmed the incident was not reported to the state agency and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated transfer for 2 (#84, #113) out of 2 (#84, #113) residents in a final sample size of 35. The deficient practice has the potential to affect a census of 112.
Findings:
Review of Resident #84's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle wasting and atrophy.
Review of Resident #84's nurse's notes revealed on 10/15/2024 at 6:00 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 10/15/2024 at 10:46 a.m., the resident returned from the hospital back to the facility.
Further review of the facility's document titled Census List revealed Resident #84 was transferred to the hospital on [DATE], 11/08/2024 and 11/17/2024.
Review of the Emergency Transfer Log for October 2024 revealed Resident #84's transfer to the hospital on [DATE] was not identified on the list. Further review of the Emergency Transfer Log for November 2024 revealed Resident #84's transfer to the hospital on [DATE] was not identified on the list.
Review of Resident #113's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia, depression, anxiety disorder, unspecified psychosis, and muscle wasting and atrophy, and repeated falls.
Review of Resident #113's nurses' notes revealed on 10/12/2024 at 7:09 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 10/12/2024 at 10:50 a.m., the resident returned from the hospital back to the facility.
Further review of the facility's document titled Census List revealed Resident #113 was transferred to the hospital on [DATE], 10/10/2024, 10/12/2024, 10/17/2024, 11/28/2024 and 12/02/2024.
Review of the Emergency Transfer Log for August 2024 revealed Resident #113's transfer to the hospital on [DATE] was not identified on the list. Further review of the Emergency Transfer Log for October 2024 revealed Resident #113's transfer to the hospital on [DATE] and 10/12/2024 was not identified on the list. Further review of the Emergency Transfer Log for November 2024 revealed Resident #113's transfer to the hospital on [DATE] was not identified on the list. Further review of the Emergency Transfer Log for December 2024 revealed Resident #113's transfer to the hospital on [DATE] was not identified on the list.
On 12/18/2024 at 2:22 p.m., an interview and record review was conducted with S15BOM (Business Office Manager). She confirmed she was responsible for the Emergency Transfer Log and to send it to the State Long Term Care Ombudsman. S3BOM reviewed Resident #84's facility document titled Census List and confirmed the resident was transferred to the hospital on [DATE], 11/08/2024 and 11/17/2024. She then reviewed the Emergency Transfer Log for October 2024 and November 2024 and confirmed the resident was not listed as having been transferred on 10/15/2024 and 11/08/2024. S3BOM reviewed Resident #113's facility document titled Census List and confirmed the resident was transferred to the hospital on [DATE], 10/10/2024, 10/12/2024, 10/17/2024, 11/28/2024 and 12/02/2024. She then reviewed the Emergency Transfer Log for August 2024, October 2024, November 2024 and December 2024 and confirmed resident was not listed as having been transferred on 08/19/2024, 10/10/2024, 10/12/2024, 11/28/2024 and 12/02/2024. S15BOM stated she was not aware that facility initiated transfers for less than 24 hours had to be listed on the Emergency Transfer Log sent to the State Long Term Care Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations and interviews, the facility failed to ensure that the enteral feeding infused at the order...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations and interviews, the facility failed to ensure that the enteral feeding infused at the ordered rate for one (Resident #63) out of 2 Residents (Resident #63 and Resident #66) investigated for tube feeding. This had the potential to effect 3 residents in the facility who had tube feedings.
Findings:
Review of the facility's policy titled, Enteral Feedings-Safety Precautions last reviewed on 10/09/2024 revealed in part, the following Preventing errors in administration, 1. Check the enteral nutrition label against the order before administration. Check the following information: g. Rate of administration (ml (milliliters)/hr (hour)).
Review of Resident #63's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, unspecified dementia, dysphagia, chronic systolic (congestive) heart failure, and encounter for attention to gastrostomy.
Review of Resident #63's physician orders revealed an order dated 10/25/2024 Enteral Feed Order every shift Isosource 1.5 @ 44ml (milliliters)/hr (hour) to provide 1584 total calories every 24 hours, 71g Protein, 1641 ml Free Water & 1896 ml Total fluid volume in 24 hours.
On 12/17/2024 at 11:41 a.m., an observation of Resident #63's enteral feeding pump and interview was conducted with S18LPN. S18LPN confirmed that the resident's enteral feeding was running at a rate of 45ml/hour. She confirmed that the enteral feeding rate was ordered to run at 45ml/hour and was not running at the rate ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by failing to ensure the comprehensive care plan was accurately documented for 1 (#53) resident. The deficient practice has the potential to affect a census of 112.
On 12/19/2024, a review of the facility's policy titled, Charting and Documentation with a last review date of 10/09/2024, read in part, All services provided to the resident, progress toward the care plan goals, or any change in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy also indicated that the following information is to be documented in the resident medical record: Progress toward or changes in the care plan goals and objectives. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
Resident #53
Review of Resident #53's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, paraplegia, spinal stenosis, muscle wasting and atrophy, and ileus.
Review of Resident #53's progress notes revealed a note dated 11/11/2024 by S7RD (Registered Dietician) that read in part, Current weight is 121.2 from 11/11/2024. Resident is 68 tall with BMI (body mass index) = 18.4 (underweight). Weight loss triggers: -5.0% change [Comparison Weight 10/16/2024, 137.0 Lbs (pounds), -11.5%, -15.8 Lbs], -7.5% change [Comparison Weight 9/10/2024, 141.4 Lbs, -14.3%, -20.2 Lbs], and -10.0% change [Comparison Weight 6/5/2024, 140.2 Lbs, -13.6%, -19.0 Lbs]. Weekly weights until stable .
Review of Resident #53's Comprehensive Care Plan revealed the resident had an alteration in nutrition r/t (related to) refuses meals at times and 11/12/2024 weight loss. Interventions included weigh monthly.
On 12/18/2024 at 9:50 a.m., a record review and interview was conducted with S10MDS/LPN (Minimum Data Set Coordinator/Licensed Practical Nurse). S10MDS/LPN reviewed Resident #53's progress notes and comprehensive care plan. She confirmed Resident #53 was to be weighed weekly and this was not accurately documented in the comprehensive care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff used personal protective equipment...
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Based on observations, record review and interviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff used personal protective equipment according to accepted standards of practice during biohazard trash removal.
Findings:
Review of a facility policy and procedure titled Personal Protective Equipment - Using Gloves, with revised date of 10/09/2024, read in part, .purpose to guide the use of gloves.
Objectives - 1. To prevent the spread of infection. 3. To protect hand from potentially infectious material.
When to use gloves:
4. When cleaning potentially contaminated items; and
5. Whenever in doubt.
On 12/17/2024 at 10:58 a.m., an observation of Hall A revealed a treatment cart positioned against the wall. The treatment cart had a trash can attached with the lid of the trash can opened. A red biohazard trash bag was observed lining the trash can. A partially discarded blue glove was observed hanging half way outside of the red trash bag along with other discarded materials.
On 12/17/2024 at 10:59 a.m., an observation and interview was conducted with S3TXN (Treatment Nurse) who stated she had completed her treatments for the day. S3TXN stated that she should have emptied her trash when she completed her treatments. Further observation revealed S3TXN removed the partially discarded blue glove from the trash can, and placed it inside the biohazard trash bag without gloves. She then proceeded to remove the biohazard trash bag from the trash can, and placed the biohazard bag on top of the treatment cart. S3TXN confirmed she should have donned gloves prior to touching the soiled blue glove, and removing the biohazard trash bag. She also confiirmed she should not have placed the biohazard bag on top of her treatment cart.
On 12/17/2024 at 4:07 p.m., an interview was conducted with S2DON (Director of Nursing) who was also the facility's Infection Preventionist. She confirmed S3TXN should have put on personal protective equipment before she handled soiled and biohazard materials. She also confirmed the nurse should not have placed the biohazard bag on top of her treatment cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on record review and interview, the provider failed to document, investigate, and maintain documentation of complaints voiced during the facility's resident council meetings that were conducted ...
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Based on record review and interview, the provider failed to document, investigate, and maintain documentation of complaints voiced during the facility's resident council meetings that were conducted on 07/09/2024 and 10/08/2024. This had the potential to effect a census of 112 residents in the facility.
Findings:
Review of the facility's policy titled Grievance/ Complaint Filing, with a last review date of 10/09/2024 revealed in part . 8. Upon receipt of a grievance or complaint, the designee will review and investigate the allegations and submit a written report of the findings to the administrator within 5 working days of receiving the complaint or grievance. 12. The person filing the complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems.
a. The administrator or his designee will make a report within 5 working days of the filing of the grievance with the facility.
b. A written summary will be provided to the resident upon request regarding any corrective action taken by the facility.
On 12/16/2024 11:19 a.m., during meeting conducted with members of the resident council, Resident # 82 expressed the complaints that the residents voiced during the July and October 2024 meetings about the facility not passing of ice that was not totally resolved. He stated, they do pass ice sometimes, but not consistently. They will correct the issue for a couple weeks but fail to keep it up. After we report it again it gets resolved for a few days then falls back to not being passed for days. Resident # 55 confirmed the inconsistency of passing the ice.
On 12/17/2024 at 10:00 a.m., an interview was conducted with Resident #15 who stated the facility's staff were inconsistent with passing ice. She further stated it would be much better if they would pass ice and water on a schedule so the residents wouldn't feel like they were bothering someone by asking them to go get ice.
On 12/17/2024 at 2:40 p.m., during an interview and review of the Resident Council meeting minutes from 07/09/2024 and 10/08/2024, S12AD (Activity Director) revealed she did not write up the complaints about no ice being passed as a grievance because it was just one resident in each meeting that complained. S12AD stated she provided the resident with ice and water then informed the CNA (Certified Nurse Assistant) supervisor.
On 12/17/2024 at 2:50 p.m., an interview was conducted with S13CNASup (Certified Nurse Assistant Supervisor) who failed to remember if she ever heard the complaint about no ice being passed in the facility. S13CNASup confirmed she had no documentation of any complaints expressed about residents not receiving ice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered careplan fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered careplan for 2 (#17 and #53) residents in a final sample of 35 residents as evidenced by failing to:
1. notify the physician of Resident #17's abnormal CBG (Capillary Blood Glucose) levels as ordered; and
2. develop a focus area and interventions related to a choking incident for Resident #53.
Findings:
1.
Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level last reviewed on 10/09/2024, revealed in part, Report abnormal results promptly to the supervisor or Attending Physician.
Review of Resident #17's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage heart failure, unspecified dementia, and type 2 diabetes mellitus.
A review of Resident #17's Order Summary Report, for the month of 08/2024, revealed an order, dated 08/01/2024, Novolin R Injection Solution (Insulin Regular (Human)) Inject as per sliding scale: if 0-150=0 units if <50, administer orange juice; 151-200=2 units; 201-250=4 units; 251-300 = 6 units; 301-350= 8 units; 351-400=10 units; 401-999= 10 units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM (Diabetes Mellitus).
Review of Resident #17's MAR (Medication Administration Record), for the month of 09/2024, 10/2024, 11/2024, and 12/2025, revealed abnormal CBG levels above 401 for the following dates:
a. September 2024:
09/06/2024 at 2000 = 505,
09/21/2024 at 2000 = 467,
09/22/2024 at 2000 = 457,
09/25/2024 at 2000 = 472,
09/27/2024 at 1600 = 439;
b. October 2024:
10/06/2024 at 1100 = 448,
10/09/2024 at 2000 = 579,
10/12/2024 at 1100 = 403,
10/14/2024 at 2000 = 541,
10/22/2024 at 1600 = 474,
10/23/2024 at 2000 = 459,
10/24/2024 at 2000 = 527,
c. November 2024:
11/03/2024 at 2000=558,
11/06/2024 at 2000= 512,
11/12/2024 at 2000 = 426,
11/29/2024 at 2000 = 421,
11/30/2024 at 2000 = 472;
d. Deceber 2024:
12/03/2024 at 2000 = 419
12/15/2024 at 2000 = 521.
.
A review of Resident #17's medical record failed to reveal documentation regarding nurses notifying Resident #17's MD of the abnormal CBG results that were listed.
On 12/18/2024 at 3:24 p.m., an interview and record review was conducted with S16CN (Corporate Nurse). A review of Resident #17's Order Summary Report and MARs for the month of 09/2024, 10/2024, 11/2024, and 12/2024 revealed a total of 19 occurrences where Resident #17's CBG levels were greater than 401. S16CN confirmed the physician's orders revealed for a CBG result of 401 and above, to call the MD. She confirmed the resident's physician was not notified for each of the occurrences and should have been.
2.
On 12/19/2024, a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered with a last revision date of 10/09/2024, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also indicated that the following information is to be documented in the resident care plan: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Incorporate identified problem area. Care plan interventions are chosen after careful data gathering and consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.
Resident #53
Review of Resident #53's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, paraplegia, dry mouth, ileus, and gastroesophageal reflux disease.
Review of Resident #53's most recent annual Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact.
Review of Resident #53's progress notes revealed a note dated 09/06/2024 by S14LPN (Licensed Practical Nurse) read in part, resident said . he was choking on brisket and coleslaw he had for lunch that was caught in his throat and was short of breath. Resident #53 requested to go to the emergency room .
Review of Resident #53's CT (Computed Tomography) of the chest w/o (without) contrast dated 09/06/2024 read in part, food in the distal esophagus with fluid present proximally, findings concerning for residual food with impaction .
Further review of Resident #53's progress notes revealed a note dated 09/07/2024 by S14LPN read in part, Resident #53 was admitted with esophageal obstruction and will see GI (Gastrointestinal).
Review of Resident #53's comprehensive care plan failed to reveal a focus area or interventions related to Resident #53's choking incident on 09/06/2024.
On 12/18/2024 at 9:50 a.m. A record review and interview was conducted with S10MDS/LPN (Minimum Data Set Coordinator/Licensed Practical Nurse). S10MDS/LPN confirmed Resident #53 had a choking incident on 09/06/2024 and was transferred to the emergency room for evaluation. She also confirmed the incident on 09/06/2024 should have been in the care plan with interventions, but it was not.
On 12/18/2024 at 10:13 a.m., an interview was conducted with S2DON (Director of Nursing) who confirmed Resident #53 had a choking incident on 09/06/2024 and was sent to the emergency room for evaluation. She confirmed this incident should have been developed in the care plan with interventions, but it was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observations, record reviews, and interviews, the facility failed to ensure recipes for pureed diets were followed. This failure had the potential to contribute to an unpleasant dining experi...
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Based on observations, record reviews, and interviews, the facility failed to ensure recipes for pureed diets were followed. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 12 residents who received pureed meals.
Findings:
Review of a facility document titled Puree Recipe Liquid Addition - Quick Guide that read in part Item - vegetables, breads, desserts, pasta, sandwiches, fish, potato dishes, eggs, port, ham, chicken, steak/beef.
Liquid - whole milk and margarine/butter for all listed items except steak/beef use gravy.
On 12/16/2024 at 10:55 a.m., S4Cook was observed preparing pureed rice with a pan filled with water, pouring a white powdery substance from a white bag that contained instant puree rice into the water, and continuously stirring with a whisk. S4Cook was asked how much water the pan held, and she stated she did not know. S4Cook stated she just poured the pureed rice into the water and stirred until she achieved the smooth blended consistency she wanted. She stated she did not measure, but she guessed the proper amounts.
On 12/16/2024 at 11:00 a.m., an observation of S5Cook was conducted while she prepared puree bread. After placing several slices of bread into the blender, she added 8 ounces of whole milk. Observations of the pureed bread after S5Cook completed the process revealed the puree bread was thin liquid. Further observations of pureed beans that were prepared by S5Cook revealed the beans were thin consistency. S5Cook was asked about the consistency of the pureed bread and pureed beans. She stated she thought puree meant not too thick and not too thin.
On 12/16/2024 at 11:15 a.m., an interview was conducted with S4Cook who confirmed the consistency of S5Cook's pureed bread and pureed red beans were not consistent for a puree diet, they were thinned liquid. S4Cook stated the consistency should have been smooth and blended.
On 12/16/2024 at 2:45 p.m., an interview was conducted with S6DS (Dietary Staff), S8Cook, and S9DS. S6DS stated she was not trained on how to puree using a recipe. S8Cook stated that she was not trained on puree recipes, S9DS stated she was not trained on puree recipes, but was shown how to puree foods from other staff. S6DS confirmed the puree recipe liquid addition - quick guide did not help her puree meals. She stated there were no measurements for puree desserts.
On 12/17/2024 at 2:37 p.m., an interview was conducted with S7RD (Registered Dietician). She confirmed puree recipes were not located in the main kitchen, and were not available for the cooks to use while preparing puree meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
A review of a document titled Hospice and Facility Agreement indicated This Hospice and nursing facility residential agreemen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
A review of a document titled Hospice and Facility Agreement indicated This Hospice and nursing facility residential agreement is made and entered into this 21st day of January, 2015, by and between Hospice Agency and Facility .4.4 Coordination with Hospice Regarding Plan of Care, c. Monitoring of Residential Hospice Patient. Nursing Facility shall immediately inform Hospice of any change in the condition of a Residential Hospice Patient.
A review of Resident #17's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, end stage heart failure, unspecified dementia, and type 2 diabetes mellitus.
A review of Resident #17's Order Summary Report, for the month of 02/2024, revealed an order dated 02/12/2024, admit to hospice agency effective 02/12/2024 with a diagnosis of end stage heart failure.
A review of Resident #17's Order Summary Report, for the month of 08/2024, revealed an order, dated 08/01/2024, Novolin R Injection Solution (Insulin Regular (Human)) Inject as per sliding scale: if 0-150=0 units if <50, administer orange juice; 151-200=2 units; 201-250=4 units; 251-300 = 6 units; 301-350= 8 units; 351-400=10 units; 401-999= 10 units and call MD (Medical Doctor), subcutaneously before meals and at bedtime for DM (Diabetes Mellitus).
Review of Resident #17's MAR (Medication Administration Record), for the month of 09/2024, 10/2024, 11/2024, and 12/2025, revealed abnormal CBG levels above 401 for the following dates:
this format is not easy to follow. spell out months and list.
a. September 2024:
09/06/2024 at 2000 = 505,
09/21/2024 at 2000 = 467,
09/22/2024 at 2000 = 457,
09/25/2024 at 2000 = 472,
09/27/2024 at 1600 = 439;
b. October 2024:
10/06/2024 at 1100 = 448,
10/09/2024 at 2000 = 579,
10/12/2024 at 1100 = 403,
10/14/2024 at 2000 = 541,
10/22/2024 at 1600 = 474,
10/23/2024 at 2000 = 459,
10/24/2024 at 2000 = 527,
c. November 2024:
11/03/2024 at 2000=558,
11/06/2024 at 2000= 512,
11/12/2024 at 2000 = 426,
11/29/2024 at 2000 = 421,
11/30/2024 at 2000 = 472;
d. December 2024:
12/03/2024 at 2000 = 419
12/15/2024 at 2000 = 521.
On 12/18/2024 at 4:40 p.m., an interview and record review was conducted with S16CN (Corporate Nurse). A review of Resident #17's Order Summary Report and MARs for the month of 09/2024, 10/2024, 11/2024, and 12/2024 revealed a total of 19 occurrences where Resident #17's CBG levels were greater than 401. She confirmed that there was no documentation in Resident #17's Hospice Binder or the resident's medical record that revealed the Hospice agency was notified of the abnormal CBG levels.
On 12/18/2024 at 4:52 p.m., a phone interview was conducted with S17HADON (Hospice Agency Director of Nursing). She stated that the Hospice agency should be notified of significantly high CBG levels for Resident #17 as collaboration between the facility and the Hospice agency.
Based on interviews and record reviews, the facility failed to provide services that met professional standards for 2(#17 and #21) of 2 (#17 and #21) residents investigated for hospice services, by failing to:
1. Collaborate with the hospice agency to ensure the hospice nurse's visit notes and certification were up-to-date in Resident #21's hospice binder; and
2. Communicate with the hospice agency of Resident #17's high blood sugars.
Findings:
1.
A review of a document titled Nursing Facility Agreement indicated This Agreement is made and entered into this 23rd day of April 2018 by and between the facility and hospice .4.1 Compilation of Records. Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving nursing facility services and hospice services under this agreement in accordance with prudent record keeping procedures and as required by applicable Federal and state law and regulations and applicable Medicare and/or Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning each resident hospice patient including evaluations, treatments, program notes, authorizations for admissions to hospice and/or nursing facility . Each such record shall be readily accessible and systematically organized to facilitate retrieval by either party.
A review of Resident #21's electronic health record (EHR) revealed an admission date of 02/19/2020, with diagnoses which included, but were not limited to heart failure and age related Osteoporosis.
A review of Resident #21's physician orders revealed an order written on 03/20/2024 to admit to hospice.
A review of resident #21's hospice binder revealed the last certification period was 03/20/2024 to 06/17/2024. Further review revealed the last hospice nurse visit notes were on 11/21/2024.
During an interview and review of Resident #21's hospice binder with S11LPNDA (Licensed Practical Nurse/Data analyst) on 12/17/2024 at 1:35 p.m., she confirmed the last certification period was 03/20/2024 to 6/17/2024 and the last hospice nurse visit notes were dated 11/21/2024.
During an interview with S2DON (Director of Nursing) on 12/17/24 at 3:25 p.m., she stated she did not know who was responsible for ensuring the hospice agency updated the resident's binder, and would find out.
During a follow-up interview with S2DON at 3:35 p.m., she stated that she called her corporate office and it was the hospice agency's responsibility to ensure the hospice binder at the facility was updated with the current certification and visit notes. She stated hospice was responsible and the facility was not responsible for ensuring hospice update the binder.
May 2024
3 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Deficiency Text Not Available
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Deficiency Text Not Available
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the resident's responsible party (RP), the nurse practition...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the resident's responsible party (RP), the nurse practitioner, and physician of a deteriorating right foot wound for 1 (#2) out of 3 (#1, #2, #3) sampled residents by failing to contact the responsible party (RP), nurse practitioner, and physician in a timely manner.
Findings:
On 05/07/2024, a review of the facility's policy titled, Wound Prevention with a last revised date of 06/14/2023 revealed in part the following: Policy: The purpose of this policy is to provide information regarding identification of wound/pressure ulcer/injury risk factors and interventions for specific risk factors for prevention of pressure ulcers/wounds. Monitoring: 1. Evaluate, report and document potential changes in the skin including new wounds/pressure ulcers. No mention of which professional discipline could perform the assessments or to who to report changes noted in the policy.
Review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Schizoaffective Disorder, Atherosclerosis of Native Arteries of Right Leg with Ulceration of Heel and Midfoot, Peripheral Vascular Disease, Contracture Right Elbow, Hypertension, Edema, Dysphagia, Aphasia Following Cerebral Infarction, Type 2 Diabetes Mellitus with other Circulatory Complications, and Chronic Ischemic Heart Disease.
Review of Resident #2's wound evaluations revealed in part:
Initial Wound Evaluation dated 03/19/2024 body location: right dorsum foot, dimensions- area: 35.9 centimeters (cm), length: 9.09cm, width: 6.58cm.
Wound Evaluation dated 03/26/2024: right dorsum foot, dimensions- area: 0.87cm (-98%), length: 1.85cm (-80%), width: 0.63cm (-90%).
Wound Evaluation dated 04/02/2024: right dorsum foot, dimensions- area: 28.69cm (+3184%), length: 7.1cm (+283%), width: 6.51cm (+926%). Positive percentage indicated the wound increased in size. There was no documentation of notification to Resident #2's responsible party or nurse practitioner or physician.
Wound Evaluation dated 04/17/2024: right dorsum foot, there was no documentation of the dimensions of the right dorsum foot.
Wound Evaluation dated 04/24/2024 dorsum foot, dimensions- area: 37.85cm (+183%), length: 9.09cm (+36%), width: 6.58cm (+135%). There was no documentation of notification to Resident #2's responsible party or nurse practitioner or physician.
On 05/06/2024 at 9:00 a.m., a phone interview was conducted with Resident #2's RP. She stated she was never notified by the facility that the resident's right foot wound was getting worse.
On 05/06/2024 at 3:32 p.m., an interview was conducted with S3WCN (Wound Care Nurse). S3WCN was asked to compare the wound evaluation from 03/19/2024 to 04/24/2024. She stated the right foot wound did not look bad in March, however every week the right foot wound looked more macerated with increase drainage noted to the wound. S3WCN stated no notification was made to the residents RP.
On 05/07/2024 at 10:41 a.m., a phone interview was conducted with S5NP (Nurse Practitioner). S5NP stated she was aware of Resident #2's right foot wound, but was not notified of the wounds worsening condition.
Nov 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form Centers for Medicare and Medicaid Services (CMS)-10055, and N...
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Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), form Centers for Medicare and Medicaid Services (CMS)-10055, and Notice of Medicare Non-Coverage form CMS-10123 was completed prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 1 (Resident #65) of 3 residents reviewed for termination of Medicare Part A services.
Findings:
Review of the Skilled Nursing Facility Advance Beneficiary Notice, form CMS-10055, completed by the facility revealed, in part, Resident #65's last day of Medicare Part A Services was on 10/04/2023.
There was no documented evidence and the facility was unable to present any documented evidence Resident #65 had a signed CMS-10055, and CMS 10123 form prior to Medicare Part A services being terminated by the facility on 10/04/2023.
On 11/29/2023 at 11:47 a.m., an interview was conducted with S2MDSA. S2MDSA stated the MDS (Minimum Data Set) coordinators are in charge of the Resident's NOMNC (Notice of Medicare Non-Coverage). She confirmed Resident #65 NOMNC was signed but there was no date. Also SNFABN, beginning on was left blank, along with options. Resident #65's signature was noted and no date was documented. She stated she is unsure of the exact date of when it was signed by the Resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean environment as evidenced by unclean floor and medical...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean environment as evidenced by unclean floor and medical equipment at the bedside of 1 (#23) out of a final of 43 final sampled residents.
Findings:
Resident #23 was admitted to the facility on [DATE] with diagnoses including: Encounter for Attention to Gastrostomy and Dysphagia. The resident had an indwelling feeding tube.
On 11/27/2023 at 09:48 a.m., an observation was conducted of Resident #23's room. The resident was lying in her bed with enteral nutrition formula hanging from an IV (intravenous) pole. A wet area was noted underneath the pole.
On 11/28/2023 at 09:29 a.m., a second observation was conducted of Resident #23's room. The resident was sleeping in her bed. She was receiving infusions of enteral nutrition formula and water hanging from an IV pole. A closer observation revealed a brown moist buildup of enteral nutrition formula on the bottom of the IV pole, and a moist area with debris underneath the right upper wheel of the resident's bed, close to the IV pole. A gnat (a tiny fly) was noted flying around the area.
On 11/28/2023 at 09:50 a.m., an interview and observation was conducted of Resident #23's room with S3LPN (Licensed Practical Nurse). S3LPN confirmed the buildup of enteral nutrition formula on the resident's IV pole, and the moist area with debris close to the IV pole, and stated it was dirty.
On 11/28/2023 at 10:16 a.m., an interview and observation was conducted with S1DONIP (Director of Nursing and Infection Preventionist). S1DONIP confirmed the buildup of enteral nutrition formula on the resident's IV pole, the moist area with debris close to the pole, and the gnat flying around the area and stated it was unacceptable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on record reviews and interview, the facility failed to ensure resident quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for 2 (Resident #14, Resident #...
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Based on record reviews and interview, the facility failed to ensure resident quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for 2 (Resident #14, Resident #90) out of 43 sampled residents.
Findings:
A review of Resident #14's EMR (Electronic Medical Record) revealed the residents last quarterly MDS assessment reference date (ARD) was 07/19/2023. Further review of the EMR revealed an assessment was overdue by 27 days.
A review of Resident #90's EMR revealed the resident's last quarterly MDS assessment reference date (ARD) was 07/19/2023. Further review of the EMR revealed an assessment was overdue by 27 days.
On 11/29/2023 at 11:21 a.m., an interview was conducted with S19MDS. She viewed both resident's EMR and confirmed assessments for both were not completed within the required time frame making them 27 days overdue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status by...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status by failing to accurately code the Minimum Data Set (MDS) for medications for 1 (Resident #8) out of a finalized sample of 43. The deficient practice had the potential to affect a total of 108 residents on the census.
Findings:
Review of Resident #8's electronic health record revealed she was admitted on [DATE] with diagnoses that included: Fusion of Spine, Neuralgia, Acquired Absence of Left Leg Above Knee, Polyneuropathy.
A review of the Quarterly MDS with an Assessment Reference Date (ARD) of 09/29/2023 for Resident #8 revealed, Section N: Medications, was coded 7 (days) for anticoagulant use.
A review of the Medication Administration Record (MAR) for September 2023 revealed the residents anticoagulant was stopped on 09/21/2023.
On 11/29/2023 at 10:20 a.m., an interview was conducted with S19MDS. She confirmed that the resident was taking an anticoagulant in the month of September 2023 and had been discontinued prior to the reference date of the 7 day look back period. She confirmed the anticoagulant should not have been included on the assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Scr...
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Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #8) resident investigated for PASARR in a final sample of 43 residents.
Findings:
A review of Resident #8's record revealed an admission date of 03/20/2017. Further review revealed he was diagnosed with Schizoaffective Disorder, Bipolar Type on 12/10/2021.
Further review of Resident #8's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 06/20/2019. There was no evidence that a rescreening had been submitted after the resident received a newly qualifying diagnosis of Schizoaffective Disorder, Bipolar Type on 12/10/2021 and there was no PASARR Level II noted in Resident #8's record.
On 11/28/2023 at 2:57 p.m., an interview was conducted with S11SSD. She stated she was not aware that a reevaluation for a Level II PASARR determination should be resubmitted when a resident receives a new qualifying diagnosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure physician orders were implemented as ordered for checking ox...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure physician orders were implemented as ordered for checking oxygen saturations every shift, monitoring blood pressure before and after dialysis, and monitoring for symptoms before and after dialysis for 1 (#10) of 43 sampled residents.
Findings:
Review of Resident #10's health record revealed an admission date of 07/14/2021 with diagnoses which included, but were not limited to, End Stage Renal Disease, Shortness of Breath, Systemic Lupus Erythematosus, Edema, and Hypertension.
Review of Resident #10's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating his cognition was intact. Section O - Special Treatments, Procedures, and Programs checked for dialysis.
Review of Resident #10's physician's orders revealed an order dated 09/08/2023 that read, check oxygen saturations every shift, monitor blood pressure pre and post dialysis every shift every Tuesday, Thursday, and Saturday, and monitor pre and post dialysis: monitor for SOB (Shortness of Breath), peripheral edema, active bleeding, severe itching, anorexia, fatigue, confusion, irregular heart rhythm and/or puffy eyes; (-) negative or (+) positive, notify MD (Medical Doctor) or dialysis every shift every Tuesday, Thursday, and Saturday.
Review of Resident #10's comprehensive plan of care revealed a focus of dialysis: at risk for infection, at risk for fluid overload and dehydration with interventions that included, blood pressure pre and post dialysis and pre and post dialysis notify MD and/or dialysis of SOB (Shortness of Breath), peripheral edema, active bleeding, severe itching, anorexia, fatigue, confusion, irregular heart rhythm and/or puffy eyes.
Review of Resident #10's November MAR (Medication Administration Record) revealed an order to check oxygen saturations every shift had blanks for day shift on November 3, 4, 5, 7, 8, 9, 14, 17, 18, 19, 22, 23, 27 and night shift on November 19. Monitor blood pressure pre and post dialysis shift every Tuesday, Thursday and Saturday had blanks for day shift on November 7, 14, 18 and 23. Monitor for SOB (Shortness of Breath), peripheral edema, active bleeding, severe itching, anorexia, fatigue, confusion, irregular heart rhythm and/or puffy eyes; (-) negative or (+) positive, every shift every Tuesday, Thursday, and Saturday had blanks for day shift on November 4, 7, 9, 14, 16 and 23.
Review of Resident #10's November Weights and Vitals Summary revealed no documentation for oxygen saturations on day shift for November 3, 4, 7, 8, 9, 14, 17, 18, 19, 22, 23, 27 and night shift on November 19. No documentation for blood pressure on day shift on November 7, 14, 18 and 23.
On 11/28/2023 at 12:40 p.m., an interview was conducted with S9LPN (Licensed Practical Nurse). S9LPN confirmed if there are blank spots MAR this means it was not done.
On 11/28/2023 at 3:07 p.m., an interview was conducted with S8ADON (Assistant Director of Nursing). S8ADON reviewed Resident #10's November 2023 MAR and confirmed the blanks on the MAR indicated that this physician's order was not completed by nursing. S8ADON reviewed Resident #10's November 2023 Weights and Vitals Summary and confirmed there was no oxygen saturation documentation on day shift for November 3, 4, 7, 8, 9, 14, 17, 18, 19, 22, 23, 27 and night shift on November 19 and no documentation for blood pressure on day shift on November 7, 14, 18 and 23 and stated this should have been done per physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident and their representative received ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident and their representative received assistance in gaining access for hearing services for 1 (#44) out of 2 (#12, #44) residents investigated for hearing impairment out of a total sample of 43 residents.
Findings:
Resident #44. On 11/27/23 at 10:40 a.m., the resident was observed sitting in her chair in her room. During this observation, the surveyor spoke to the resident and the resident was observed having difficulty understanding. The resident stated that she has trouble with her hearing.
Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified Dementia without Behavioral Disturbance, and Anxiety.
Review of the resident's quarterly MDS (Minimum Data Set Assessment) dated 9/27/2023 revealed the resident was coded having moderate difficulty for hearing.
Review of the resident's care plan revealed the resident was care planned for HOH (Hard of Hearing).
Review of the resident's social service note dated 9/27/2023 at 14:28 (2:28 p.m.) revealed, Late Entry: She is hard of hearing . There was no evidence that assistance was made or offered for the resident to have an evaluation for her hearing.
On 11/29/2023 at 10:40 a.m., an interview was conducted with S13CNA (Certified Nursing Assistant). She stated the resident was hard of hearing and that she had to speak loud to the resident or get really close to the resident for her to hear. She stated the resident did not have assistive devices for hearing.
On 11/29/2023 at 10:50 a.m., an interview was conducted with S10LPN (Licensed Practical Nurse). She stated the resident was hard of hearing and that she had to get really close to the resident for her to hear. She stated the resident did not have assistive devices for hearing.
On 11/29/2023 at 11:15 a.m., S11SSD (Social Service Director) confirmed that she was aware the resident was hard of hearing. She confirmed that she did not assist the resident or their representative with arrangements getting an evaluation for her hearing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to ensure that a resident who had a urinary catheter received servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to ensure that a resident who had a urinary catheter received services to prevent urinary tract infection for 1 (#65) of 43 sampled residents.
Findings:
Resident #65 was admitted to the facility on [DATE] with diagnoses including Urinary Retention. The resident had an indwelling catheter.
Review of Resident # 65's plan of care revealed she had a history of Urinary Tract Infections, with the last one on 10/09/2023 and a goal to have no urinary Tract Infections this quarter. The resident was also care planned for having a Foley Catheter (indwelling urine drainage tube) and at risk for infections. Goal was for the catheter to remain patent, and interventions include ensuring tube is patent and free from twists and kinks.
Review of Physician's Orders revealed an order written on 08/15/2023 to change indwelling catheter leg strap weekly and PRN (as needed).
On 11/28/2023 at 09:05 a.m., an observation was conducted of S14CNA (Certified Nursing Assistant) and S16CNA performing perineal care on Resident #65. The resident had an indwelling catheter, but there was no leg strap securing the catheter to the resident's leg.
On 11/28/2023 at 09:20 a.m., an interview was conducted with S14CNA. She stated she could not remember the resident having a catheter leg strap.
On 11/28/2023 at 09:36 a.m., an interview and observation of Resident #65 with S3LPN (Licensed Practical Nurse). She checked the resident's catheter and confirmed that there was no leg strap. S3LPN stated that the resident should have a leg strap and did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's continuous positive airway pressu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's continuous positive airway pressure (CPAP) mask stored properly for 1 (Resident #63) of 4 sampled residents reviewed for respiratory care.
Findings:
Review of facility's policy, titled, Respiratory Therapy, read in part . Infection Control Considerations Related to Oxygen Administration . 5. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.
Review of Resident #63's record revealed the resident was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Obstructive Sleep Apnea (OSA).
Review of Resident #63's care plan read in part . Diagnosis- sleep apnea: at risk for altered sleep pattern, interventions: change tubing/mask as ordered.
Review of Resident #63's Physician Orders for November 2023 revealed, in part, Resident #63's Auto-PAP 9-15 (CPAP) worn for every sleep.
On 11/27/2023 at 09:23 a.m., an observation was made of Resident #63's room. The resident was sleeping, and the resident's CPAP mask was on a nightstand to the left of the resident's bed. The mask was not stored in a bag.
On 11/27/2023 at 12:37 p.m., a second observation was made of Resident #63's room. His CPAP was observed on his bedside table and was not stored in a bag. An interview was then conducted with S7LPN (Licensed Practical Nurse). She stated the resident wears a CPAP at night and they have to assist him with putting it on and taking it off. She confirmed Resident#63's CPAP mask was on his bedside table and not properly stored in a bag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility through dialysis communication forms for 1 (#10) out of 1 (#10) residents sampled for dialysis services.
Findings:
Review of the facility's policy, End-Stage Renal Disease, Care of a Resident with revealed, in part, the following: Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation . 3. Agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be manages, including: a. How information will be exchanged between facilities.
Review of Resident #10's health record revealed an admission date of 07/14/2021 with diagnoses which included, but were not limited to, End Stage Renal Disease, Systemic Lupus Erythematosus, Edema, and Hypertension.
Review of Resident #10's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating his cognition was intact. Section O - Special Treatments, Procedures, and Programs checked for dialysis.
Review of Resident #10's physician's orders revealed an order dated 09/08/2023 that read, Dialysis: Fresenius, Tuesday, Thursday, and Saturday.
Review of Resident #10's Dialysis Communication Record since September 2023. No documented evidence of Dialysis Communication Record on 09/19/2023, 09/23/2023, 10/05/2023, 10/10/2023, 10/19/2023, 10/24/2023, 11/02/2023,11/04/2023, 11/07/2023, 11/11/2023, 11/14/2023, 11/18/2023, 11/22/2023 and 11/25/2023.
On 11/29/2023 at 7:51 a.m., an interview was conducted with S12WARDC1 (Ward Clerk). S12WARDC1 stated the nurses fill out dialysis communication record form for each day the resident goes to dialysis. She stated the dialysis communication record must come back with the resident each time they return back from dialysis and it must be filled out.
On 11/29/2023 at 7:55 a.m., and interview was conducted with S10LPN (Licensed Practical Nurse). S10LPN stated the dialysis communication record form is completed every time the resident has to go to dialysis and must return with the resident. S10LPN confirmed this is how both facilities are able to communicate with each other about the resident.
On 11/29/2023 at 7:55 a.m., an interview was conducted S1DONIP (Director of Nursing/Infection Preventionist). S1DONIP stated nurses must complete a dialysis communication record every time the resident goes to dialysis and after the resident returns back from dialysis the form must be reviewed by nursing and scanned into the resident's health record. Reviewed Resident #10's dialysis communication record forms with S1DONIP. S1DONIP confirmed there was no documented evidence of dialysis communication record on 09/19/2023, 09/23/2023, 10/05/2023, 10/10/2023, 10/19/2023, 10/24/2023, 11/02/2023, 11/04/2023, 11/07/2023, 11/11/2023, 11/14/2023, 11/18/2023, 11/22/2023 and 11/25/2023. She confirmed the dialysis communication record form should have been filled out for these dates and stated this is how information is exchanged between facilities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to honor and accommodate food preferences for 1(#7) out of 2 (#7, #55) residents reviewed for food. This deficient practice had t...
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Based on observation, interview and record review, the facility failed to honor and accommodate food preferences for 1(#7) out of 2 (#7, #55) residents reviewed for food. This deficient practice had the potential to affect 107 residents who consumed meals from the kitchen.
Findings:
Review of Resident #7's record revealed an admission date of 08/24/2023 with diagnoses that included Gastro-Esophageal Reflux Disease, Diarrhea, Nausea, Constipation, Abnormality of Albumin, Dysphagia, Hyperlipidemia, Vitamin B Deficiency.
Review of Resident #7's care plan revealed a focus area for food preferences that stated no peanuts.
Review of admission progress note dated 08/24/2023 revealed no peanuts.
On 11/27/2023 at 10:35 a.m., an interview was conducted with Resident #7. She stated she was allergic to peanuts and still received it on her food tray.
On 11/27/2023 at 11:15 a.m., an observation was made of Resident #7's lunch time meal tray. She was served peanut butter frosting on her dessert. The meal ticket indicated no peanuts.
On 11/27/2023 at 11:17 a.m., an interview was conducted with S2DM (Dietary Manager). S2DM stated that the kitchen staff should serve the resident the correct meal and they should also make sure they honor the resident's preferences. At that time, an observation was conducted with S2DM of Resident #7's meal ticket. S2DM confirmed that she was aware that Resident #7 was served icing that contained peanuts and that the resident's meal ticket indicated no peanuts. She confirmed she should not have been served anything containing peanuts.
On 11/29/2023 11:25 a.m., an interview was conducted with S18RD (Registered Dietician). S18RD reviewed Resident #7's care plan and progress notes upon admission and stated that it indicated that she did not want peanuts. She stated she spoke with Resident #7 on 11/28/2023 and confirmed she was served dessert that contained peanuts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards in the kitchen by failing to ensure compromised cans in the dry storage ...
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Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards in the kitchen by failing to ensure compromised cans in the dry storage room were disposed and not readily available for use.
Findings:
On 11/27/2023 at 8:40 a.m., an observation of the dry storage room with S2DM (Dietary Manager) revealed 4 cans of vegetable soup, 1 can of condensed cream of mushroom soup, and 3 cans of mandarin oranges that were dented near the lip of the cans. An interview with S2DM confirmed the cans on the shelf were compromised, available for use, and should have been discarded.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide colostomy care as required by the facility's ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide colostomy care as required by the facility's policy for 1 (Resident #79) of 1 (Resident #79) residnet's reviewed for colostomy care.
Findings:
Review of facility's policy titled, Colostomy/Ileostomy care read in part . Documentation: the following information should be recorded in the resident's medical record: 1. the date and time the colostomy/ileostomy care was provided. 2. The name and initial of the individual who provided the colostomy/ileostomy care. 3. Any breaks in resident's skin, signs of infection. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason why and the intervention taken. 6. The signature and title of the person recording the data.
Resident #79 was admitted to the facility on [DATE] with diagnoses included Diverticulitis of Large Intestine with perforation and abscess without bleeding, Encounter for attention to Colostomy.
A review of Resident #79's physician orders revealed an order dated 05/18/2021 that read, Change colostomy bag and flange every 3 days and PRN (as needed).
A review of Resident #79's Care Plan read in part . colostomy: at risk for infection and trauma . interventions: change colostomy wafer and bag as ordered.
Review of the resident's Minimum Data Sets (MDS) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 06, indicating that the resident is severely impaired cognition.
On 11/28/2023 at 1:31 p.m., an observation and interview with Resident #79 was conducted. Observation revealed the resident's colostomy bag was empty with no date noted on the wafer or bag. He stated his colostomy was emptied out this morning and changed probably 2-3 days ago.
On 11/28/2023 at 1:42 p.m., an interview was conducted with S6LPN (Licensed Practical Nurse) she stated she was unsure of the last time the colostomy bag was changed. She reviewed Resident #79's medical record and treatment record but could not find any documentation of the last time it was changed.
On 11/28/2023 at 2:16p.m., an interview was conducted with S5LPNWC (Licensed Practical Nurse/ Wound Care Nurse). She confirmed there was no date or label on the resident's colostomy bag or wafer. S5LPNWV further stated she was unsure exactly when it was last changed and confirmed it should have been changed per physician orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to accurately assess and document the location and inten...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to accurately assess and document the location and intensity of pain for 1 (Resident #34) of 1 residents reviewed for pain.
Findings:
Resident #34 was admitted to the facility on [DATE] with diagnoses that included Polyneuropathy, Type 2 Diabetes Mellitus, Spinal Stenosis, Pain, Neuropathy, Osteoarthritis, Parkinson's Disease with Dyskinesia, and Abnormal Posture.
Review of the resident's Minimum Data Sets (MDS) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10, indicating that the resident is moderately impaired.
Review of Resident #34's care plan revealed, in part, alteration in comfort related to pain, neuropathy, OA (Osteoarthritis). Interventions read in part .if pain noted, assess location and intensity of pain.
Review of Resident #34's November 2023 Physician orders revealed, in part, Naproxen Tablet (medication used for pain) 500mg (milligrams) give 1 tablet orally every 12 hours as needed for pain.
Review of Resident #34's Medication Administration Record (MAR) showed revealed Naproxen 500mg tablet was signed out on: 10/13/2023 at 9:57 p.m., 10/15/2023 at 7:50 p.m., 10/23/2023 at 8:07 p.m., 11/5/2023 at 11:12 a.m., 11/5/2023 at 4:31 p.m., 11/12/2023 at 11:57 p.m., 11/13/2023 at 1:58 a.m., 11/13/2023 at 12:46 p.m., 11/13/2023 at 1:47 p.m., 11/14/2023 at 9:00 p.m., 11/15/2023 at 11:31 p.m., 11/26/2023 at 8:15 p.m., and 11/26/2023 at 10:29 p.m. There was no documentation was noted of location and intensity of the resident's pain.
On 11/28/2023 at 1:48 p.m., an interview was conducted with S1DONIP (Director of Nursing/Infection Preventionist). She confirmed the nurses did not assess the pain location, or intensity of pain. S1DON/IP stated that the location and intensity of pain it should have been be documented on the MAR.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#34) of 43 sampled residents. This was evidenced by S4LPN (Licensed Practical Nurse) leaving Resident #34's medication at the bedside.
Findings:
Resident #34 was admitted to the facility on [DATE], with diagnoses that included Polyneuropathy, Type 2 Diabetes Mellitus, Spinal Stenosis, Parkinson's Disease with Dyskinesia, and Abnormal Posture.
Review of the resident's Minimum Data Sets (MDS) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10, indicating that the resident is moderately impaired.
Review of the resident's physician's orders dated 11/2023 revealed the following orders:
- Sinemet 10-100mg (miligrams) give 1 tablet by mouth three times a day.
- Duloxetine 30mg give 1 capsule orally one time a day.
- Furosemide 40mg give 1 tablet orally two times a day.
- Linzess 145mcg(micrograms) 1 capsule orally one time a day every Monday, Wednesday, and Friday.
- Meloxicam 7.5mg give 1 tablet orally one time a day.
- Aspirin 81mg give 1 tablet by mouth one time a day.
- Colace 100mg give 1 capsule by mouth one time a day.
- Divalproex 500mg give 3 tablets orally one time a day.
- Metformin 500mg give 2 tablet by mouth one time a day.
- Vitamin D capsule 50000 give 1 capsule orally one time a day every Monday, Wednesday, and Friday.
- Glipizide 5mg give 1 tablet orally two times a day.
On 11/28/2023 at 9:24 a.m., an observation and interview was conducted with Resident #34. A white cup with thirteen pills was observed at the bedside table. Resident #34 stated her nurse brought the medications to her around 8:50 a.m. and she has been waiting for water to be able to take her medications.
On 11/28/2023 at 9:28 a.m., an observation and interview of Resident #34's room was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed that Resident #34 did not have a doctor's order to self-administer her medications. S4LPN stated that she left Duloxetine, Furosemide, Linzess, Meloxicam, Aspirin, Colace, Divalprox Metformin, Vitamin D, Glipizide, and Sinemet at the resident's bedside around 8:45 a.m. S4LPN confirmed that she should not have left the medication at the resident's bedside. S1DONIP (Director of Nursing/Infection Preventionist) walked into the resident's room and confirmed medications should not be left at the bedside unattended.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on staff interview and observation the facility failed to ensure all medications were properly stored and labeled as evidenced by:
1.
Failing to ensure Novolog Multidose Insulin Pen was labeled...
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Based on staff interview and observation the facility failed to ensure all medications were properly stored and labeled as evidenced by:
1.
Failing to ensure Novolog Multidose Insulin Pen was labeled with resident identification; and,
2.
Failing to ensure controlled drugs awaiting disposal were stored and separately locked.
The deficient practice had the potential to affect a total census was 108.
Findings:
1. A review of the facility's policy titled Administering Medications revealed; 17. Insulin pens are clearly labeled with the resident's name or other identifying information.
On 11/28/2023 at 10:15 a.m., an observation was made in Med Room A medication refrigerator accompanied by S4LPN. Upon inspection, a Novolog Multidose Insulin Pen was discovered. It was noted with no resident label/information. S4LPN could not confirm to which this medication belonged to and confirmed the medication should have been labeled with resident identification and was not.
2. A review of the facility's policy titled Discarding and Destroying Medications revealed; 1. All unused controlled substances are retained in a securely locked area/container until disposed of.
On 11/28/2023 at 11:00 a.m., an observation was made with S1DONIP in her office with the door to her office opened. Concurrent interview revealed that controlled drugs awaiting disposal were kept and a single locked cabinet in her office. She stated she was unaware that discontinued controlled medications were to be in separately locked, permanently affixed compartments.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #65 was admitted to the facility on [DATE] with diagnoses including Urinary Retention. The resident had an indwellin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #65 was admitted to the facility on [DATE] with diagnoses including Urinary Retention. The resident had an indwelling catheter.
On 11/28/2023 at 9:05 a.m., an observation was conducted of S14CNA (Certified Nursing Assistant) and S16CNA performing perineal care on Resident #65. S16CNA completed perineal care and emptied the resident's urine drainage bag in a urinal. She gave the urinal to S14CNA, removed her gloves, and did not wash or sanitize her hands. S16CNA immediately pressed the button to raise the head of the resident's bed. On further observation, S14CNA took the urinal from S16CNA, emptied it in the resident's toilet, then removed her gloves and did not wash or sanitize her hands. S14CNA then picked up Resident #65's cup from her night stand and placed it on her over bed table.
On 11/28/2023 at 9:20 a.m., a congruent interview was conducted with S14CNA and S16CNA. Both CNA's confirmed that they did not wash or sanitize their hands after conducting perineal care on the resident and before touching her equipment and personal items and should have.
On 11/28/2023 at 10:14 a.m., an interview was conducted with S1DONIP (Director of Nursing and Infection Preventionist). S1DONIP stated that the CNAs should have washed their hands after removing their gloves, and should not have handled the resident's cup and equipment before washing their hands.
Based on observations, record review, and interviews, the facility failed to maintain an effective infection control and prevention program by:
1.
Failing to ensure staff sanitized reusable resident care equipment after each resident use.
2.
Failing to perform proper hand hygiene after removing gloves
This deficient practice had the potential to affect the 108 residents residing in the facility.
Findings:
Review of a policy titled Cleaning/Disinfection of Resident-Care Items and Equipment read in part Policy Interpretation and Implementation: 3. Reusable resident care equipment will be sterilized between residents according to manufacturer's instructions.
Review of a policy titled, Handwashing/Hand Hygiene read in part. Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections .6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap .and water for the following situations .m. after removing gloves.
1.On 11/28/2023 at 8:55 a.m., an observation of the facility's television area revealed residents who were seated in their wheelchairs or geri chairs. Further observation revealed that S15WARDC2 (Ward Clerk) was obtaining their vital signs. S15WARDC2 was observed taking Resident #26's blood pressure. When S15WARDC2 completed the task, she failed to sanitize the blood pressure cuff. S15WARDC2 was then observed immediately going to Resident #83 and using the same blood pressure cuff that she used to check Resident #83's vital signs. An immediate interview was conducted with S15WARDC2, who stated that she checks the blood pressure, pulse, temperature, and oxygen level on all residents daily.
On 11/29/2023 at 7:50 a.m., an interview was conducted with S13CNA who stated that she obtained the vital signs from Resident #12 this morning. S13CNA stated that she did not have disinfecting wipes and she confirmed that she sanitized the vital sign machine with wipes she used for perineal care. S13CNA confirmed that perineal care wipes were not disinfectant wipes and she should have used disinfectant wipes to clean the machine.
On 11/29/2023 at 8:40 a.m., S15WARDC2 was observed on Hall 2 entering Resident #67's room and to take the resident's vital signs. Further observation revealed S15WARDC2 placing the blood pressure cuff inside the vital sign machine basket without sanitizing the blood pressure cuff after she checked the resident's blood pressure
On 11/29/2023 at 8:45 a.m., S15WARDC2 entered Resident #19's room and obtained her vital signs. Further observation did not revealed that S15WARDC2 did not sanitize the blood pressure cuff or equipment after use.
On 11/29/2023 at 8:50 a.m., S15WARDC2 entered Resident #107's room and obtained her vital signs. S15WARDC2 did not sanitize the blood pressure cuff or equipment after use.
On 11/29/2023 at 8:55 a.m., S15WARDC2 entered Resident #46's room and obtained her vital signs. Further observation revealed that S15WARDC2 did not sanitize the blood pressure cuff and equipment after use.
On 11/29/2023 at 9:05 a.m., S1DONIP (Director of Nursing/Infection Preventionist) was observed handing S15WARDC2 a container of disinfecting wipes.
On 11/29/2023 at 9:06 a.m., an immediate interview was conducted with S15WARDC2, who stated that she did not know why S1DONIP gave her the disinfectant wipes. She stated that she does not use the disinfecting wipes. S15WARDC2 was asked if she was supposed to sanitize the blood pressure cuff after each resident use and she stated yes. She confirmed that she did not wipe the blood pressure cuff or the machine with disinfecting wipes after each resident's use.
On 11/29/23 at 11:23 a.m., an interview was conducted with S1DONIP, who confirmed that the blood pressure cuff and machine should have been sanitized between each resident use.
Oct 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its policy and procedure for residents and their family me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow its policy and procedure for residents and their family members filing a grievance/complaint for 1 (#412) of 1 (#412) residents reviewed for grievances by:
1. Failing to initiate grievances voiced by the resident's spouse on 09/16/2022 regarding the temperature of the resident's room and on 10/01/2022 regarding loose pills discovered by the resident's spouse in the resident's bed; and
2. Failing to inform the Administrator of the investigation findings for grievances filed on 09/30/2022 and 10/03/2022; and
3. Failing to inform the resident's spouse of the resolution to the grievances filed on 09/30/2022 and 10/03/2022.
This deficient practice had the potential to affect the 114 residents who resided in the facility.
Findings:
Review of the facility's policy and procedure titled Grievance/Complaints Filing revealed:
Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.
Policy Interpretation and Implementation: Read in part .
1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, .or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished .
5. Grievances and/or complaints may be submitted orally or in writing .
8. Upon receipt of a grievance and/or complaint, the designee will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint .
11. The Administrator will review the findings to determine what corrective actions, if any, need to be taken.
12. The resident or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems .
Review of the Resident # 412's medical record revealed the resident was admitted to the facility on [DATE].
On 10/04/2022 at 11:08 a.m. an interview was conducted with Resident #412's spouse who reported upon admit the resident was roomed on Hall 2 and she had voiced her concerns to one of the nurse's during the weekend of 09/15/2022 about the temperature of the room being too hot. She added that the family had purchased a portable air conditioner and used in the room for approximately one week and then they were informed they could not have it because it was against policy. She also reported that she had filed a complaint regarding the resident having dried feces in his adult brief when she arrived in the mornings between 7:00 am and 7:30 am and has spoken to S8SSD (Social Services Director) about it and had not been made aware of what corrective actions were taken. The resident's spouse also reported that while visiting the resident on 10/01/2022, S11LPN/Tx (Licensed Practical Nurse/Treatments) was present in the room providing care when a total of three round white pills that were still whole were discovered in the resident's bed. This concerned her because the resident's medications were supposed to be crushed. The resident's spouse reported she had not heard anything from any staff regarding the incident and informed S2DON (Director of Nursing) and S8SSD on 10/3/2022 and was awaiting for details about the status of the grievances.
A follow up interview was conducted with the resident's spouse on 10/05/2022 at 9:04 a.m. regarding the grievance regarding the three white round pills discovered on 10/01/2022. The resident's spouse reported that the S8SSD and/or the S2DON had not returned and she remained unaware of the resolution.
On 10/05/2022 at 1:21 p.m., a second follow up interview was conducted with the resident's spouse who reported she still had not been updated of the grievance she filed on 10/03/2022 regarding the loose pills in the resident's bed.
An interview was conducted with S8SSD on 10/05/2022 at 1:36 p.m., who reported she was the designated staff who handled grievances. S8SSD provided two separate grievances that were filed on behalf of Resident #412 dated 09/30/2022 and 10/03/2022. S8SSD denied having any knowledge of a complaint involving Resident # 412 and the temperature of his room on 09/16/2022. S8SSD reported she was not aware that S1ADM (Administrator) was supposed to be informed of grievance findings.
A record review of the forms titled Grievance/Complaint Report was made with S8SSD on 10/05/2022 at 1:36 p.m. which revealed a report with the date received of 09/30/2022 regarding the resident's spouse voicing concern about the resident having dried bowel movement down his leg and buttocks when she arrived that morning. S8SSD and S9CNASupervisor (Certified Nursing Assistant) were assigned as the designated individuals to take action on the identified concern. S8SSD instructed surveyor to speak to S9CNASupervisor for information on action taken to resolve the concern. A second report dated 10/03/2022 was reviewed which involved three round white pills found in the resident's room. S2DON was assigned as the designated individual listed to take action on the concern. S8SSD reported she had not informed the resident's spouse of the resolution and instructed surveyor to speak to S2DON for additional information.
On 10/05/2022 at 2:41 p.m., an interview was conducted with S9CNASupervisor who reported she was aware of the incident involving Resident #412 on 09/30/2022 and that she had counseled the CNA who worked that shift on performing thorough brief checks. S9CNASupervisor confirmed she had no documentation of the reported counseling. She confirmed that she should have documented evidence of the CNA being counseled. She also stated that she was not aware that she had to inform the resident's spouse of the resolution to her grievance.
On 10/05/2022 at 3:02 p.m., an interview was conducted with S2DON. S2DON reported she had not been made aware of a grievance regarding the resident's room temperature on 09/16/2022 and was unaware of a portable air conditioning unit being used. S2DON confirmed she worked on 10/01/2022 and denied being informed of pills being found in the resident's room. She reported she was made aware on 10/03/2022 when the resident's spouse informed her. S2DON notified S11LPN/TX via phone and S11LPN/TX confirmed that she saw the white round pills during her shift on 10/01/2022 and failed to report the resident's spouse's concern. S2DON confirmed the resident's spouse's concerns should have been filed on 10/01/2022.
On 10/05/2022 at 3:31 p.m., S2DON notified S1ADM via phone regarding the portable air conditioning unit and S1ADM confirmed he had not filed a grievance nor informed S2DON or S8SSD of the concern voiced by Resident #412's family
On 10/05/2022 at 4:03 p.m., an interview was conducted with S10LPN who reported she had worked the weekend of 09/16/2022- 09/18/2022. S10LPN reported the resident's spouse had complained that the resident's room was too hot and confirmed she had not informed S2DON or S8SSD of the grievance and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary and send a copy of the discharge summa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary and send a copy of the discharge summary to the receiving facility at the time of a resident's discharge for 1 (#110) of 1 residents investigated for discharge in a final sample of 53 residents.
Findings:
Review of the facility's policy titled, Discharge Summary and Plan revealed in part: The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations .a copy of the discharge summary will be provided to the resident and receiving facility.
A review of Resident #110's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Dementia With Behavioral Disturbance, Vitamin Deficiency, Edema, Right Heel Unstageable Pressure Ulcer, and Unspecified Mood Disorder. He was discharged from the facility on 07/08/22.
A review of Resident #110's physician's orders revealed a discharge order dated 07/08/22 discharge to the [facility name] Nursing Home.
A review of the nursing notes revealed:
07/08/22 0900 (9:00 a.m.) OOP (out on pass) with family.
07/08/22 1740 (5:40 p.m.) spoke with RP (resident representative) he stated that resident had been admitted to a nursing home in __ and would not be returning. N.O. (new order) discharge to the [facility name] Nursing Home.
A review of Resident #110's discharge summary revealed it was completed by S2DON and signed by the doctor on 7/17/2022.
On 10/05/22 at 09:56 a.m., an interview and record review was conducted with S2DON who stated that Resident #110 did not return to facility when he left on pass with the family on 07/08/22. The resident was discharged on 07/08/22 to another facility to be closer to his family. S2DON stated she completed the discharge summary and faxed it to the receiving facility on 07/17/22 at 10:41a.m (9 days after discharge). She confirmed she did not complete and send a copy of the discharge summary to the receiving facility at the time of the resident's discharge as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate nursing competencies to assure resident safety a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate nursing competencies to assure resident safety and maintain the highest practicable physical well-being by:
1. failing to ensure an accurate weekly skin assessment was completed for Resident #58; and
2. failing to ensure neuro-checks were resumed timely after Resident #62, who had an unwitnessed fall with major injury, returned from the hospital on 7/26/22 for 2 (#58 and #62) out of 53 final sample resident.
The deficient practice had the potential to affect all 114 residents who reside in the facility.
Findings:
Resident #58
Review of a facility document titled Resident Examination and Assessment read in part . The purpose of this procedure is to examine and assess the resident for an abnormalities in health status, which provides a basis for the care plan. Physical Exam: 8. Skin - intactness; moisture; color; texture and presence of bruises, pressure sores, redness, edema, rashes. Reporting: Notify the physician of any abnormalities. Report other information in accordance with facility policy and professional standards of practice.
Review of Resident #58's medical record revealed that she was admitted on [DATE] with diagnoses that included Seizure Disorder, Diabetes Mellitus and Hypertension.
Review of Care Plan dated 6/16/2022 revealed that the resident had the potential for skin breakdown related to frail skin. Interventions were to observe for skin issues like redness, discoloration, open/breaks in skin and weekly skin assessment.
On 10/3/2022 at 9:41 a.m., an observation was conducted in Resident #58's room. The resident was observed lying in bed and a fifty-cent sized light purple round bruise was observed on her right upper arm. Further observation revealed a quarter-sized yellow, red, green and purple round bruise to the right chest wall. Resident was asked if she was aware that she had bruising to her right arm and right chest wall. The resident responded yes. The resident was unable to determine when the bruising had occurred.
Review of facility document titled Licensed Nurses Progress Notes per S12LPN read, On 10/3/2022 at 8:00 a.m., resident was lying in bed. Voices needs. Feeds self with tray set up. Performs activities of daily living herself. Propels self in wheelchair. Continent of bowel and bladder. No complaint at this time.
On 10/4/2022 at 2:00 p.m., a review of a facility document titled Weekly Audit dated 10/3/2022, revealed no documentation that the resident was assessed with a bruise on the right upper arm and a bruise on the right chest wall.
On 10/4/2022 at 2:10 p.m., an observation and interview was conducted with S12LPN, in Resident #58's room. The resident was lying in bed on her left side and her right arm was exposed. An observation was made with S12LPN of the bruising on the resident's right upper arm and right chest wall. S12LPN confirmed that she performed an assessment of Resident #58's skin on 10/3/2022, and stated she did not see the bruising on the resident's right arm or right chest wall. S12LPN stated that the bruising appeared to be in various stages of healing and confirmed that she did not conduct an accurate skin assessment of Resident #58.
Resident #62
A review of the facility's policy titled Assessing Falls and Their Causes read in part Observe for delayed complications of a fall for approximately forty-eight hours after an observed or suspected fall, and document findings in the medical record. Document any observed sign or symptoms of pain, swelling, bruising, deformity and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings.
Resident #62 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, Generalized Anxiety Disorder, Insomnia and Cognitive Communication Deficit.
A review of an MDS (Minimum Data Set) assessment conducted on 8/10/2022 revealed a BIMS (Brief Interview of Mental Status) score of 00, indicating that Resident #62 had severe cognitive impairment.
A review of Resident #62's Care Plan revealed she was care planned as high risk for falls related to a history of falls, decreased mobility, medication effects, confusion, recent falls, and multiple falls.
A review of an Incident Report dated 7/25/22 provided by the facility revealed that on 7/25/2022 at 8:30 p.m., Resident #62 had an unwitnessed fall that resulted in a major injury of a fracture of the left maxillary bone.
A review of Resident #62's clinical chart revealed a document titled Neurological Assessment Flow Sheet with a date of 7/25/22 which read in part For every fall with an actual or suspected head injury, vital signs and neuro-checks will be done using the following schedule: Every 15 minutes x 2; Every 30 minutes x 2; Every hour x 4 and Every shift x 6 shifts. Further review of the flow sheet revealed that an initial neuro-check was done on Resident #62 at 8:40 p.m. Resident was then transported to the hospital at 8:45 p.m. and returned to the facility 2:00 a.m. Neuro-checks were not restarted until 4:55 a.m., over 2 hours later.
On 10/05/22 at 12:30 p.m., an interview and record review of Resident #62's clinical chart was conducted with S13 LPN (Licensed Registered Nurse). S13LPN stated that when a resident has an unwitnessed fall with a head injury, they are immediately started on neuro-checks which are documented on a Neurological Assessment Flow Sheet. After a review of Resident #62's Neuro Assessment Flow Sheet dated 7/25/22, S13LPN confirmed that following the resident's fall with a major injury , staff failed to continue neuro- checks in a timely manner after the resident returned from the hospital.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interview, and record review, the facility failed to ensure foods were not expired and equipment in the kitchen were properly stored. This deficient practice had the potential t...
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Based on observations, interview, and record review, the facility failed to ensure foods were not expired and equipment in the kitchen were properly stored. This deficient practice had the potential to affect 109 residents whom consume food from the kitchen. The facility's census was 114.
Findings:
Review of the facility's policy titled, Food Receiving and Storage read in part, Foods shall be received and stored in a manner that complies with safe food handling practices. E. Other opened containers must be dated and sealed or covered during storage.
On 10/03/2022 at 09:35 a.m., an initial tour of the kitchen conducted with S3DM revealed the following was observed in the dry storage pantry:
4 canisters of Italian bread crumbs with a printed expiration date of 9/19/22. S3DM stated that expired food items should not be stored on the shelf. She confirmed the bread crumbs should have been discarded.
A gallon of white distilled vinegar ¼ full was observed open without a top. S3DM confirmed the bottle of vinegar was stored on the shelf without a top, open to air. She stated the vinegar should have been capped and now needed to be discarded.
A large bin containing loose rice was observed with the scoop inside the bin. S3DM stated that scoops should not be stored inside dry good bins because it was unsanitary.
An open gallon of kitchen bouquet was observed on the shelf without a date. S3DM confirmed it was opened and not dated. She stated that she was unsure when it was opened and should be discarded.
On 10/3/22 at 10:20 a.m., another observation of the kitchen revealed a cart of food items including 3 small bowls each containing 2 cornbread muffins. The bowls were covered with clear wrap and dated 9/27. A black substance on the surface resembling mold was observed on the surface of one of the muffins. S4Kitchen stated that these food items remained on cart and are used to prepare breakfast trays. She observed the muffin and confirmed she observed a black substance on the surface. S4Kitchen stated she was not sure what the substance was. S3DM approached the food cart at this time and observed the muffin. She stated that the muffins were placed on cart on 9/27/22. S3DM stated that she was not sure what the black substance on the muffins was. She stated that the muffins should not be served to residents and needed to be discarded.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on interview and record review, the facility failed to ensure written notices to the resident or his or her legal representative included items and services which are/are not covered under Medic...
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Based on interview and record review, the facility failed to ensure written notices to the resident or his or her legal representative included items and services which are/are not covered under Medicare or by the facility's per diem rate, including the cost of those items and services and the potential liability for payment for the non-covered services. This deficient practice was identified for 3 of 3 (#19, #30, and #108) sampled residents for Advance Beneficiary Notices (ABN) out of a total of 46 residents remaining in the facility, discharged from a Medicare covered Part A in the past 6 months.
Findings:
Review of the facility's policy titled, Resident Right - Medicaid/Medicare Coverage/Liability Notice read in part: It is the policy of the facility to notify the resident and or legal representative of Medicare/Medicare Coverage/Liability in such a manner to acknowledge and respect resident rights. The facility will inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the changes as soon as is reasonably possible.
Review of an attached document to this policy titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 (2018) read in part: Medicare requires SNFs (Skilled Nursing Facilities) to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary or considered custodial. The SNFABN provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. A subheading of this document titled, Completing the SNFABN revealed in part .The SNF must give the applicable Medicare coverage guideline(s) and brief explanation of why the beneficiary's medical needs or condition do not meet Medicare coverage guidelines.
Review of the SNFABN Review forms completed by the facility revealed the following:
Resident # 19 - Medicare Part A Skilled Services start date 7/14/22; last covered day 9/24/22. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review revealed form CMS (Centers for Medicare & Medicaid Services) 10055 and NOMNC (Notice of Medicare Non-coverage) form CMS 10123 was not issued.
Resident # 108 - Medicare Part A Skilled Services start date 9/13/22; last covered day 9/25/22. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review revealed form CMS 10055 and NOMNC form CMS 10123 was not issued.
Resident # 30 -Medicare Part A Skilled Services start date 7/26/22; last covered day was 9/29/22. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review revealed form CMS 10055 and NOMNC form CMS 10123 was not issued.
On 10/03/22 at 04:19 p.m., a review of the SNFABN Review forms was conducted with S8SSD who stated that she became responsible for SNFABN notices in July 2022. She stated that Residents #19, #30, and #108 were not issued form CMS 10055 and NOMNC form CMS 10123 at admission or prior to their benefit days ending. She stated she was not aware these residents were skilled due to lack of communication between the facility's staff, so she did not complete nor have these residents sign the required forms until today.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0657
(Tag F0657)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to revise the care plan based on the current needs of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to revise the care plan based on the current needs of the resident for 1 (#73) of 24 residents in the final sample.
Review of Resident #73's medical record revealed she was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease and Dysphagia.
Review of the resident's quarterly MDS (Minimum Data Set) dated 8/24/22 revealed a
BIMS (Brief Interview for Mental Status) score of 99 indicating the resident did not or was unable respond appropriately. Further review revealed was totally depended on staff for care and required total assistance for eating due to a significant swallowing disorder. Further review of her medical record revealed the resident began speech therapy on 8/18/22 for dysphagia (swallowing issues).
Review of the resident's physician's orders revealed an order dated 8/19/22 revealed in part that the resident was prescribed a puree diet with nectar thick liquid (mildly thick), allowed regular liquids between meals.
Review of the resident's care plan revealed the resident had a potential for dehydration related to Alzheimer's/fed per staff. Interventions included keep fresh pitcher of water at bedside.
Resident #73 was observed in bed without a pitcher of water at the bedside on 10/03/22 at 01:22 p.m., 10/04/22 at 09:43 a.m., and 10/04/22 at 11:20 a.m.
On 10/04/22 at 11:32 a.m., S5SA stated that she was responsible for refreshing resident water pitchers. She stated that residents on puree diets do not get water pitchers per the facility's protocol.
On 10/04/22 at 11:39 a.m., S14CNA confirmed water pitchers are not given to residents on puree diets. Resident #73 is prescribed a puree diet with thickened liquids, has swallowing issues, and should not have a water pitcher at her bedside.
On 10/04/22 11:44 a.m., S6LPN stated that Resident #73 is unable to drink without assistance and must be supervised while drinking due to swallowing issues. She further stated that the resident should not have a pitcher of water at the bedside.
On 10/04/22 11:57 a.m., a review of Resident #73's care plan was conducted with S7LPN/MDS who stated that this was the most current care plan for the resident. S7LPN/MDS stated that because Resident #73 had swallowing issues, she could not a have water pitcher at the bedside. She further stated that the intervention of the water pitcher at the bedside should have been removed from the resident's care plan when the resident was placed on a puree diet.
On 10/05/22 04:35 p.m., S2DON stated that Resident #73 was on thickened liquids and should not have a water pitcher at her bedside. She agreed the resident's care plan should have been revised.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s). Review inspection reports carefully.
- • 36 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • Grade F (9/100). Below average facility with significant concerns.
- • 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 9/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Maison Du Monde Living Center's CMS Rating?
CMS assigns MAISON DU MONDE LIVING CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Maison Du Monde Living Center Staffed?
CMS rates MAISON DU MONDE LIVING CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 55%, which is 9 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Maison Du Monde Living Center?
State health inspectors documented 36 deficiencies at MAISON DU MONDE LIVING CENTER during 2022 to 2024. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 32 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Maison Du Monde Living Center?
MAISON DU MONDE LIVING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 128 certified beds and approximately 107 residents (about 84% occupancy), it is a mid-sized facility located in ABBEVILLE, Louisiana.
How Does Maison Du Monde Living Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, MAISON DU MONDE LIVING CENTER's overall rating (1 stars) is below the state average of 2.4, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Maison Du Monde Living Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Maison Du Monde Living Center Safe?
Based on CMS inspection data, MAISON DU MONDE LIVING CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Maison Du Monde Living Center Stick Around?
Staff turnover at MAISON DU MONDE LIVING CENTER is high. At 55%, the facility is 9 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Maison Du Monde Living Center Ever Fined?
MAISON DU MONDE LIVING CENTER has been fined $5,600 across 1 penalty action. This is below the Louisiana average of $33,135. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Maison Du Monde Living Center on Any Federal Watch List?
MAISON DU MONDE LIVING CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.