REGENCY HOUSE OF ALEXANDRIA
For profit - Limited Liability company
58 Beds
Independent
Data: November 2025
Trust Grade
50/100
#98 of 264 in LA
Photo by pam mckinley
Photo by Regency House of Alexandria
Photo by Regency House of Alexandria
1 / 5 photos
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Regency House of Alexandria has a Trust Grade of C, which means it is average and sits in the middle of the pack compared to other nursing homes. It ranks #98 out of 264 facilities in Louisiana, placing it in the top half, and #1 out of 9 in Rapides County, indicating it is the best option locally. However, the facility is worsening, with issues increasing from 12 in 2024 to 13 in 2025. Staffing is a concern, with a turnover rate of 75%, significantly higher than the state average of 47%, but it does have more RN coverage than 94% of Louisiana facilities, which is a positive aspect as RNs are essential for monitoring residents closely. The facility has not incurred any fines, which is a good sign, but recent inspections revealed that medication administration practices were not consistently followed, such as failing to document medications properly and experiencing a medication error rate of 11.76%, which exceeds the acceptable limit. Overall, while there are strengths like RN coverage and the absence of fines, families should be aware of the staffing issues and recent medication administration failures when considering this facility.
- Trust Score
- C
- In Louisiana
- #98/264
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 75% turnover. Very high, 27 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ○ Average
- Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Louisiana. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Top 37%
No red flags
12 → 13 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 13 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Above Louisiana average (2.4)
Meets federal standards, typical of most facilities
Staff Turnover: 75%
29pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is very high (75%)
27 points above Louisiana average of 48%
The Ugly 30 deficiencies on record
Mar 2025
2 deficiencies
CONCERN
(D)
📢 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
Record Review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part .Alz...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1
Record Review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part .Alzheimer Disease; Fibromyalgia; Osteoarthritis of first Carpometacarpal Joint; Primary Osteoarthritis, Right Hip; Primary Generalized Osteoarthritis; Displaced Mid-cervical Fracture of Left Femur; and Low Back Pain.
Review of Resident #1's Quarterly MDS with an ARD of 05/16/2025 revealed a BIMS Score of 08, indicating moderate cognitive impairment. Resident #1 required partial/moderate assistance with toileting hygiene, dressing, personal hygiene, and transfers. Resident #1 used a wheelchair for mobility.
Review of Resident #1's Departmental Progress Notes revealed in part .
02/16/2025 8:46 a.m. S8 LPN documented: Resident #1 noted with complaint of pain to left knee this a.m. grimacing upon touch. Resident #1 denies hitting/bumping left knee during transfer. No bruising/discoloration noted. No swelling. PRN pain medication administered. MD notified of sign/symptoms of pain/discomfort with new order noted for x-ray to left knee. Imaging notified. RP made aware.
02/16/2025 11:07 a.m. S8 LPN documented: Imaging at facility at this time to obtain x-ray to left knee. 3 views obtained. Resident #1 tolerated well. Awaiting results.
02/16/2025 12:28 p.m. S8 LPN documented: Received results of x-ray with findings of suspected minimally displaced femoral peri arthroplasty acute to subacute fracture. RP notified. Resident #1's RP requested that resident is not sent to ER, if possible, and to keep Resident #1 as comfortable as possible with ordered pain medication. Notified NP of x-ray results and family request. NP stated that family can provide knee immobilizer to stabilize knee, or send Resident #1 to ER for stabilization.
Review of Radiology Results Report revealed in part .Examination date: 02/16/2025 11:10 a.m., Reported date: 02/16/2025 11:43 a.m. Impression: Suspected minimally displaced femoral peri arthroplasty acute to subacute fracture.
Interview on 03/18/2025 at 12:48 p.m. with S2 DON accompanied with S4 Admin Nurse revealed the facility did an onsite x-ray on 02/16/2025. S4 Admin Nurse stated x-ray results were given the same day, which confirmed a fracture. S2 DON stated all Administrative staff were in contact and S1 Administrator was notified on Sunday, 02/16/2025, of the findings.
During an interview on 03/18/2025 at 3:31 p.m. with S1 Administrator, stated that when she saw the report of the x-ray results for Resident #1 on 02/16/2025, she should have submitted the SIMS report within the 2 hour timeframe. S1 Administrator confirmed she should have reported the fracture as soon as she reviewed the x-ray results on 02/16/2025, but did not.
Based on record review and interview the facility failed to ensure an injury of unknown origin and a serious bodily injury of an unknown origin were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (#1 and #2) of 3 (#1, #2 and #3) sampled residents reviewed for accidents. The facility failed to:
1. Ensure injury of unknown origin of Resident #1 was reported within 2 hours in accordance with State law through established procedures.
2. Ensure serious bodily injury and injury of unknown origin of Resident #2 was reported within 2 hours in accordance with State law through established procedures.
Findings
Review of the facility undated policy titled Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation read in part . This policy is concerned with all incidents and accidents involving residents. Certain incidents and accidents involving residents must also be reported to the appropriate state agencies. The Policy also addresses proper investigation and documentation of incidents and accidents involving residents that are not caused by abuse, exploitation and misappropriation of resident property.
D. Suspicious Injuries of Unknown Origin. An injury should be classified as an injury of unknown origin when both of the following conditions are met: (1) the source of the injury was not observed by any person and the source of the injury could not be explained by the resident and (2) the injury is suspicious because of the extent of the injury or the location of the injury . suspicious injuries of unknown origin may include, but are not limited to: unwitnessed fractures that are unusual in nature.
VI. Investigations and Facility Response to Incidents or Accidents. a).The facility will report all instances of . suspicious injuries of unknown origin . in the following manner: b). Investigation and Reporting Steps. The Administrator will report to the State Agency and all other required agencies, according to regulations. All . instances that result in serious bodily injury must be reported within 2 hours. Serious Bodily Injury is defined as an injury . requiring medical interventions .
Resident #2
Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE], with diagnoses that included: Protein Calorie Malnutrition, Fall, Syncope and Collapse, Laceration without foreign body of Cheek and Temporomandibular area, and Fracture of Mandible. Resident #2 was discharged on 02/22/2025.
Review of Resident #2's progress notes revealed a note authored by S7 RN dated 02/11/2025 at 2:29 a.m., which read in part . Around 1:10 a.m. I heard a knocking sound followed by a loud thump on resident's door. I opened the door and found the resident lying on the floor on her left side. Bleeding noted from a laceration on the back of her scalp . the laceration was cleaned and a pressure dressing was applied.
Review of Resident #2's Post Fall Evaluation authored by S2 DON dated 02/13/2025 at 10:58 a.m., revealed in part . Fall Details: Date / Time of Fall: 02/11/2025 1:10 AM Fall was not witnessed . The reason for the fall was not evident . Did an injury occur as a result of the fall: Yes. Injury details: laceration to scalp. Did fall result in an ER visit/hospitalization: Yes. Skin: Skin note: laceration to back of head. Skin Issue: #001: New skin Issue. Location: Rear scalp. Issue type: Laceration. Progress: New: new wound. Wound acquired in-house. Wound is new. Incision approximated: No.
Interview with S1 Administrator on 03/17/2025 at 4:15 p.m. revealed that she was notified at 6:01 a.m. of Resident #2's fall with major injury.
Interview with S2 DON on 03/18/2025 at 11:45 a.m. revealed that if an unwitnessed fall with a head injury does occur, the Resident is sent out. The Administrator/EMS/Physician and Family are all notified immediately and the Administrator has 2 hours to report the injury to the state agency.
Telephone Interview with S7 RN on 03/18/2025 at 2:07 p.m., revealed that S7 RN heard knocking at 1:00 a.m. on a door. S7 RN stated that she was unable to determine where it was coming from, she then heard a thumping sound against a door. S7 RN stated that she realized it was coming from Resident #2's room. S7 RN went in and Resident #2 was on the floor behind the door. S7 revealed that Resident #2 was laying on her side and Resident #2 could not tell S7 RN what happened. Resident #2 had a gash on the back of her scalp that was actively bleeding, and observed blood dripping from Resident #2's head on to her neck. S7 RN stated that she called S1 Administrator, the Physician, the Ambulance, the ER and Resident #2's Daughter while another nurse came in and dressed the wound.
Interview with S1 Administrator on 03/18/2025 at 3:31 p.m., revealed that she wanted to clarify her earlier statement of when she received the call of Resident #2's injuries. S1 Administrator stated that she was notified of Resident #2's fracture on 02/11/2025 at 6:01 a.m., but she received a phone call from S7 RN that Resident #2 had fallen at 1:48 a.m. on 02/11/2025, and was being sent out to the emergency room. S1 Administrator stated that she did not think Resident #2's unwitnessed fall was a reportable injury. S1 Administrator confirmed that no one saw Resident #2 fall and that Resident #2 was sent out to the emergency room. S1 Administrator confirmed that a reportable injury is an injury of unknown origin and unknown origin means that is not witnessed and no one is able to tell what happened. S1 Administrator stated that an injury would be a fracture, bruise, major injury or suspicion of abuse and a major injury would be a hematoma or a head injury. S1 Administrator stated that she reported the injury after it was revealed to be a fracture.
Phone Interview with S7 RN on 03/19/2025 at 2:24 p.m. confirmed that she called S1 Administrator about Resident #2's fall right after it occurred on 02/11/2025, and informed S1 Administrator that Resident #2 had bleeding from the back of her head.
CONCERN
(D)
📢 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
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 interview and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure a CNA staff reported Resident #1's complaint of pain to the nurse as indicated in the plan of care.
Findings:
Review of facility policy titled Pain Management, with a revision date of 12/31/2024 on 03/17/2025, read in part .Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Pain Management and Treatment: 2.The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain, or may be included as a specific pain management need or goal.
Record Review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part .Alzheimer Disease; Fibromyalgia; Osteoarthritis of first Carpometacarpal Joint; Primary Osteoarthritis, Right Hip; Primary Generalized Osteoarthritis; Displaced Mid-cervical Fracture of Left Femur; and Low Back Pain.
Review of Resident #1's Quarterly MDS with an ARD of 05/16/2025, revealed BIMS Score of 08, indicating moderate cognitive impairment. Resident #1 required partial/moderate assistance with toileting hygiene, dressing, personal hygiene, and transfers. Resident #1 used a wheelchair for mobility. Resident #1 rarely exhibits pain and had pain present during the 7 day lookback of this assessment.
Review of Resident #1's Care Plan revealed, in part .Resident #1 has (acute/chronic) pain related to low back pain/Fibromyalgia/Osteoarthritis/epigastric pain/spinal stenosis/headaches, OA .Interventions: Monitor/record/report to Nurse Resident #1 complaints of pain or requests for pain treatment-Position: CNA (initiated 09/19/2024).
Review of 03/2025 Physician Orders for Resident #1 revealed, in part .Hydrocodone-Acetaminophen Tablet 7.5-325mg. Give 1 tablet by mouth every 6 hours as needed for pain. Order dated 04/10/2020.
Observation of Resident #1 on 03/17/2025 at 10:13 a.m. revealed Resident #1 sitting in a wheelchair in her bedroom. Resident #1's left leg was observed with knee immobilizer on, and her call light within reach. Resident #1 was in a pleasant mood, no facial grimacing, moaning, or non-verbal indicators of pain observed at this time.
Telephone Interview with S6 CNA on 03/18/2025 at 4:14 p.m. revealed she worked with Resident #1 on 02/15/2025, on the 11:00 p.m. to 7:00 a.m. shift. S6 CNA stated she provided incontinent care to Resident #1, the morning of 02/16/2025 and when she uncovered Resident #1 to change her brief, Resident #1 said ouch. S6 CNA stated she asked resident #1 what was wrong and resident #1 told her that her leg was hurting. S6 CNA denied seeing any bruising or swelling after uncovering Resident #1. S6 CNA stated she asked Resident #1 if she wanted to get the nurse, and Resident #1 told her no. S6 CNA stated she got Resident #1 dressed, picked her up out of the bed, and placed her in the wheelchair. S6 CNA stated she notifies the nurse anytime Resident #1 complains of pain. S6 CNA stated she received training on reporting pain, and knew to notify nurses if a resident complained of, or appeared to be in pain, even if a resident told her not to report it. S6 CNA stated she didn't tell the nurse Resident #1 was in pain because Resident #1 told her not to. S6 CNA confirmed she should have notified the nurse about Resident #1 complaint of pain, but did not.
During an interview with S5 CNA Supervisor on 03/19/2025 at 11:18 a.m., she stated she expected all of her CNA staff to report all resident's pain to the nurse even if a resident told them not too. S5 CNA Supervisor confirmed S6 CNA should have reported Resident #1's complaint of pain to the nurse, but did not.
Feb 2025
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of...
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Based on interview and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, by failing to honor a resident's right to request an incontinent wipe.
Findings:
1. Review of a Facility Policy titled Federal Rights of Residents with an effective date of 04/08/2024 read in part .
Purpose:
All residents in long term care facilities have rights guaranteed to them under Federal and State law.
Standard:
(E) The resident has a right to be treated with respect and dignity, including.
(e)(2) The right to retain and use personal possessions.
(f)(2) The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.
Review of Resident #13's medical record revealed an admit date of 10/12/2018, with diagnoses which included in part . Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side, Major Depressive Disorder, Anxiety Disorder, and Irritable Bowel Syndrome with Diarrhea.
Review of Resident #13's Quarterly MDS with an ARD of 11/20/2024, revealed a BIMS score of 14, indicating intact or mildly impaired cognition. Resident #13 was dependent for toileting hygiene, and required partial/moderate assistance with personal hygiene.
Review of Resident #13's Care Plan with a Target date of 05/21/2025, revealed in part .Resident #13 had an ADL self-care performance deficit related to limited mobility: CVA with Right Hemiparesis, and bilateral hands and legs contractures, with approaches that included: Extensive assist of one person with bathing, dressing, oral care, hair care, and nail care. Resident #13 had bladder and bowel incontinence, and a diagnosis of Irritable Bowel Syndrome, with approaches that included check every two hours and provide peri-care as needed.
Interview on 02/11/2025 at 9:30 a.m. with S1 Administrator, revealed on 01/19/2025 she received a call from Resident #13's niece stating Resident #13 had called her upset because a CNA refused to give her an incontinent wipe. S1 Administrator revealed S7 CNA stated she had already cleaned Resident #13, and was not going to give her an incontinent wipe. S1 Administrator revealed she terminated S7 CNA because she refused to honor a request from Resident #13. S1 Administrator confirmed S7 CNA should have given Resident #13 the incontinent wipe when she asked for it.
Telephone interview on 02/12/2025 at 12:46 p.m. with Resident #13's private sitter revealed she was sitting with Resident #13 on 01/19/205 when S7 CNA told Resident #13 she was not going to give her an incontinent wipe. The private sitter revealed S7 CNA stated you can give her a wipe if you want to. The private sitter revealed Resident #13 often asked for an incontinent wipe because she didn't feel as if she was clean.
Telephone interview on 02/12/2025 at 3:52 p.m. with S7 CNA revealed she provided care for Resident #13 on 01/19/2025 7:00 a.m. to 3:00 p.m. shift. S7 CNA revealed Resident #13 had a private sitter in the room. S7 CNA revealed she had cleaned Resident #13 when she asked for an incontinent wipe. S7 CNA revealed she did not give Resident #13 the incontinent wipe because she performed inappropriate behavior with it. S7 CNA confirmed she should have given Resident #13 the incontinent wipe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to ensure each resident was treated with respect and dignity for 1 (Resident # 205) out 19 sampled residents. The facility failed to ensure Resid...
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Based on observation and interview the facility failed to ensure each resident was treated with respect and dignity for 1 (Resident # 205) out 19 sampled residents. The facility failed to ensure Resident #205 had adequate clothing.
Findings:
Review of Resident #205's medical record revealed an admit date of 01/14/2025, with diagnoses that included in part .Major Depressive Disorder, Type 2 Diabetes Mellitus, Acute Respiratory Failure, and Unspecified Protein Calorie Malnutrition.
Review of Resident # 205's admission MDS with an ARD of 01/18/2025, revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #205 required supervision or touching assistance with upper body dressing, and partial/moderate assistance with lower body dressing.
Review of Resident #205's Care Plan with no review date, revealed in part .
1. Resident had an ADL self-care performance deficit related to impaired balance, with approaches that included staff to supervise/assist resident with ADL's as needed.
2. Resident had a potential for cognitive decline due to Neurocognitive Disorder with Lewy Bodies, with approaches that included I will be provided with a homelike environment.
Observation and interview on 02/10/2025 at 9:49 a.m., revealed Resident #205 had on a white t-shirt, a coat and a pair of blue jeans. Resident #205 revealed he had a pair of stretch pants (joggers) that he had sent to the laundry a week ago, and they had not been returned to him. Resident #205 revealed he told two different employees (couldn't remember their names), about the missing joggers, but had not heard anything back.
Observation of Resident #205 on 02/11/2025 at 2:15 p.m. revealed he had on a white t-shirt, a coat and a pair of blue jeans.
Observation and interview of Resident #205 on 02/12/2025 at 10:24 a.m., revealed he had on a white t-shirt, a coat and a pair of blue jeans. Resident #205 revealed he came to the facility from the hospital, and never got the chance to return home to retrieve any of his clothes or other belongings.
Observation on 02/12/2025 at 10:33 a.m. of Resident #205's closet, revealed a pack of white t-shirts, socks, underwear and a coat. No other clothes were in Resident #205's closet. Resident #205 revealed he only had one pair of jeans that he had been wearing every day for a week. Resident #205 revealed the joggers were given to him by the facility, but laundry had not returned them. Resident #205 stated It made me feel really bad not to have clothes.
Interview on 02/12/2025 at 10:51 with S13 LPN, revealed she provided care for Resident #205. S13 LPN revealed she was not aware of Resident #205 wearing the same pants every day for a week.
Interview on 02/12/2025 at 10:58 a.m. with S24 Admissions/Marketing/Acting SSD, revealed she was not aware of Resident #205 not having clothes (outwear).
Interview on 02/12/2025 at 11:00 a.m. with S1 Administrator, revealed the facility did not currently have a Social Service Director, and S24 was the Acting SSD. S1 Administrator revealed she had purchased Resident #205 t-shirts, socks, and underwear. S1 Administrator revealed she had not purchased any other clothing items for Resident #205. S1 Administrator confirmed the facility should have assisted Resident #205 with obtaining clothes for outwear.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to promptly notify the physician and responsible party after a change in resident's condition for 1 (Resident #49) of 3 (Resident #49, Residen...
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Based on interview and record review, the facility failed to promptly notify the physician and responsible party after a change in resident's condition for 1 (Resident #49) of 3 (Resident #49, Resident #13, and Resident #158) residents investigated for accidents. The facility failed to notify the physician and responsible party in a timely manner after an unwitnessed fall.
Findings:
Review of Resident #49's medical record revealed an admission date of 12/13/2024 with diagnoses that included in part .Vascular Dementia, Moderate, With Other Behavioral Disturbance, Non-St Elevation (Nstemi) Myocardial Infarction, Lack Of Coordination, Difficulty In Walking, and Need For Assistance With Personal Care .
Review of Resident #49's admission MDS with an ARD of 12/27/2024 revealed a BIMS score of 10, which indicated moderate cognitive impairment and no history of falls. Resident #49 was independent with rolling left to right, sit to lying, and lying to sitting. Resident #49 required set-up clean-up assist with chair/bed to chair transfer, with no wheelchair usage indicated.
Review of Resident #49's nursing progress notes revealed in part .On 02/08/2025 at 3:11 p.m. S10 Medical Records LPN wrote .It was reported to me that resident fell. No injury noted at this time. Move all extremities. Resident sitting at nurses station .
In an interview on 02/11/2025 at 9:11a.m., Resident #49's Son/RP, revealed that his father started falling after he was admitted to the facility. He did not have any falls at home. He stated S11 LPN called him on 02/09/2025 to inform him that his father had fallen on 02/08/2025 and the facility performed x-rays of his ribs.
In an interview on 02/11/2025 at 10:50 a.m., S8 CNA stated she was scheduled 7:00 a.m. - 3:00 p.m. on 02/08/2025. S8 CNA was assigned to Resident #49 and was aware of Resident #49's fall on 02/08/2025. S8 CNA stated that on 02/08/2025 at about 3:00 p.m., she and S18 CNA were notified by the activity director that Resident #49 had fallen. S8 CNA stated when she and S18 CNA entered Resident #49's room he was sitting upright on the floor with his back/side against his wheelchair and feet out in front of him. S8 CNA stated she notified S10 Medical Records LPN of the fall and S10 Medical Records LPN came in to assess the resident. S8 CNA stated she and S18 CNA transferred him back into his wheelchair.
In an interview on 02/11/2025 at 11:45 a.m., S10 Medical Records LPN stated she worked 2:00 p.m.-10:00 p.m. on 02/08/2025 and was assigned to Resident #49. S10 Medical Records LPN stated she was alerted by S8 CNA that Resident #49 had fallen in his room at 3:00 p.m. on 02/08/2025. S10 Medical Records LPN stated she observed Resident #49 sitting upright with his back/side against the wheelchair in his room. S10 Medical Records LPN stated she completed a head-to-toe assessment, obtained his vital signs, and assessed for any injuries. S10 Medical Records LPN stated she did write a progress note regarding Resident #49's fall but failed to notify the physician/nurse practitioner and responsible party. S10 Medical Records LPN stated she knew she was supposed to notify the MD/NP and RP immediately of the resident's fall when it happened; she just did not because she had too much going on at that time. She confirmed that she should have taken the time to notify them to obtain new orders.
In an interview on 02/11/2025 at 12:18 p.m., S2 DON revealed that the floor nurses have a certain processes to follow when a resident falls. S2 DON confirmed part of the fall/incident procedure does involve the floor nurse to notify the MD/NP and RP of the fall/incident on her shift. She would then document and obtain/carry-out any new orders. S2 DON stated all nurses know that if there is a fall/incident they should notify the MD/NP and RP on their shift. S2 DON confirmed that S10 Medical Records LPN should have notified the MD/NP and RP of resident #49's fall on her shift (2:00 p.m.-10:00 p.m.) to obtain any new orders and she failed to do so.
In an interview on 02/12/2025 at 2:08 p.m., S2 DON confirmed that the Fall Incident Report that was completed by S10 Medical Records was back-dated to 02/08/2025. S2 DON stated the time of notification of the MD/NP and RP was completed on 02/09/2025 at 11:50 a.m. and the notification was performed by S11 LPN and not S10 Medical Records LPN.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0659
(Tag F0659)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care are delivered by individuals who have...
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Based on observation, interview and record review, the facility failed to ensure that services provided or arranged in accordance with the resident's plan of care are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity. This includes proper licensure or certification, if required. The facility failed to ensure that S6 CNA did not apply Zinc Oxide cream to Resident #206's stage 3 Sacral pressure sore.
Findings:
Review of Resident #206's clinical record revealed an admit date of 02/06/2025, with diagnoses that included Acquired Absence of Left Leg Below Knee; and Encounter for Change or Removal of Surgical Wound Dressing
Review of Resident #206's admission MDS with an ARD of 02/12/2025, revealed a BIMS of 15, which indicated Resident #206 was cognitively intact. Resident #206 used a wheelchair as a mobility device, and required supervision or touching assistance with eating, oral hygiene, and personal hygiene; substantial/maximal assistance with toileting, lower body dressing, putting on/taking off footwear; showering/bathing; and partial/moderate assistance with upper body dressing.
Review of Resident #206's Care Plan revealed in part I have a Stage 3 pressure ulcer to my sacrum. Interventions to include . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Monitor/document/report PRN any changes in my skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage.
Review of Resident #206's February 2025 Physician's Orders revealed in part . Cleanse stage 3 to sacrum with wound cleanser, pat dry, apply zinc oxide BID and PRN until healed.
Observation on 02/10/2025 at 9:39 a.m. revealed Resident #206 in bed waiting for his diaper to be changed. Two plastic clear medicine cups, one with a yellow cream substance, and the other with a white cream substance with Resident #206's room number written on them, were observed on the nightstand in Resident #206's room.
Observation and Interview with S13 LPN on 02/10/2025 at 10:55 a.m., confirmed that the creams in the two medication cups should not be in Resident #206's room. Resident #206 stated that the creams were applied to his bottom during his diaper change.
Interview with S6 CNA on 02/10/2025 at 11:07 a.m., confirmed that she applied the two creams to Resident #206's bottom area during toileting care.
Interview with S16 ADMIN RN on 02/11/2025 at 10:46 a.m., revealed that the yellow cream in the medicine cup was moisture barrier, and the white cream was Zinc. S16 ADMIN RN revealed Resident #206's wound was not covered with a dressing due to the physician not wanting the area to retain moisture.
Interview with S2 DON on 02/11/2025 at 12:25 p.m. revealed that Zinc cannot be applied by CNAs if the resident has a wound. S2 DON confirmed the Zinc should not have been left in Resident #206's room, and the CNA should not have applied Zinc to the wound area. S2 DON stated that the Zinc is a part of Resident #206's wound care and only nurses were allowed to perform wound care.
Observation of Resident #206's toileting care by S8 CNA on 02/11/2025 at 12:49 p.m. revealed an uncovered reddened softball sized stage 3 pressure ulcer to his sacral area.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #156) of 2 (Resident #13 and Resident #156) sam...
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Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #156) of 2 (Resident #13 and Resident #156) sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly labeled and stored. Total sample size was 18.
Findings:
Review of the facility's policy titled, Oxygen Concentrator, dated 12/31/2024 read in part .
C. Nurse responsibilities: 1. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.
Review of Resident #156's medical record revealed an admit date of 01/23/2025 with a re-entry date of 02/05/2025 with diagnoses that included in part .Acute and Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia; Chronic Systolic (Congestive) Heart Failure; Depression. Anxiety Disorder; Dependence on other Enabling Machines and Devices; Respiratory Disorders in Diseases.
Review of Resident #156's 02/2025 Physician orders revealed the following orders in part .Change O2 (Oxygen) mask/nasal cannula and tubing every night shift every Wednesday and as needed.
Review of Resident #156's admission MDS with an ARD of 04/27/2025 revealed a BIMS summary score of 14 indicating intact cognition. Resident #156 required oxygen therapy.
Observation on 02/10/2025 at 11:15 a.m. revealed Resident #156 lying in bed awake and alert with nasal cannula present in nares. Resident #156 stated she required continuous oxygen administration at 3 liters/minute. Oxygen tubing observed with a date of 01/29/2025.
Observation on 02/11/2025 at 8:30 a.m. revealed Resident #156 lying in bed asleep wearing a nasal cannula with oxygen flowing at 3 liters/minute. Oxygen tubing observed with a date of 01/29/2025.
Interview on 02/11/2025 at 8:32 a.m. with S9 LPN revealed Resident #156 wore oxygen continuously and all nurses were responsible for changing oxygen tubing. Observation with S9 LPN confirmed Resident #156's oxygen tubing had a date of 01/29/2025 and should been changed but had not been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside...
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Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in a secure manner by failing to ensure medications were not left at the bedside for 1 (Resident #25) of 19 sampled residents.
Findings:
Review of a facility policy on 02/11/2025 at 1:39 p.m. titled, Medication Storage (unknown original date) with a revised date of 09/01/2024, revealed the following part .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .1. A. All drugs and biologicals will be stored in locked compartments (medication carts) .
Review of Resident #25's medical record revealed an admission date of 11/15/2023, with diagnoses that included in part .Pressure Ulcer of Sacral Region, Stage 4, Peripheral Vascular Disease, Bipolar Disorder, Schizoaffective Disorder, Bipolar Type, and Need for Assistance with Personal Care .
Review of Resident #25's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/06/2025 revealed a BIMS (Brief Interview for Mental Status) score of 11, which indicated moderate cognitive impairment. Resident #25 required dependence/total care for bed mobility (roll left/right), transfer (tub/shower), and toileting hygiene.
Review of Resident #25's current clinical physician orders revealed no orders for Zinc Oxide ointment or Nystatin powder.
Review of Resident #25's discontinued/completed clinical physician orders revealed the following:
1. A discontinued order for Zinc Oxide External Paste 20 % (Zinc Oxide (Topical)) Apply to decubitus wound buttock topically two times a day for decubitus wound care apply after Mupirocin with a start date of 07/31/2023 and a discontinued date of 08/04/2023.
2. A completed order for Nystatin Powder (Nystatin (Bulk)) Apply to bilateral groin and peri-area topically two times a day for fungal dermatitis for 7 Days with a start date of 12/22/2024 and a discontinued date of 12/29/2024.
Observation on 02/10/2025 at 9:30 a.m. revealed 1 tube of Zinc Oxide ointment and 1 bottle of Nystatin powder on Resident #25's bedside dresser drawer. Both medications observed unsecure and unattended on the resident's bedside dresser drawer.
On 02/10/2025 at 9:35 a.m., in an interview and observation with S9 LPN, S9 LPN confirmed that Resident #25 had 1 tube of Zinc Oxide ointment and 1 bottle of Nystatin powder left at the bedside unattended. S9 LPN stated the Zinc Oxide ointment and Nystatin powder should not have been left at the resident's bedside unattended. S9 LPN confirmed that all medications (including ointments and powders) should be secured and locked on the medication cart when not in use.
Further review of the record revealed there was no physician's order to allow Resident #25 to keep any medications in the room at the bedside and there was no assessment to determine if Resident #25 was safe to have the medications in the room at the bedside to self-administer.
On 02/11/2025 at 10:05 a.m., S2 DON revealed in an interview that Resident #25 had previous orders for Nystatin Powder that were completed on 12/29/2024 and previous Zinc Oxide ointment orders that were discontinued on 08/04/2023. S2 DON confirmed that Resident #25 does not self-administer his medications and the tube of Zinc Oxide ointment and bottle of Nystatin powder should have been disposed of properly. S2 DON confirmed that Resident #25 should not have medications left at the bedside unattended and all medications should be stored and locked in the medication cart when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interviews the facility failed to ensure garbage and refuse were disposed of properly.
Findings:
Review of a Facility Policy on 02/12/2025, titled Disposal of Garbage and Ref...
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Based on observation and interviews the facility failed to ensure garbage and refuse were disposed of properly.
Findings:
Review of a Facility Policy on 02/12/2025, titled Disposal of Garbage and Refuse with a review/revision date of 09/01/2024 read in part .
Policy Explanation and Compliance Guidelines:
7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.
Observation and interview on 02/11/2025 at 8:30 a.m., of the area outside of the facility's kitchen revealed one blue dumpster. Dirty gloves and debris (old cardboard boxes), littered the ground surrounding the dumpster. S22 Dietary Manager confirmed the findings at the time of observation.
Interview on 02/11/2025 at 8:33 a.m. with S23 Maintenance Director, revealed the trash was left by the sanitation employees.
Interview on 02/12/2025 at 12:20 p.m. with S1 Administrator revealed S23 Maintenance Director was responsible for ensuring debris was picked up around the dumpster.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were administered and ac...
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Based on observation, interview and record review, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were administered and accurately documented on the MAR for 1 (#44) of 4 sampled residents (#44,#155,#157,#159) observed during medication administration. The facility had a total census of 54 residents according to the Resident List Report provided by the facility.
Findings:
Review on 02/12/2025 of the facility's policy and procedure dated 09/01/2024, and titled Medication Administration read in part .
Policy: Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice .
Policy Explanation and Compliance Guidelines:
10. Ensure that the six rights of medication administration are followed:
f. Right documentation
11. Review MAR to identify medication to be administered.
12. Compare medication source (bubble pack, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
23. Correct any discrepancies and report to nurse manager.
Observation of Medication Administration on 02/11/2025 at 9:30 a.m. revealed S13 LPN punched out 1 tablet of Aspirin 81mg, 1 tablet of Vitamin D 50 mcg, 1 tablet of Iron 324mg, 1 tablet of Tamsulosin 0.4mg, 1 tablet of Furosemide 40mg, 1 tablet of Hydralazine 50mg, 1 tablet of Calcitriol 0.25mcg, 1 tablet of Carvedilol 6.25mg, 1 tablet of Clopidogrel 75mg, 1 tablet of Clonidine 0.2mg, 1 tablet of Finasteride 5mg, 1 tablet of Nifedipine 60mg, and 2 tablets of Sertraline 100mg and placed them in a medication cup. S13 LPN confirmed with this surveyor a total of 14 pills were administered to Resident #44.
Review of Resident #44's February 2025 MAR revealed that on 02/11/2025 for 8:00 a.m. medication administration he received these PO medications as follows: Aspirin 81mg,Calcitriol 0.25mcg, Cholecalciferol 50mcg, Clopidogrel 75mg, Cyanocobalamin 1000mcg, Finasteride 5mg, Furosemide 40mg, Sertraline 200mg, Tamsulosin 0.4mg, Carvedilol 6.25mg, Clonidine 0.2mg, Ferrous Gluconate 324mg, Nifedipine 60mg, Sacubitril-Valsartan 49-51mg, Sodium Bicarbonate 650mg, and Hydralazine 50mg. Resident #44's MAR revealed Bactrim DS 800/160mg with a start date of 02/10/2025 was also to be administered with the 8:00 a.m. medications, but there was a (9) coded for see other/progress notes. This was a total of 18 pills to be administered.
Telephone interview on 02/12/2025 at 4:10 p.m. with S13 LPN confirmed that only 14 pills were administered to Resident #44 during the morning medication administration. S13 LPN revealed that she did not administer any other PO medications to Resident #44 scheduled for 02/11/2025 morning medication administration before or after this Surveyor observed Resident #44's morning medication administration. S13 LPN revealed that she did not administer the Bactrim DS 800/160mg, Sacubitril-Valsartan 49-51mg or Sodium Bicarbonate 650mg tablets due to them not being available. S13 LPN revealed that she did not administer the Cyanocobalamin because she forgot to pull it from the cart. S13 LPN confirmed that she did document the medications as administered but meant to go back and strike them out but there was a lot going on.
Review of Resident #44's progress notes revealed a note dated 02/11/2025 at 9:35 a.m. that read in part . Bactrim DS Oral Tablet 800-160 mg; give 1 tablet by mouth two times a day for Abscess to buttocks for 7 days; Medication Unavailable. Authored by: S13 LPN.
Observation of the Team 2 medication cart on 02/12/2025 at 4:26 p.m. with S12 LPN revealed Sodium Bicarbonate 650mg was on the cart in the over the counter medication area with an open date of 12/30/2024, Resident #44's Bactrim DS Oral Tablet 800-160 mg tablet blister card was on the cart with two pills removed. S12 LPN confirmed that he administered one Bactrim tablet on 02/10/2025 during Resident #44's night medication administration and one on 02/11/2025 during Resident #44's night medication administration. Resident #44's Sacubitril-Valsartan was not on the cart at all.
Review of Resident #44's MAR and Bactrim DS Oral Tablet 800-160mg tablet blister medication card with a start date of 02/10/2025(8:00p.m.) on 02/12/2025 revealed three documented administrations 02/10/2025 at 8:00 p.m., 02/11/2025 at 8:00 p.m. and 02/12/2025 at 8:00 a.m. with only two pills removed from the blister pack.
Interview on 02/12/2025 at 4:31 p.m. with S2 DON confirmed that Resident #44's Bactrim DS 800-160mg tablet, Sodium Bicarbonate 650mg, and Cyanocobalamin 1000mcg were on the medication cart and should have been administered according to the Resident #44's physician's orders but had not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure acquiring, receiving, dispensing and administration of a non-c...
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Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure procedures that assure acquiring, receiving, dispensing and administration of a non-controlled medication (Sacubitril-Valsartan) to meet the needs of the resident for 1 (Resident #44) of 4 sampled residents (#44, #155,#157 and #159) observed during medication administration. The facility had a total census of 54 residents according to the Resident List Report provided by the facility.
Findings:
Review on 02/12/2025 of the facility's policy titled Medication Ordering and Receiving from Pharmacy Provider, Section 3.2: Ordering and Receiving Non-Controlled Medications dated 01/2023 read in part .
Policy: Medications and related products are received from the provider pharmacy on a timely basis.
Procedures: Ordering medications from provider pharmacy:
Timely delivery of new orders is required so that medication administration is not delayed.
2. Receiving medications from the pharmacy:
a. A licensed nurse or appropriate personnel as required by law
Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/ supervisor.
Retains a copy of the delivery receipt for an appropriate time to reconcile any ordering issues.
Observation of Medication Administration on 02/11/2025 at 9:30 a.m. revealed S13 LPN punched out 1 tablet of Aspirin 81mg, 1 tablet of Vitamin D 50 mcg, 1 tablet of Iron 324mg, 1 tablet of Tamsulosin 0.4mg, 1 tablet of Furosemide 40mg, 1 tablet of Hydralazine 50mg, 1 tablet of Calcitriol 0.25mcg, 1 tablet of Carvedilol 6.25mg, 1 tablet of Clopidogrel 75mg, 1 tablet of Clonidine 0.2mg, 1 tablet of Finasteride 5mg, 1 tablet of Nifedipine 60mg, and 2 tablets of Sertraline 100mg and placed them in a medication cup. S13 LPN confirmed with this surveyor a total of 14 pills were administered to Resident #44.
Review of Resident #44's February 2025 Physician Orders revealed an active order for Sacubitril-Valsartan Oral Table 49-51mg, Give 1 tablet by mouth two times a day for CHF (Congestive Heart Failure), with a start date of 09/26/2024.
Review of Resident #44's February 2025 MAR revealed that on 02/11/2025 for 8:00 a.m. medication administration he was administered Sacubitril-Valsartan 49-51mg documented by S13 LPN.
Telephone interview on 02/12/2025 at 4:10 p.m. with S13 LPN confirmed that only 14 pills were administered to Resident #44 during the morning medication administration. S13 LPN revealed that she did not administer any other PO medications to Resident #44 scheduled for 02/11/2025 8:00 a.m. medication administration before or after this Surveyor observed Resident #44's morning medication administration. S13 LPN revealed that she did not administer the Sacubitril-Valsartan 49-51mg tablet because it was not available. S13 LPN confirmed that she did document the medication as administered but meant to go back and strike it out but did not.
Observation of the Team 2 medication cart on 02/12/2025 at 4:26 p.m. with S12 LPN revealed Resident #44's Sacubitril-Valsartan blister card was not on the cart at all. S12 LPN was not able to recall when he last administered the medication to Resident #44.
Interview on 02/12/2025 at 4:31 p.m. with S2 DON revealed nurses are to look in the resident's cubby in the medication storage room first, then check the Pixus for any medication that is ordered to be administered and is not on the medication cart. The nurse is then to report to Nursing Administration staff that the medication is out. S2 DON confirmed that Resident #44's Sacubitril-Valsartan 49-51mg blister pack was not on the medication cart.
Observation of the Medication storage room on 02/12/2025 at 4:35 p.m. with S2 DON and S17 Corporate Nurse confirmed Resident #44's Sacubitril Valsartan 49-51mg blister pack was not in his cubby or in the Pixus.
Review of the facility's Drug Record Book with a Supply Date Range: Orders from 01/01/2025-02/28/2025 revealed the facility last received a quantity of 28 tablets which is a 2 week supply of Sacubitril-Valsartan for Resident #44 on 01/20/2025.
Interview on 02/12/2025 at 5:12 p.m. with S16 ADMIN RN and S17 Corporate Nurse revealed that there was an order created for the Sacubitril-Valsartan for Resident #44 on 01/30/2025 but was not released due to Insurance denial. S16 ADMIN RN confirmed that Resident #44 would have run out of this medication by 02/03/2025 even though it was still being documented as administered by nursing staff.
Interview on 02/12/2025 at 5:42 p.m. with S16 ADMIN RN revealed that all nurses are responsible for ordering resident medications. S16 ADMIN RN stated medications are usually ordered by the night nurse when a medication runs low. The night nurse then reconciles all medications received from pharmacy via a pharmacy delivery manifest. S16 ADMIN RN confirmed that there was no further follow-up for Resident #44's missing Sacubitril-Valsartan and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure their medication error rate was not 5 percent or greater. The facility had 4 medication errors (11.76%) out of 34 opport...
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Based on observation, interview and record review the facility failed to ensure their medication error rate was not 5 percent or greater. The facility had 4 medication errors (11.76%) out of 34 opportunities for errors observed. The facility had a total census of 54 residents according to the Resident List Report provided by the facility.
Findings
Review on 02/12/2025 of the facility's policy and procedure dated 09/01/2024, and titled Medication Administration read in part .
Policy: Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice .
Policy Explanation and Compliance Guidelines:
10. Ensure that the six rights of medication administration are followed:
f. Right documentation
11. Review MAR to identify medication to be administered.
12. Compare medication source (bubble pack, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
23. Correct any discrepancies and report to nurse manager.
Observation of Medication Administration on 02/11/2025 at 9:30 a.m. revealed S13 LPN punched out 1 tablet of Aspirin 81mg, 1 tablet of Vitamin D 50 mcg, 1 tablet of Iron 324mg, 1 tablet of Tamsulosin 0.4mg, 1 tablet of Furosemide 40mg, 1 tablet of Hydralazine 50mg, 1 tablet of Calcitriol 0.25mcg, 1 tablet of Carvedilol 6.25mg, 1 tablet of Clopidogrel 75mg, 1 tablet of Clonidine 0.2mg, 1 tablet of Finasteride 5mg, 1 tablet of Nifedipine 60mg, and 2 tablets of Sertraline 100mg and placed them in a medication cup. S13 LPN confirmed with this surveyor a total of 14 pills were administered to Resident #44.
Review of Resident #44's February 2025 MAR revealed that on 02/11/2025 for 8:00 a.m. medication administration: Aspirin 81mg,Calcitriol 0.25mcg, Cholecalciferol 50mcg, Clopidogrel 75mg, Cyanocobalamin 1000mcg, Finasteride 5mg, Furosemide 40mg, Sertraline 200mg, Tamsulosin 0.4mg, Carvedilol 6.25mg, Clonidine 0.2mg, Ferrous Gluconate 324mg, Nifedipine 60mg, Sacubitril-Valsartan 49-51mg, Sodium Bicarbonate 650mg, and Hydralazine 50mg was documented as administered by mouth. Resident #44's MAR revealed Bactrim DS 800/160mg with a start date of 02/10/2025 was also to be administered with the 8:00 a.m. medications, with a (9) coded for see other/progress notes. This was a total of 18 pills to be administered.
Telephone interview on 02/12/2025 at 4:10 p.m. with S13 LPN confirmed that only 14 pills were administered to Resident #44 during the morning medication administration. S13 LPN revealed that she did not administer any other oral medications to Resident #44 scheduled for 02/11/2025 morning medication administration before or after this Surveyor observed Resident #44's morning medication administration. S13 LPN revealed that she did not administer the Bactrim DS 800/160mg, Sacubitril-Valsartan 49-51mg or Sodium Bicarbonate 650mg tablets due to the medications not being available. S13 LPN revealed that she did not administer the Cyanocobalamin because she forgot to pull it from the cart. S13 LPN confirmed that she did document the medications as administered but meant to go back and strike them out but did not.
Review of Resident #44's progress notes revealed a note dated 02/11/2025 at 9:35 a.m. that read in part . Bactrim DS Oral Tablet 800-160 mg; give 1 tablet by mouth two times a day for Abscess to buttocks for 7 days; Medication Unavailable. Authored by: S13 LPN.
Observation of the Team 2 medication cart on 02/12/2025 at 4:26 p.m. with S12 LPN revealed Sodium Bicarbonate 650mg was on the cart in the over the counter medication area with an open date of 12/30/2024. Resident #44's Bactrim DS Oral Tablet 800-160 mg tablet blister card was on the cart with two pills removed. S12 LPN confirmed that he administered one Bactrim tablet on 02/10/2025 during Resident #44's night medication administration and one on 02/11/2025 during Resident #44's night medication administration. Resident #44's Sacubitril-Valsartan blister pack was not on the cart at all.
Review of Resident #44's MAR revealed Bactrim DS Oral tablet with a start date of 02/10/2025 at 8:00 p.m. and three documented administrations: 02/10/2025 at 8:00 p.m., 02/11/2025 at 8:00 p.m. and 02/12/2025 at 8:00 a.m.
Review of Resident #44's Bactrim DS Oral Tablet 800-160mg tablet blister pack with a start date of 02/10/2025 revealed only two pills were removed from the blister pack.
Interview on 02/12/2025 at 4:31 p.m. with S2 DON confirmed that Resident #44's Bactrim DS 800-160mg tablet, Sodium Bicarbonate 650mg, and Cyanocobalamin 1000 mcg were on the medication cart and should have been administered according to Resident #44's physician's orders. S2 DON confirmed Resident #44's Sacubitril-Valsartan tablets were not on the cart, in the medication storage room cubby or in the Pixus. S2 DON confirmed that if the medications had not been given by the nurse, the medications should not have been documented as administered but had been.
Interview on 02/12/2025 at 5:12 p.m. with S16 ADMIN RN confirmed Resident #44 would have run out of the Sacubitril-Valsartan tablets by 02/03/2025 even though it was still being documented as administered by nursing staff and should not have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development an...
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Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infections, by failing to test the facility's water system for Legionella.
Findings:
Review of the Facility's Water Management Program with no review date read in part .
Abstract:
All facilities are required to demonstrate measures to minimize the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems and devices.
Scope: The primary focus of the Water Management Team is to ensure that residents have the safest and sanitary environment based on best practice processes throughout their continuum of care.
9. Establishment of a surveillance process to detect health-care associated Legionnaires Disease.
Goals:
1. Ensure chemical and physical control measures and limits are performing as desired per industry standards to reduce the risk of Legionella growth.
Review of the Infection Prevention and Control Program revealed no documented evidence of testing for Legionella in the facility's water system.
Interview on 02/12/2025 at 3:19 p.m. with S1 Administrator confirmed the facility had not been testing for Legionella in the water system. S1 Administrator revealed the last time the facility tested for Legionella in the water system was 09/16/2024.
Resident #155
Review of Resident #155's medical record revealed an admission date of 02/07/2025, with diagnoses that included in part .Aftercare Following Joint Replacement Surgery; Infection following a procedure, Surgical Site; Other Mechanical Complication of other Internal Orthopedic Devices, Implants, and Grafts; Other Staphylococcus.
On 02/12/2025 at 5:45 p.m. S16 Admin RN stated Resident #155's admission MDS is still in progress and not yet submitted due to Resident #155 being a new admit.
Review of Resident #155's Baseline Care Plan revealed in part .PICC line; Total x2 assist with ADL's. Maintain safety precautions due to generalized weakness; Provide supportive devices: Brace to left knee.
Review of Resident #155's 02/2025 Physician's Orders revealed in part . Enhanced Barrier Precautions required for high contact resident care activities (PICC line) every shift.
Observation on 02/10/2025 at 10:57 a.m. of Resident #155's name plate revealed a red dot next to Resident #155's name upon entrance into her room. Resident #155 stated she was admitted on Friday and had a PICC line for IV antibiotics. Observed PICC line to Resident #155's upper right arm. Resident #155 stated she is incontinent, wears an adult brief, and is dependent on staff to provide incontinent care.
Observation on 02/11/2025 at 9:40 a.m. of Resident #155's name plate revealed a red dot next to Resident #155's name upon entrance into her room.
Observation of Resident #155's incontinent care on 02/11/2025 at 10:00 a.m. revealed S5 CNA and S20 CNA wore gloves and provided incontinent care for Resident #155. Neither S5 CNA nor S20 CNA wore a gown while providing incontinent care for Resident #155.
Interview on 02/11/2025 at 10:32 a.m. with S5 CNA revealed she saw Resident #155's PICC line and should have worn a gown while providing incontinent care but did not.
Interview on 02/11/2025 at 10:41 a.m. with S14 CNA Supervisor revealed all CNA's received online training during orientation on EBP. S14 CNA Supervisor confirmed S5 CNA and S20 CNA should have worn appropriate PPE while providing incontinent care for Resident #155 but did not.
Interview on 02/11/2025 at 10:50 a.m. with S2 DON revealed all staff were in-serviced on EBP and were aware to wear the correct PPE for resident's who require EBP.
Based on observation, record review, and interview the facility failed to follow infection control practices to prevent the development and transmission of infection. The facility failed to: (1) Implement Enhanced Barrier Precautions for Resident #206. (2) Ensure staff wore proper PPE while providing incontinent care to Resident #155. (3) Ensure that the facility's water management system was tested for Legionella.
Findings:
Review on 02/11/2025 of the facility's policy and procedure dated 09/01/2024, and titled Enhanced Barrier Precautions read in part .
Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.
Policy Explanation and Compliance Guidelines:
1. Prompt recognition of need:
a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.
b. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions.
2. Initiation of Enhanced Barrier Precautions:
b. An order for enhanced barrier precautions will be obtained for residents with any of the following:
i. Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds .) and/ or indwelling medical devices (PICC lines) even if the resident is not known to be infected or colonized with a MDRO.
3. Implementation of Enhanced Barrier Precautions:
a. Make gowns and gloves available near or outside of the resident's room.
4. High-contact resident care activities include:
d. Providing hygiene
10. Enhanced Barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound .
Table 1: Implementing Contact versus Enhanced Barrier Precautions
Resident Status:
Has a wound . and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with an MDRO. - Use EBP: Yes, if they do not meet the criteria for contact precautions.
Has a wound . without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with an MDRO. - Use EBP: Yes
Examples of secretions or excretions include diarrhea . or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.
Resident #206
Review of Resident #206's clinical record revealed an admit date of 02/06/2025, with diagnoses which included Elevated [NAME] Blood Cell Count, Type II Diabetes; Cerebral Infarction; Acquired Absence of Left Leg Below Knee; and Encounter for Change or Removal of Surgical Wound Dressing.
Review of Resident #206's admission MDS with an ARD of 02/12/2025 revealed a BIMS of 15, which indicated the resident was cognitively intact. Resident used a wheelchair as a mobility device. Resident required supervision or touching assistance with eating, oral hygiene, and personal hygiene; substantial/maximal assistance with toileting, lower body dressing, putting on/taking off footwear; showering/bathing; and partial/moderate assistance with upper body dressing.
Review of Resident #206's Care Plan revealed in part I have a Stage 3 pressure ulcer to my sacrum. Interventions included . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Monitor/document/report PRN any changes in my skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. I have a diabetic ulcer of my right heel. Interventions included . Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate.
Review of Resident #206's 02/2025 Physician's Orders revealed no order for Enhanced Barrier Precautions.
Interview with Resident #206 on 02/10/2025 at 9:39 a.m. revealed he recently had a leg amputation a week and a half ago.
Observation of Resident #206 in bed on 02/10/2025 at 10:48 a.m. revealed Resident #206's wife in the room. Resident #206's wife stated that Resident #206 had a sore on his bottom and a pressure sore to his heel area. No enhanced barrier precaution signage or personal protective equipment (PPE) noted in Resident #206's room or outside door. Resident #206's wife stated that she had not been educated on any type of infection control precautions.
Interview with S9 LPN on 02/11/2025 at 8:45 a.m. revealed that Enhanced Barrier Precaution was notated by a red dot next to a resident's name by the resident's door.
Observation of Resident #206 in bed on 02/11/2025 at 12:39 p.m. revealed no red dot located next to Resident #206's name by his door and no other signage for Enhanced Barrier Precaution.
Observation of Resident #206's toileting care on 02/11/2025 at 12:49 p.m. revealed Resident #206 had a bowel movement and S8 CNA did not wear a gown during toileting care.
Interview with S2 DON on 02/11/2025 at 2:30 p.m. revealed that residents with any type of wound should be on Enhanced Barrier Precautions. S2 DON confirmed that Resident #206 had wounds, did not have a red dot located next to his name by his door and was not on Enhanced Barrier Precautions but should have been.
Aug 2024
1 deficiency
CONCERN
(D)
📢 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to prevent and control the spread of COVID-19 by failing to ensure proper...
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Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to prevent and control the spread of COVID-19 by failing to ensure proper signage was utilized for 2 of 2 (Resident #2 and #R1) residents on Transmission Based Precautions out of a total sample of 4 (Resident #1, Resident #2, Resident #3, and #R1) residents.
Findings:
Review of the facility's policy titled Application of Transmission-Based Precautions dated 06/30/2023 read in part . Transmission-Based Precautions are a group of Infection Prevention and Control practices that are used in addition to Standard Precautions for residents who may be infected or colonized with infectious agents that require additional control measures to effectively prevent transmission.
Transmission-Based Precautions are used when the route(s) of transmission is (are) not completely interrupted using Standard Precautions alone.
Droplet Precautions: Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Staff caring for residents on Droplet Precautions should wear a facemask for close contact with the resident. Consider adding goggles or a face shield to protect eyes from exposure to respiratory droplets, especially when caring for residents with significant cough or respiratory secretions.
5. Communication about Transmission-Based Precautions.
a. Room entry signage indicating what type of Transmission-Based Precautions and appropriate PPE to be used.
Resident #2
Review of Resident #2's clinical record revealed an admit date of 06/06/2024 with diagnoses which included: COVID-19, Disorder involving the Immune Mechanism, Atherosclerotic Heart Disease, and Acquired Absence of Right Leg Below Knee.
Review of Resident #2's progress notes revealed in part .
07/30/2024 1:59 p.m. Resident placed in isolation for COVID positive. Author: S1 RN Infection Preventionist
Review of Resident #2's Care Plan with target date of 09/09/2024 revealed in part . COVID precautions. Interventions: COVID testing per DHH guidelines. Isolation precautions if positive test or symptomatic.
Review of Resident #2's admission MDS with an ARD of 06/11/2024 revealed a BIMS score of 14. Resident #2 was dependent with toileting, chair/bed to chair transfers and toilet transfers. Resident #2 required substantial/maximal assistance with upper body dressing and lower body dressing and partial/moderate assistance with eating, oral hygiene, and personal hygiene.
Observation on 08/05/2024 at 9:09 a.m. of Resident #2's door revealed signage for Enhanced Barrier Precautions.
Observation on 08/05/2024 at 10:44 a.m. of Resident #2's door revealed signage for Enhanced Barrier Precautions.
Observation on 08/05/2024 at 11:07 a.m. of Resident #2's door, accompanied by S1 RN Infection Preventionist, revealed signage for Enhanced Barrier Precautions. Interview at that time with S1 RN Infection Preventionist confirmed the resident was on Transmission Based Precautions and the signage was not the appropriate signage.
#R1
Review of #R1's clinical record revealed an admit date of 06/20/2024 with diagnoses which included: COVID-19, Rhabdomyolysis, Cerebral Infarction, Unspecified Dementia, and Unspecified A-fib.
Review of #R1's Progress Notes revealed in part .
07/30/2024 Resident placed in isolation due to positive COVID test Author: S1 RN Infection Preventionist
Review of #R1's Care Plan with target date of 09/23/2024 revealed in part . COVID precautions. Interventions: COVID testing per DHH guidelines. Isolation precautions if positive test or symptomatic.
Review of #R1's admission MDS with an ARD of 06/25/2024 revealed a BIMS score of 4. #R1 required substantial/maximal assistance with toileting hygiene, upper body dressing, lower body dressing, and personal hygiene. #R1 required partial/moderate assistance with oral hygiene.
Observation on 08/05/2024 at 9:05 a.m. of #R1's door revealed signage for Enhanced Barrier Precautions.
Observation on 08/05/2024 at 10:49 a.m. of #R1's door revealed signage for Enhanced Barrier Precautions.
Observation on 08/05/2024 at 11:06 a.m. of #R1's door, accompanied by S1 RN Infection Preventionist, revealed signage for Enhanced Barrier Precautions. Interview at that time with S1 RN Infection Preventionist confirmed #R1was on Transmission Based Precautions and the signage was not the appropriate signage.
Apr 2024
2 deficiencies
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring side effects and effectiveness of an anticoagulant medi...
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Based on interview and record review the facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring side effects and effectiveness of an anticoagulant medication, for 1 (Resident #3) of 3 sampled residents. (Resident #1, Resident #2, and Resident #3).
Findings:
Review of Resident #3's medical record revealed an admit date of 12/05/2024, with diagnoses that included in part .Gastrointestinal Hemorrhage Unspecified, Anal Fissure Unspecified, Chronic Atrial Fibrillation Unspecified, End Stage Renal Disease, and Dependence on Renal Dialysis.
Review of Resident #3's Significant Change MDS with an ARD of 03/30/2024, revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #3 was dependent for toileting hygiene, lower body dressing and putting on/taking off footwear, and required supervision or touching assistance with oral and personal hygiene.
Review of physician's orders for Resident #3 revealed the following order: 03/19/2024 - Warfarin Sodium (Coumadin) oral tablet 5 Milligrams, give 1 tablet by mouth in the evening every Monday, Wednesday, Friday and Sunday for Atrial Fibrillation; Warfarin (Coumadin) Sodium oral tablet 7.5 Milligrams, give 1 tablet by mouth in the evening every Tuesday, Thursday, and Saturday related to Chronic Atrial Fibrillation.
Review of Resident #3's care plan with a target date of 06/28/2024, revealed the following problem in part .Resident at risk for complications related to taking anticoagulant medication. Interventions included: administer anticoagulant medications as ordered by physician, and monitor for side effects and effectiveness every shift.
Review of Resident #3's medical record revealed no monitoring for side effects and effectiveness were in place for his anticoagulant therapy, as indicated by his person-centered plan of care.
Interview on 04/09/2024 at 11:57 a.m., with S2 RN confirmed Resident #3 had no monitors implemented to assess for possible side effects and effectiveness of Resident #3's anticoagulant therapy.
Interview on 04/09/2024 at 12:19 .m. with S1 DON, confirmed Resident #3 had no monitors implemented to assess for possible side effects and effectiveness of his anticoagulant therapy.
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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#3) of 3 (Resident #1, Resident #2, and Resident #3) sample...
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Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
The facility failed to:
1. Ensure Physician's orders for obtaining labs for a medication that required a drug level were followed for Resident #3; and
2. Ensure Resident #3's physician was notified of and immediately responded to abnormal lab test results for an anticoagulant.
Findings:
1. Review on 04/11/2024 of the facility's policy titled Lab and Diagnostic Test Results-Clinical (with a revision date of 11/2018), read in part . Review by Nursing Staff
4. A nurse will try to determine whether the test was done:
C. To monitor a drug level.
1. The reason for getting a test often affects the urgency of acting upon the result.
Physician Responses
1. Time frames. A physician will respond within an appropriate time frame, based on the request from Nursing staff, and the clinical significance of the information.
D. A physician should respond within one hour regarding a lab test requiring immediate notification, and by the end of the next office day to a non-emergency message regarding notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response.
E. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance.
Review of the medical record for Resident #3 revealed an admit date of 12/05/2024, with diagnoses that included in part .Gastrointestinal Hemorrhage Unspecified, Anal Fissure Unspecified, Chronic Atrial Fibrillation Unspecified, End Stage Renal Disease, and Dependence on Renal Dialysis.
Review of Resident #3's Significant Change MDS with an ARD of 03/30/2024, revealed a BIMS score of 15, which indicated intact cognition. The MDS revealed Resident #3 was dependent for toileting hygiene, lower body dressing and putting on/taking off footwear, and required supervision or touching assistance with oral and personal hygiene. Setup or clean-up assistance with eating.
Review of Resident #3's care plan with a target date of 06/28/2024, revealed the following problems in part .
Resident at risk for alteration in hematological status related to history of Gastrointestinal Hemorrhage and Anemia. Interventions included obtain and monitor lab/diagnostic work as ordered, and report results to MD and follow up as indicated.
Review of physician's orders for Resident #3 revealed the following orders:
01/04/2024 - PT/INR (a blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot) weekly per MD, due to Coumadin (medication used to treat and prevent blood clots), secondary to Atrial Fibrillation.
Review of Resident #3's medical record revealed a PT/INR was drawn on 12/06/2024 with results as follows: PT =15.6/INR=1.3 (Normal range PT=11.7/INR=0.9-1.1). Written on the lab sheet was MD notified on 12/06/2024 at 2:00 p.m. Review of the fax sheet revealed the results were faxed to the physician on 12/06/2024 at 2:00 p.m.; however, review of Resident #3's progress notes revealed there was documentation that the Medical Director was notified when the attending physician did not immediately respond to the abnormal PT/INR.
2. Review of Resident 3's medical record revealed in part . a physician's order dated 01/04/2024 to obtain a PT/INR weekly. Review of Resident #3's lab results revealed a PT/INR was not drawn from 02/01/2024 until 02/20/2024.
Interview on 04/09/2024 at 11:11 a.m. with S2 RN and S3 LPN/ADON, confirmed Resident #3 had orders to obtain a weekly PT/INR. S2 RN stated she was responsible for monitoring labs and following-up on labs with the physician as needed. S2 RN and S3 LPN/ADON confirmed Resident #3 did not have a weekly PT/INR drawn from 02/01/2024 until 02/20/2024.
Interview on 04/09/2024 at 12:19 a.m. S1 DON confirmed the following: Resident #3 had orders for a weekly PT/INR that was not obtained weekly and it should have been, and Resident #3 had an abnormal PT/INR test result which was out of range with no follow-up with the MD, and there should have been.
Feb 2024
9 deficiencies
CONCERN
(D)
📢 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #24) of 20 sampled residents by failing to ensure resident was free of facial hair.
Findings...
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Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #24) of 20 sampled residents by failing to ensure resident was free of facial hair.
Findings:
Review of the Facility's policy Resident's Right- Respect, Dignity/Right to have Personal Property read in part
Intent:
It is the policy of the facility to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that residents have autonomy and choice, to the maximum extent possible about how they wish to live their everyday lives and receive care.
Review of Resident #24's medical records revealed an admit date of 12/16/2019 with diagnoses that included: Unspecified Dementia, Major Depressive Disorder, Coronary Artery Disease, Type 2 Diabetes, and Essential Hypertension.
Review of Resident #24's MDS with ARD of 02/06/2024 revealed a BIMS score of 00, indicating severely cognitively impaired requiring partial to moderate assistance with personal hygiene.
Review of Resident #24's Care plan with target completion date of 02/06/2024 read in part .
Personal hygiene/oral care: Resident requires extensive assistance x 1 staff member to maximize independence.
Observation on 02/12/2024 at 3:29 p.m. revealed Resident #24 sitting in wheelchair with long, wiry facial hair noted to her chin.
Interview on 02/14/2024 at 1:35 p.m. with S5 CNA revealed Resident #24 has never refused care and will let staff shave her without any problem.
Interview on 02/12/24 at 3:20 p.m. with S3 DON confirmed Resident #24's long facial hair and stated that it needed to be shaved but had not been.
CONCERN
(D)
📢 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maint...
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Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (#24) of 3 (#4, #24 and #102) residents reviewed for ADL care.
Findings:
Review of the Facility's Activities of Daily Living policy read in part .
Procedure:
1. Based on the comprehensive assessment of a resident and consistent with the residents needs and choices, the facility will provide the necessary care and services to ensure the resident's abilities in ADL's (Activities of Daily Living) do not diminish unless the resident's condition demonstrates that such diminution was unavoidable.
2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living
3. The facility will provide care and services for the following ADL's: a. hygiene- bathing, dressing, grooming, and oral care.
Review of Resident #24's medical records revealed an admit date of 12/16/2019 with diagnoses that included: Unspecified Dementia, Major Depressive Disorder, Coronary Artery Disease, Type 2 Diabetes, and Essential Hypertension.
Review of Resident #24's February 2024 Physician Orders read in part .
Fingernails/toenails care as needed for the day shift on the 17th of each month.
Review of Resident #24's Care plan with target completion date of 02/06/2024 read in part .
The resident has an ADL self-Care performance deficit related to Dementia: Check nail length and trim and clean on bath days as needed.
Observation on 02/12/2024 at 3:29 p.m. revealed Resident #24 sitting in wheelchair with long jagged fingernails.
Interview on 02/14/2024 at 1:55 p.m. with S4 LPN revealed the nail care order schedule was not completed, therefore it did not fire on the electronic treatment administration record for the care to be provided.
Interview on 02/12/24 at 3:20 p.m. with S3 DON confirmed Resident #24's long and jagged fingernails needed to be cut but had not been due to a problem with the physician order not scheduled correctly in the electronic record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interviews and record review, the facility failed to ensure a resident received the necessary care and services in accordance with the resident's comprehensive assessment and pro...
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Based on observation, interviews and record review, the facility failed to ensure a resident received the necessary care and services in accordance with the resident's comprehensive assessment and professional standards of practice by failing to provide wound care as ordered for 1 (Resident #7) of 2 (#7, #14) residents reviewed for skin conditions.
Findings:
Review of the facility's policy titled Clean Dressing Change read in part
Intent: It is the policy of the facility to ensure dressing are changed in accordance with state and federal regulation, and national guidelines.
Procedure: 1. Verify and review physician's orders for procedure.
Review of Resident #7's medical record revealed an admit date of 08/04/2021 with diagnoses that included: Diastolic Heart Failure, Need for Assistance with Personal Care, Dysphagia, Coronary Artery Disease, Chronic Kidney Disease, Type 2 Diabetes, and Anxiety.
Review of Resident #7's 02/2024 Physician Orders revealed:
02/09/2024- Skin tear to dorsum left hand: Cleanse with wound cleanser and 4x4 gauze, pat dry, apply Xeroform and cover with dry dressing every other day.
Review of Resident #7's Care plan with completion date of 01/16/2024 read in part .
Potential for impairment to skin integrity related to fragile Skin-Provide wound treatment as ordered.
During an interview on 02/12/2024 at 09:45 a.m., Resident #7 stated she had a skin tear on her left hand that was covered with a band aide. Resident #7 stated the staff applied the band aide to left hand several days ago and no one had looked at it since.
During observations and interview on 02/12/2024 at 1:45 p.m., Resident #7 was observed siting in wheelchair in hall way picking at her band aide on her left hand. Resident #7 stated she had not had a nurse come by to change dressing in several days.
Observation on 02/12/2024 at 2:00 p.m. revealed S1 Treatment Nurse removed the band aide from Resident #7's left hand. S1 Treatment Nurse stated there was no Xeroform dressing observed to wound bed or old band aide and that the proper dressing may have fallen off. S1 Treatment Nurse confirmed the wound care provided for Resident #7 was not the proper wound care that was ordered by the physician for the left hand skin tear but should had been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, the facility failed to ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary trac...
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Based on record review, observation, and interview, the facility failed to ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections for 1 (#39) of 1 resident reviewed for urinary catheters. The facility failed to change Resident #39's catheter every 30 days as ordered by the physician. Findings:
Review of Resident #39's medical record revealed an admit date of 08/14/2023 with diagnoses that included in part Hemiplegia and Hemiparesis, Muscle Wasting and Atrophy, and Other Specified Disorder of the Bladder.
Review of Resident #39's Quarterly MDS with an ARD of 02/13/2024 revealed a BIMS score of 7, which indicated moderately impaired cognition. Review of the MDS revealed Resident #39 was dependent with toileting, hygiene, and shower/bathing, had an indwelling catheter, and was always incontinent of bowel.
Review of Resident #39's medical record revealed Resident #39 was care planned for alteration in elimination related to urinary retention with an 18 French indwelling catheter. Interventions included catheter care every shift with soap and water, change catheter monthly and prn occlusion or leaking, and position catheter bag and tubing below the level of the bladder and away from entrance room door.
Review of Resident #39's Physician's Orders revealed the following:
01/04/2024: Change Foley catheter 18Fr/5cc balloon monthly and prn for occlusion.
In an observation on 02/12/2024 at 9:30 a.m., Resident #39 was lying in bed and noted to have an indwelling catheter in a privacy bag hanging from the bed. Interview with Resident #39 at the time of observation revealed her catheter had not been changed in a long time and confirmed it had been more than a month.
Review of Resident #39's January and February 2024 TARS revealed no evidence Resident #39's urinary catheter had been changed. Review of the February 2024 TAR revealed an order to Change Foley catheter 18Fr/5 cc balloon monthly and prn for occlusion with 02/06/2024 as the scheduled date to be completed. Review revealed there was no documentation on 02/06/2024 indicating the catheter had been changed.
Review of Resident #39's nurses' notes revealed the following:
01/10/2024 at 2:14 p.m.: Foley catheter removed and replaced with #16 Fr Foley catheter; Procedure tolerated well. Returning light amber urine.
In an interview on 02/15/2024 at 10:00 a.m., S3 DON acknowledged Resident #39's indwelling urinary catheter had not been changed in over 30 days per review of the MARs, TARS, and nursing notes.
In an interview on 02/15/2024 at 10:40 a.m., S6 ADON acknowledged Resident #39's catheter had not been changed in the past 30 days as ordered by Resident #39's physician and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (Resident #32) of 1 sampled residents revie...
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Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 (Resident #32) of 1 sampled residents reviewed for respiratory care.
Findings:
Review of the Facility's policy Safety and Maintenance of Respiratory Equipment read in part Oxygen and Nebulizer (nasal cannula, 02 mask/tubing, nebulizer masks/tubing/mouthpiece) will be changed and dated weekly on night shift and PRN for residents with routine orders.
Review of Resident #32's medical record revealed an admit date of 11/09/2023 with diagnoses that included: Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Alzheimer's Disease, Epilepsy, and Congestive Heart Failure.
Review of Resident #32's care plan with review date of 02/06/2024 read in part .
Resident is at risk for respiratory complications due to diagnosis of Chronic Obstructive Pulmonary Disease- Nebulizer treatment as ordered
Review of Resident #32's 02/2024 Physician Orders revealed in part
11/21/2023-Albuterol nebulizer solution 2.5 mg inhale orally daily at 8 a.m.
11/21/2023-Albuterol nebulizer solution 2.5 mg inhale orally every 4 hours as needed for shortness of breath, coughing, and wheezing.
Observation on 02/12/2024 at 09:41 a.m. revealed Resident #32's nebulizer mask was observed in a bag on the bedside table dated 01/15/2024.
Interview on 02/12/2024 at 9:50 a.m. with S3 DON confirmed the nebulizer mask bag was dated 01/15/2024 and that it should have been changed weekly but had not been.
Interview on 02/14/2024 at 3:10 p.m. with S6 ADON confirmed there was no physician order written to change out tubing and nebulizer mask weekly for Resident #32 and there should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to include the Medical Director or Medical Director designee in the Quality Assessment & Assurance (QAA) process. The facility's total census w...
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Based on interview and record review the facility failed to include the Medical Director or Medical Director designee in the Quality Assessment & Assurance (QAA) process. The facility's total census was 53 as per information provided by S7 Administrator.
Findings:
Review of the facility's QA meeting minutes revealed none of the meeting signature sheets included the signature of the facility's Medical Director.
Interview on 02/15/2024 at 12:20 p.m. with S3 DON revealed QA (Quality Assurance) meetings were held twice a week on Tuesdays and Thursdays and high risk meetings were also held on Thursdays and monthly. S3 DON stated the Medical Director did not attend any of the meetings.
Interview on 02/15/2024 at 1:17p.m. with S7 Administrator confirmed the Medical Director did not sign as having reviewed QA committee meeting minutes at least quarterly regarding all issues identified in the facility. S7 Administrator stated the Medical Director met with department heads and reviewed and signed meeting minutes pertaining to facility COVID initiatives only.
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 observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall B) of 2 (Hall A ...
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Based on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall B) of 2 (Hall A and Hall B) medication carts and 1 of 1 medication storage rooms Findings:
Observation on 02/14/2024 at 11:30 a.m. of the facility medication storage room accompanied by S6 ADON revealed the following items on shelves for use:
(3) 44 ml bottles of Saline Nasal Spray with expiration dates of 01/2024.
(1) 100 count bottle of Oyster Shell Calcium Plus D 500mg tablets with an expiration date of 04/2023.
(1) 4oz. bottle of sugar free Adult Tussin DM with an expiration date of 12/2023.
(1) 90 count bottle of Loratadine 10mg tablets with an expiration date of 01/2024.
(4) 100 count bottles of Vitamin B-12 500mcg tablets with an expiration date of 01/2024.
Observation of the Hall B medication cart accompanied by S6 ADON revealed the cart contained (1) Albuterol Sulfate 90mcg inhaler with an expiration date of 01/2024.
Observation also revealed the first and second drawers of the medication cart each contained 3 loose pills.
Interview on 02/14/2024 at 11:45 a.m. with S6 ADON confirmed the medication storage room and medication cart findings. S6 ADON revealed it was the responsibility of all nurses to ensure medication carts were free of lose pills and expired medications. S6 ADON also stated nurses stocking shelves in the medication room were responsible for rotating stock medications and discarding expired items.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to provide evidence that ongoing monitoring or evaluations were being done to ensure the corrective actions put in place after identification o...
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Based on record review and interview the facility failed to provide evidence that ongoing monitoring or evaluations were being done to ensure the corrective actions put in place after identification of an increase in the number of residents with weight loss, falls, and wounds.
Findings:
Review of the facility policy titled: Quality Assurance and Performance Improvement Program-Governance and Leadership revealed in part .The responsibilities of the QAPI Committee are to collect and analyze performance indicator data and other information, identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services, establish benchmarks and goals by which to measure performance improvement and utilize root cause analysis to help identify where identified problems point to underlying systematic problems.
Interview on 02/15/2024 at 12:26 p.m. with S3 DON revealed current high risk issues identified in the facility included wounds, weights, and falls.
Interview on 02/15/2024 at 12:27 p.m. with S3 DON revealed there were significant variances in weights so the facility scale had been recalibrated and residents' providers and the Dietician had been notified. S3 DON stated all residents were placed on weekly weights until a baseline could be established. S3 DON stated a QAPI related to inconsistent weights had been initiated in October and again on 01/17/2024. Interview with S3 DON revealed she did not have any monitoring, tracking or trending related to weight discrepancies identified in October nor did she have any current tracking on hand.
Interview on 02/15/2024 at 12:30 p.m. with S1 Treatment Nurse revealed she was not sure what the facility's current wound rate percentage was. S1 Treatment Nurse stated she could calculate and provide the percentage to this Surveyor at the time of interview.
Review of a graph provided by S1 Treatment Nurse revealed the facility's current wound rate was 26%.
Interview on 02/15/2024 at 12:33 p.m. with S1 Treatment Nurse revealed the high percentage of wounds had been attributed to the number of residents admitted with wounds. S1 Treatment Nurse stated she had no other tracking or trending related to wounds.
Interview on 02/15/2024 at 12:34 p.m. with S3 DON revealed she did not have any evidence of ongoing monitoring, tracking or trending for the current high risk areas identified by the facility as weight loss, wounds, or falls.
Interview on 02/15/2024 at 1:17p.m. with S7 Administrator confirmed the facility did not have documentation of monitoring, tracking and/or trending of identified high risk areas and should.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to...
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Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following:
1. Proper hand hygiene during wound care for Resident # 14.
2. [NAME] gloves prior to administration of eye drops for Resident #251.
This failed practice had the potential to affect all residents who receive medications and treatments that are managed by the facility.
Findings:
Review of Facility policy Clean Dressing Change read in part .
Procedure:
10. Preform hand hygiene
11. put on gloves
12: remove dressing and place in trash can
13, remove gloves and perform hand hygiene
14. Put on clean gloves
15. Cleanse wound with gauze
16. Use dry gauze to pat the wound
17. Remove gloves and preform hand hygiene
1.
Review of Resident #14's medical record revealed an admit date of 04/12/2019 with diagnoses that included: Unspecified Dementia, Anxiety Disorder, and Essential Hypertension
Review of Resident #14's February 2024 Physician Orders read in part
Skin Tear to Right outer elbow: Cleanse with wound cleanser and 4x4 gauze, pat dry, apply Xeroform and cover with dry dressing every Monday, Wednesday and Friday.
Skin Tear to Left upper arm: Cleanse with wound cleanser and 4x4 gauze, pat dry, apply Xeroform and cover with dry dressing every Monday, Wednesday and Friday.
An observation of wound care for Resident #14 on 02/12/2024 at 2:35 p.m. revealed S1 Treatment nurse observed removing old dressing from Left upper arm skin tear. S1 Treatment nurse then removed glove, applied new gloves without sanitizing hands first. S1 Treatment nurse then cleaned both right elbow skin tear and left forearm skin tear without changing out gloves or sanitizing hands. S1 Treatment nurse then picked up the clean dressings with soiled gloves and applied dressing to left forearm wound then to Right elbow wound. S1 Treatment nurse confirmed she did not change out gloves or use hand sanitizer after cleansing each wound or before applying new dressing to both wounds but should have.
2.
Review of Facility Policy Instillation of Eye Drops read in part .Steps in Procedure
2. Wash and dry your hands thoroughly
3. Put on Gloves.
Review of Resident #251's medical record revealed an admit date of 01/29/2024 with diagnoses that include: Hemiplegia, Hemiparesis, Dysphagia and Unspecified Glaucoma.
Review of Resident #251's February 2024 Physician Orders read in part
01/30/2024- Istalol 0.5% solution 1 drop to each eye daily for glaucoma.
Observation of medication administration for Resident #251 on 02/14/2024 at 8:10 a.m. revealed S2 LPN administered Istalol 0.5% 1 drop to each eye without wearing gloves.
Interview on 02/14/2024 at 8:12 a.m. with S2 LPN confirmed she did not wear gloves while administering eye drops and stated she was not aware that she needed to wear gloves when administering eye drops.
Interview on 02/14/24 at 9:00 a.m., S3 DON revealed S2 LPN was unaware that she was to wear gloves while administering eye drops and was immediately in-serviced on proper instillation of eye drops.
Dec 2022
5 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
FACILITY
Beneficiary Notification
Based on record review and interview the facility failed to inform each resident as soon as was possible of changes in Medicare covered services as evidenced by the p...
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FACILITY
Beneficiary Notification
Based on record review and interview the facility failed to inform each resident as soon as was possible of changes in Medicare covered services as evidenced by the provider's failure to send the Centers for Medicare and Medicaid Services (CMS) Form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage as required for 1 (#8) of 1 residents reviewed for Beneficiary Notification who required the notification.
Findings:
Review of the SNF Beneficiary Protection Notification Review form completed by the facility on 12/06/2022 revealed Resident #8 was discharged from Medicare Part A Services on 09/28/2022 with benefit days remaining because the resident was at max potential. Further review revealed the facility did not provide the CMS-10055 form to the resident or resident's representative.
In an interview on 12/06/2022 at 2:30 p.m., S2 Account Manager confirmed she did not send the CMS-10055 form to Resident #8 or his representative and reported she didn't know she needed to send it.
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 observation, interview and record review the facility failed to develop and implement a comprehensive person-centered c...
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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 develop and implement a comprehensive person-centered care plan with interventions to ensure a resident maintained the highest physical well-being for 1 (Resident #26) of 16 sampled Residents by failing to include appropriate interventions in the care plan and timely reposition a resident with a Stage 3 pressure ulcer. Findings:
Review of Resident #26's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included: Stage 3 Pressure Ulcer, Late Onset Alzheimer's Disease, Chronic Kidney Disease Stage 3, Unspecified Protein-Calorie Malnutrition, Contracture of the Right Knee, Contracture of the Left Knee, and Dementia with Behavioral Disturbance.
Review of Resident #26's Quarterly MDS with an ARD of 11/06/2022 revealed Resident had a BIMS score of 99 (which indicated unable to complete interview). The MDS revealed Resident #26 was coded as total dependence requiring 1 person physical assistance for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing. Further review revealed Resident #26 had range of motion impairment on both sides of lower extremities.
Review of Resident #26's Care Plan with a target date of 11/28/2022 revealed a focus for Stage 3 pressure ulcer to Sacrum with interventions/tasks to contact MD as needed, monitor area until healed and treatment as ordered.
Review of Resident #26's Braden scale for predicting pressure sores (dated 11/22/2022) revealed Resident #26 had a score of 9 which indicated very high risk for developing pressure ulcers.
Review of Resident #26's physician's orders for December 2022 revealed Nursing measure: Turn every two hours according to schedule posted in room, Pressure relieving cushion while in Geri chair to decrease the risk of skin impairment and place pillow under left leg while Resident is up in Geri chair as pressure area preventative.
Observation on 12/05/2022 at 10:55 a.m. revealed Resident #26 in her room sitting in a Geri chair on her buttocks with her hips and legs leaning toward the left.
Observation on 12/05/2022 at 1:00 p.m. revealed Resident #26 sitting in a Geri chair in her room in the same position she was in at 10:55 a.m. (on her buttocks with hips and legs leaning toward the left).
Observation on 12/05/2022 at 2:00 p.m. revealed Resident #26 in bed on her back with her hips and legs leaning toward the left side of the bed. Resident's turn schedule posted on the wall above her bed revealed she should be turned on her right side.
Observation on 12/05/2022 at 4:14 p.m. revealed Resident #26 was in bed in the same position she was in at 2:00 P.M.
Observation on 12/06/2022 at 9:30 a.m. revealed Resident #26 in her room sitting in a Geri chair on her buttocks with her hips and legs leaning toward the left side.
Observation and interview on 12/06/2022 at 1:00 p.m. revealed Resident #26 sitting in her Geri chair in the same position she was in at 10:90 a.m.
Interview on 12/06/2022 at 11:30 a.m. with S1 DON revealed Resident #26 acquired a Stage 2 pressure ulcer to her Sacrum on 09/20/2021 and advanced to a Stage 3 on 08/01/2022. S1 DON confirmed Resident #26's Care Plan did not reflect all appropriate interventions for her Stage 3 pressure ulcer, including turning every two hours according to turn schedule posted in room, pressure relieving cushion while in Geri chair to decrease the risk of skin impairment, and place a pillow under left leg while Resident is up in Geri chair as pressure area prevention, and should have.
Interview on 12/06/2022 at 1:43 p.m. with S1 DON confirmed Resident #26 should be turned/repositioned at least every 2 hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 services were provided to meet professional sta...
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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 services were provided to meet professional standards of quality as evidenced by failing to obtain an order for suctioning for 1 (#45) of 1 Residents reviewed for respiratory care out of a sample size of 16 Residents.
Findings:
Observation on 12/05/2022 at 10:29 a.m. in Resident #45's room revealed a suction machine on top of nightstand that was set up and turned on. Resident stated that I suction myself when I need it, so the staff leaves the machine on for me.
Review of the clinical record revealed Resident #45 was admitted on [DATE] with diagnoses to include: Amyotrophic Lateral Sclerosis, Dysphagia, Type 2 Diabetes Mellitus, Hypertension Coronary artery disease, Chronic Obstructive Pulmonary Disease.
Review of the admission MDS with ARD date of 10/27/2022 revealed a BIMS of 15 which indicated the resident was cognitively intact.
Record review of Resident #45's care plan read in part:
Suction: Resident suctions self, turns suction on and off as he sees fit. Suctioning will be performed by resident- Observe inside of mouth for ulcers and contact md as needed. Staff to change yankauer as ordered and PRN, staff to empty canister as needed.
An interview on 12/6/2022 at 2:34 p.m. was conducted with S1 DON where she confirmed that nursing staff failed to obtain a physician order for suctioning for Resident # 45.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The physician failed to evaluate the appropriateness for the continued use of a PRN psychotropic medication beyond 14 days and failed to document in the medical record the rationale to extend the use beyond 14 days for 2 (#17, and #42) of 5 (#10, #17, #30, #37, and #42) Residents sampled for unnecessary medications. Findings:
Resident #17
Review of Resident #17's medical record revealed an admit date of 04/12/2019 with diagnoses that included, in part, Osteoporosis, Major Depressive Disorder, Anxiety Disorder, and Unspecified Dementia.
Review of the MDS assessment with an ARD date of 09/08/2022 revealed Resident #17 had a BIMS score of 3, which indicated severe cognition impairment.
Review of Resident #17's physician orders revealed an order dated 09/30/2022 that was discontinued on 10/20/2022 for Lorazepam (a psychotropic medication used to treat seizures and anxiety) 0.5 mg by mouth every 8 hours as needed. Further review revealed it was reordered on 10/20/2022 for 90 days.
Review of the Consultant Pharmacist's Medication Regimen Review revealed the following:
On 10/19/2022, the pharmacist notified the pharmacy PRN psychotropics have a limit of 14 days unless the prescriber specifies a reason for further use and a time limit of that use. Please obtain further instructions from the MD to meet these guidelines for: Lorazepam prn reordered, needs a new duration.
Review of Resident #17's medical record revealed no clinical rationale was documented by the MD to extend the use of prn Lorazepam when it was reordered on 10/20/2022.
In an interview on 12/07/2022 at 11:40 a.m., S1 DON acknowledged no rationale to extend the use of prn Lorazepam was documented in the chart by the physician.
Resident # 42
Review of the facility's policy titled: Pharmacy Services-Role of the Consultant Pharmacist, read in part .
The consultant Pharmacist will provide specific activities related to medication regimen review including: B. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medication and pharmacy services, including medication irregularities, and pertinent Resident-specific documentation in the medical record, as indicated.
Review of the clinical record revealed Resident # 42 was admitted to the facility on [DATE] with diagnoses that included, in part, Anxiety Disorder, Dementia without behavioral disturbances, Psychotic disturbance, Mood disturbance, and Anxiety.
Review of Resident # 42's MDS with an ARD of 09/15/2022 revealed a BIMS score of 02, which indicated severe cognition impairment.
Review of Resident # 42's Physician's Orders revealed:
Alprazolam (a psychotropic medication used to treat anxiety and panic disorder) tablet 0.5mg, Give 0.5mg by mouth q 6 hrs prn. Order dated 09/12/2022.
Lorazepam 2mg/ml injection, Inject 1ml IM q 8hrs prn. Order dated 09/21/2022, and Discontinued 10/20/2022. The Lorazepam 2mg/ml injection was reordered on 10/20/2022 for 90 days.
Review of Resident #42's September, October, November, and December MARs revealed he received Alprazolam tablet 0.5mg the following months and number of days:
09/2022 - 3 of 30 days.
10/2022 - 10 of 31 days.
11/2022 - 6 of 30 days.
12/2022 - 0 of 31 days.
Lorazepam 2mg/ml injection the following months and number of days:
09/2022 - 0 of 30 days.
10/2022 - 5 of 31 days.
11/2022 - 4 of 30 days.
12/2022 - 0 of 31 days.
Review of a document titled Consultant Pharmacist's Medication Regimen Review dated 10/19/2022 revealed the pharmacist reviewed the Resident's drug regimen; she found items that must be addressed. The report stated PRN psychotropics have a limit of 14 days unless the prescriber specifies a reason for further use and a time limit of that use. Please obtain further instructions from the MD to meet these guidelines for: LORAZEPAM injection
Review of Resident (#42's) medical record further revealed there was no documented evidence of a clinical rationale for continuing the Lorazepam written by the physician.
Interview on 12/06/2022 03:30 p.m. with S1 DON confirmed Resident #42 received Alprazolam and Lorazepam, as listed above. S1 DON further confirmed there was no documented evidence that the physician had provided a rationale for continuation of Lorazepam. She did not have a documented response from the provider for the pharmacist recommendation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a Resident received care consistent with profess...
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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 received care consistent with professional standards of practice, to promote the prevention/development of pressure ulcers and to promote the healing of an existing pressure ulcer for 1 of 1 (#26) of 16 sampled Residents by failing to provide incontinence care and repositioning every two hours. Findings:
Review of Facility Policy labeled Pressure Ulcer, Prevention of read in part .
10. Establish a turning and positioning schedule in bed and chair to meet the Resident's needs.
Review of Resident #26's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included: Late Alzheimer's Disease, Chronic Kidney Disease Stage 3, Unspecified Protein-Calorie Malnutrition, Contracture of the Right Knee, Contracture of the Left Knee, Unspecified Dementia with Behavioral Disturbance.
Review of Resident #26's Quarterly MDS with an ARD of 11/06/2022 revealed a BIMS score of 99 (which indicated unable to complete interview). The MDS revealed Resident #26 was coded as total dependence requiring 1 person physical assistance for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing. Further review revealed Resident #26 had range of motion impairment on both sides of lower extremities.
Review of Resident #26's Care Plan with a target date of 11/28/2022 revealed a focus for Stage 3 to Sacrum with interventions/tasks to contact MD as needed, monitor area until healed and treatment as ordered.
Review of Resident #26 Braden scale for predicting pressure sores (dated 11/22/2022) revealed Resident #26 had a score of 9 which indicated very high risk for developing pressure ulcers.
Observation and interview on 12/05/2022 at 10:55 a.m. revealed Resident #26 in her room sitting in a Geri chair on her buttocks with her hips and legs leaning toward the left. Resident's spouse in room and stated his wife was not being turned or repositioned as she should and no staff checks to see if she is wet. Spouse further revealed Resident #26 had a cyst on her buttocks. Spouse stated he visits his wife daily from 10:00 a.m. to 6:00 p.m. and feeds her lunch and dinner every day. Spouse reported Resident #26 is already in her Geri chair when he arrives to the facility at 10:00 a.m. and doesn't go back to bed until 2:00 p.m. or so.
Observation and interview on 12/05/2022 at 1:00 p.m. revealed Resident #26 sitting in a Geri chair in her room in the same position she was in at 10:55 a.m. (on her buttocks with hips and legs leaning toward the left). Spouse still in room and stated no staff had been in to reposition Resident #26.
Observation on 12/05/2022 at 2:00 p.m. revealed Resident #26 in bed on her back with her hips and legs leaning toward the left side of the bed. Resident's turn schedule posted on the wall above her bed revealed she should be turned on her right side. Spouse still in attendance.
Observation on 12/05/2022 at 4:14 p.m. revealed Resident #26 was in bed in the same position she was in at 2:00 P.M. Spouse remained in Resident's room and reported no staff had been in to check on Resident #26 since 2:00 p.m.
Observation on 12/06/2022 at 8:30 a.m. revealed Resident #26 in bed on her back with her hips and legs leaning toward the left side of the bed. Resident's turn schedule revealed she should only be turned from left to right, no back positioning.
Observation on 12/06/2022 at 9:30 a.m. revealed Resident #26 in her room sitting in a Geri chair on her buttocks with her hips and legs leaning toward the left side.
Interview on 12/06/2022 at 9:50 a.m. with S3 LPN treatment nurse confirmed Resident #26's turn schedule is for left to right positioning, no back positioning.
Observation and interview on 12/06/2022 at 1:00 p.m. revealed Resident #26 sitting in her Geri chair in the same position she was in at 10:00 a.m. Spouse was in Resident's room and stated he arrived at the facility at 10:00 a.m. and no staff had been in to reposition or change Resident #26.
Interview on 12/06/2022 at 11:30 a.m. with S1 DON revealed Resident #26 acquired a Stage 2 pressure ulcer to her Sacrum on 09/21/2021 and progressed to a stage 3 pressure ulcer on 08/01/2022. DON stated Resident's spouse visits daily and feeds her.
Interview on 12/06/2022 at 1:30 p.m. with S4 CNA revealed she checked on Resident #26 at 10:30 a.m. and had not been back in Resident's room to reposition her or provide incontinence care.
Interview on 12/06/2022 at 1:43 p.m. with S1 DON confirmed Resident #26 should be turned/repositioned at least every 2 hours and checked for incontinent episodes.
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
- "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
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
- • 75% turnover. Very high, 27 points above average. Constant new faces learning your loved one's needs.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Regency House Of Alexandria's CMS Rating?
CMS assigns REGENCY HOUSE OF ALEXANDRIA an overall rating of 3 out of 5 stars, which is considered average nationally. Within Louisiana, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Regency House Of Alexandria Staffed?
CMS rates REGENCY HOUSE OF ALEXANDRIA's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 75%, which is 29 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Regency House Of Alexandria?
State health inspectors documented 30 deficiencies at REGENCY HOUSE OF ALEXANDRIA during 2022 to 2025. These included: 30 with potential for harm.
Who Owns and Operates Regency House Of Alexandria?
REGENCY HOUSE OF ALEXANDRIA 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 58 certified beds and approximately 46 residents (about 79% occupancy), it is a smaller facility located in ALEXANDRIA, Louisiana.
How Does Regency House Of Alexandria Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, REGENCY HOUSE OF ALEXANDRIA's overall rating (3 stars) is above the state average of 2.4, staff turnover (75%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Regency House Of Alexandria?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Regency House Of Alexandria Safe?
Based on CMS inspection data, REGENCY HOUSE OF ALEXANDRIA has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Regency House Of Alexandria Stick Around?
Staff turnover at REGENCY HOUSE OF ALEXANDRIA is high. At 75%, the facility is 29 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. 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 Regency House Of Alexandria Ever Fined?
REGENCY HOUSE OF ALEXANDRIA has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Regency House Of Alexandria on Any Federal Watch List?
REGENCY HOUSE OF ALEXANDRIA 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.