RIVER OAKS NURSING & REHABILITATION CENTER LLC
For profit - Corporation
132 Beds
CENTRAL MANAGEMENT COMPANY
Data: November 2025
Trust Grade
38/100
#100 of 264 in LA
Photo by LCP Media
Photo by LCP Media
Photo by LCP Media
1 / 5 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
River Oaks Nursing & Rehabilitation Center LLC has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. Ranked #100 out of 264 facilities in Louisiana and #9 out of 25 in East Baton Rouge County, it falls within the top half of state facilities but still has serious issues to address. The facility's performance has remained stable over recent years, with 7 reported issues in both 2024 and 2025. Staffing is a relative strength, with a turnover rate of 41%, which is below the state average, but the facility has faced concerning incidents, including a serious case of physical abuse between residents that resulted in injury and inadequate infection control measures during COVID-19. While the facility has good ratings in quality measures, the presence of fines totaling $8,278 and a troubling history of incidents raises important questions for families considering this nursing home.
- Trust Score
- F
- In Louisiana
- #100/264
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- 41% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ○ Average
- $8,278 in fines. Higher than 75% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 10 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Top 37%
Review needed
7 → 7 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 7 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below Louisiana average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Above Louisiana average (2.4)
Meets federal standards, typical of most facilities
Staff Turnover: 41%
Near Louisiana avg (46%)
Typical for the industry
Federal Fines: $8,278
Below median ($33,413)
Minor penalties assessed
Chain: CENTRAL MANAGEMENT COMPANY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 25 deficiencies on record
1 actual harm
Jul 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect a resident's right to be free from physical abuse by anot...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect a resident's right to be free from physical abuse by another resident for 2 (#22 and #101) of 3 (#9, #22, and #101) residents reviewed for abuse. Findings: Review of the facility's manual with a revision date of 04/03/2025 and titled Abuse-Neglect Prevention Manual, revealed the following, in part:iii. Physical abuse includes hitting, slapping. Resident #22Review of Resident #22's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. On 07/14/2025 at 1:26 p.m., an interview was conducted with Resident #22. Resident #22 stated he got into an altercation with Resident #101 about two weeks ago. He stated he was unable to recall the exact date. Resident #22 stated he was going to his seat in the dining room, and Resident #101 cut him off. Resident #22 stated he grabbed the back of Resident #101's wheelchair, and Resident #101 backhanded him to the side of the face. Resident #22 stated he then hit Resident #101 in the face. Resident #22 stated S7CNA separated them. Resident #22 stated Resident #101 then got up from his wheelchair, walked to him, and tried to hit him while his back was turned. Resident #22 stated he hit Resident #101 in the lower jaw, and Resident #101 went and sat back down in his chair. Review of Resident #22's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. Resident #101Review of Resident #101's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #101's Quarterly MDS with an ARD of 05/02/2025 revealed a BIMS score of 11, which indicated moderately impaired cognition. On 07/16/2025 at 8:42 a.m., an interview was conducted with Resident #101. Resident #101 stated he got into a fight with Resident #22. Resident #101 stated Resident #22 hit him first behind the head on the right side so Resident #101 stated he retaliated. Resident #101 stated the incident happened in the dining room at dinnertime and staff were around. Review of Resident #101's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. On 07/15/2025 at 1:51 p.m., an interview was conducted with S7CNA. S7CNA confirmed she witnessed a physical altercation between Residents #22 and #101 about a month ago in the dining room. S7CNA stated the trays were delivered, she turned around, and Residents #22 and #101 were punching each other. S7CNA stated she told the residents to stop and broke them up. S7CNA stated she placed Resident #101 into his wheelchair and went to get the nurse. S7CNA stated she was unable to recall the exact day the altercation occurred nor the nurse she reported to. S7CNA confirmed the residents hitting each other was physical abuse. On 07/16/2025 at 11:25 a.m., an interview was conducted with S5LPN. S5LPN stated Resident #101 reported he had hit Resident #22 on the evening shift. S5LPN stated she was unable to recall the exact date, but it was around 06/19/2025. S5LPN confirmed Resident #101 hitting Resident #22 was an allegation of resident to resident physical abuse. On 07/16/2025 at 1:22 p.m., an interview was conducted with S2DON. S2DON denied staff reporting a physical altercation between Residents #22 and #101. S2DON confirmed residents hitting each other was physical abuse. S2DON confirmed she would expect staff to report if two residents were involved in a physical altercation. On 07/16/2025 at 1:45 p.m., an interview was conducted with S1ADM. S1ADM stated staff did not report an incident between Residents #22 and #101. S1ADM confirmed residents punching or hitting each other was physical abuse. He confirmed the incident should have been reported to him immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an incident involving abuse was reported to the facility a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an incident involving abuse was reported to the facility administrator and State Agency in accordance with the mandated reporting guidelines for 2 (#22 and #101) of 3 (#9, #22, and #101) residents sampled for abuse. Findings: Review of the facility's manual with a revision date of 04/03/2025 and titled Abuse-Neglect Prevention Manual revealed the following, in part:iii. Physical abuse includes hitting, slapping, pinching.5. Investigation and Protection: in the event that any evidence involving.abuse.the issue will be reported immediately to the administrator or his designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines.1. Any person who has knowledge of any act or suspected act of abuse. will notify his/her supervisor immediately.Internal Reporting a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or his designee of the facility. Findings: Review of Facility Reported Incidents from 06/14/2025 to 07/14/2025 revealed no incidents had been reported to the state agency for Residents #22 and #101. Resident #22Review of Resident #22's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #22's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/03/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. On 07/14/2025 at 1:26 p.m., an interview was conducted with Resident #22. Resident #22 stated he got into an altercation with Resident #101 about two weeks ago. He stated he was unable to recall the exact date. Resident #22 stated he was going to his seat in the dining room, and Resident #101 cut him off. Resident #22 stated he grabbed the back of Resident #101's wheelchair, and Resident #101 backhanded him to the side of the face. Resident #22 stated he then hit Resident #101 in the face. Resident #22 stated S7CNA separated them. Resident #22 stated Resident #101 then got up from his wheelchair, walked to him, and tried to hit him while his back was turned. Resident #22 stated he hit Resident #101 in the lower jaw, and Resident #101 went and sat back down in his chair. Review of Resident #22's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. Resident #101Review of Resident #101's Clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #101's Quarterly MDS with an ARD of 05/02/2025 revealed a BIMS score of 11, which indicated moderately impaired cognition. On 07/16/2025 at 8:42 a.m., an interview was conducted with Resident #101. Resident #101 stated he got into a fight with Resident #22. Resident #101 stated Resident #22 hit him first behind the head on the right side. Resident #101 stated he retaliated. Resident #101 stated the incident happened in the dining room at dinnertime and staff were around. Resident #101 stated he reported the incident but could not recall who he reported it to. Review of Resident #101's Nurse's Notes and Care Plan revealed no documentation of the aforementioned altercation. On 07/15/2025 at 1:51 p.m., an interview was conducted with S7CNA. S7CNA confirmed she witnessed a physical altercation between Residents #22 and #101 about a month ago in the dining room. S7CNA stated the trays were delivered, she turned around, and Residents #22 and #101 were punching each other. S7CNA stated she told the residents to stop and broke them up. S7CNA stated she placed Resident #101 into his wheelchair and went to get the nurse. S7CNA stated she was unable to recall the exact day the altercation occurred nor the nurse she reported to. S7CNA confirmed the residents hitting each other was physical abuse. On 07/16/2025 at 11:25 a.m., an interview was conducted with S5LPN. S5LPN stated Resident #101 reported he had hit Resident #22 on the evening shift. S5LPN stated she was unable to recall the exact date, but it was around 06/19/2025. S5LPN stated Resident #101 told her he had reported the incident to a nurse already, but did not tell her which nurse. S5LPN confirmed Resident #101 hitting Resident #22 was an allegation of resident to resident physical abuse. On 07/16/2025 at 1:22 p.m., an interview was conducted with S2DON. S2DON denied staff reporting a physical altercation between Residents #22 and #101. S2DON confirmed residents hitting each other was physical abuse. S2DON confirmed she would expect staff to report if two residents were involved in a physical altercation. On 07/16/2025 at 1:45 p.m., an interview was conducted with S1ADM. S1ADM stated staff did not report an incident between Residents #22 and #101. S1ADM confirmed residents punching or hitting each other was physical abuse. He confirmed the incident should have been reported to him immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#3) resident out of a total of 28 sampled residents by failing to ensure Resident #3 was accurately coded for PASRR (Pre-admission Screening and Resident Review). Findings: Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Recurrent Depressive Disorders, Bipolar Disorder, and Post-Traumatic Stress Disorder. Review of Resident #3's Form 142 titled Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification dated 05/22/2024, revealed an approval for admission by the state Level II Authority for a temporary period effective 05/22/2024 through 05/21/2025. Review of Resident #3's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/2025 revealed Section A1500: Preadmission Screening and Resident Review (PASRR) was coded 0-No. Section A1510: Serious Mental Illness was blank. On 07/17/2025 at 12:25 p.m., an interview was conducted with S8MDS. S8MDS verified Resident #3's Form 142 indicated Resident #3 was approved for admission by the state Level II Authority for a temporary period effective 05/22/2024 through 05/21/2025. She reviewed Resident #3's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. On 07/17/2025 at 12:50 p.m., an interview was conducted with S2DON. S2DON reviewed and confirmed Resident #3's Form 142 indicated Resident #3 was approved for admission by the state Level II Authority for a temporary period effective 05/22/2024 through 05/21/2025. She reviewed Resident #3's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 2 (#7 and #9) of 4 (#5, #7, #9, and #19) sampled residents reviewed for PASRR Level II.Resident #7
Review of the Clinical Record revealed Resident #7 was admitted to the facility on [DATE]. Further review revealed he was diagnosed with Undifferentiated Schizophrenia on 01/09/2023.
Review of Resident #7’s Form 142 dated 09/22/2014 revealed he did not meet the criteria for PASRR Level II services.
On 07/16/2025 at 10:58 a.m., an interview was conducted with S3SSD. She stated she was responsible for submitting Resident Review Forms to OBH. She reviewed Resident #7’s Form 142 dated 09/22/2014 and confirmed it was the most recent on file. She then reviewed Resident #7’s diagnoses, which included Undifferentiated Schizophrenia with an onset date of 01/09/2023. S3SSD confirmed a Resident Review Form should have been resubmitted and was not.
Resident #9Review of the Clinical Record revealed Resident #9 was admitted to the facility on [DATE]. Further review revealed he was diagnosed with Post-Traumatic Stress Disorder (PTSD) and Delusional Disorder upon admission.
On 07/17/2025 at 10:10 a.m., an interview was conducted with S3SSD. She stated Resident #9 admitted to the facility on [DATE] with diagnoses of PTSD and Delusional Disorder with a Level I dated 4/8/2025. She stated upon review of the OBH PASSR Level II Request for Resident Review indicated Delusional Disorder was a Tier 2 diagnosis. She confirmed Resident #9 diagnosis of Delusional Disorder should have been captured on the Level I screening form and was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety as evidenced by faili...
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Based on observations, interviews, and record reviews, the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety as evidenced by failing to:1. Ensure opened foods were sealed properly; and2. Ensured expired food items were disposed.This deficient practice had the potential to affect all 130 residents served from the kitchen. Findings: Review of the undated facility policy titled Food Safety and Sanitation Policy and Procedure revealed the following, in part:Food Storage1. Food that is stored is protected from contamination and growth of any pathogenic organisms.10. Foods with expiration dates are used prior to the use by date on the package Review of the provider's policy dated 2021 and titled Food Storage Safety revealed the following, in part:Food storage from top to bottom when items are stored in the same refrigerator or freezer - Cooked foods are stored over Raw Poultry. On 07/14/2025 at 10:30 a.m., an initial tour of the kitchen was conducted with S4DM. The following observations were made and confirmed: Freezer a 1 case of uncooked fritter style chicken breasts and 1 plastic bag of raw chicken tenderloins were stored over 1 case of Boston cream pies and 1 case of Philadelphia cheese cakes Refrigerator a 1 1/2 gallon of 100% lactulose free 2% reduced fat milk with an expiration date of 07/08/2025. Refrigerator b1 open and unsealed plastic bag of cheese slices1 open and unsealed plastic bag of ham1 open and unsealed plastic bag of bacon On 07/14/2025 at 10:30 a.m., an interview was conducted with S4DM. S4DM confirmed Boston cream pies and Philadelphia cheese cakes should not be stored under raw chicken. S4DM confirmed expired milk should be discarded. S4DM confirmed items stored in the refrigerator should be sealed. On 07/17/2025 at 10:31 a.m., an interview was conducted with S1ADM. S1ADM confirmed items in the kitchen should be stored in a clean, safe way.
Mar 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 (#3 and #6) of 6 (#1, #2, #3, #4, #5, and #6) residents reviewed for abuse. The facility failed to ensure:
1. Resident #3 was free from physical abuse by Resident #4; and
2. Resident #6 was free from physical abuse by Resident #5.
This deficient practice resulted in an actual physical harm on 02/23/2025 when Resident #4, a severely cognitively impaired resident, pushed Resident #3, a severely cognitively impaired resident, onto the floor in the hallway causing Resident #3 to sustain a left eyebrow laceration. Resident #3 was sent to the local emergency room (ER) where he received 9 sutures to his left eyebrow.
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
Review of the facility's policy titled Abuse/Neglect Policy Statement dated 09/2024 revealed the following, in part:
Each resident residing in this facility has the right to be free from physical abuse.
Residents must not be subjected to abuse by anyone, including but not limited to, other residents.
Abuse and Neglect Reporting Definitions
1. Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
5. Physical Abuse - includes hitting, slapping, pinching, and kicking.
1.
Resident #3
Review of Resident #3's clinical record revealed an admission date to the facility of 06/24/2024 with diagnoses, which included Vascular Dementia, Sequelae of Cerebral Infarction, and Bipolar Disorder.
Review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/2025 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 3, which indicated severe cognitive impairment.
Review of Resident #3's current Care Plan revealed the following, in part:
Risk for altered skin integrity/pressure ulcers 02/23/2025 - in altercation with another resident after wandering into that resident's room, end result laceration above left brow, new order send to ER for Evaluation; 02/23/2025 - return from ER 9 sutures to left brow, no complaint of pain noted; 02/26/2025 -redness bruising swelling noted to left eyebrow
Interventions: 02/23/2025 immediate separation from other resident; Neuro checks as ordered; Send to ER as ordered; Unit change to keep both residents separated; Monitor sutures to left brow, report any changes to Medical Doctor (MD)
Review of Resident #3's current Physician's Orders revealed the following, in part:
02/24/2025 Left forehead: Monitor dissolvable sutures and area for signs and sysmptoms of infection until resolved. every day shift
08/01/2024 Visual check for resident's location every 1 hour every shift
Review of Resident #3's Incident Report dated 02/23/2025 revealed the following, in part:
Around 10:45 a.m. S5LPN was called to the unit. Resident #3 was observed on floor with blood coming from area above his eyebrow. Resident #3 was crying and frightened. Certified Nursing Assistant (CNA) stated Resident #4 hit Resident #3 because Resident #3 wandered into Resident #4's room.
Immediate Action Taken
Charge nurse attempted to stop bleeding. Resident #3 was sent out to a local hospital via ambulance for evaluation and treatment.
Injury Type: Laceration
Injury Location: Face
Review of Resident #3's Hospital records with a date of service 02/23/2025 revealed the following, in part:
Laceration Repair: 02/23/2025 at 7:15 p.m.
Location: Left Eyebrow
Length: 3 centimeter (cm) Depth: 1 millimeter
Number of Sutures: 9
Review of Resident #3's Psychiatric Nurse Practitioner noted dated 02/24/2025 revealed the following, in part:
Chief complaint/nature of presenting problem: Assault from another resident. Pushed, unwitnessed fall with laceration .evaluation this morning in bed sleeping, then resident noted ambulating up and down hallways, zero distress is noted.
Plan: Bipolar Affective disorder, current episode severity unspecified: No medication other than Paxil at present- Recent altercation - no behaviors now other than pulling at dressings over left eye.
Resident #4
Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Paranoid Schizophrenia.
Review of Resident #4's Optional State Assessment (OSA) MDS with an ARD of 02/19/2025 revealed a BIMS of 1, which indicated severe cognitive impairment.
Review of Resident #4's Incident Report dated 02/23/2025 revealed the following, in part:
Around 10:45 a.m., S5LPN was called to the unit. Resident #4 was observed to be standing over Resident #3 with fist balled up, cursing, and telling resident, I told you, I will kill you. It appeared Resident #4 had made physical contact with Resident #3. CNA stated Resident #4 had hit Resident #3 because he wandered into his room.
Review of Resident #4's current Care Plan revealed the following:
Focus: The resident is physically aggressive with others. 02/23/2025-Noted with physical aggression toward another resident. New orders to send to a local emergency room (ER) for Psychiatric evaluation. 02/24/2025-admitted to a Behavioral Health Unit.
Interventions: 02/23/2025- 1:1 supervision with resident until transported to behavior for Physician's Emergency Certificate (PEC); PEC to a local hospital's behavioral unit; Send to a local hospital for psychiatric evaluation; Psychiatric/Psychogeriatric consult as needed.
On 03/03/2025 at 2:08 p.m., 03/03/2025 at 2:42 p.m., and 03/05/2025 at 11:05 a.m., unsuccessful attempts were made to interview Resident #3's responsible party.
On 03/03/2025 at 11:01 a.m., an interview was conducted with Resident #3. Resident #3 had a scabbed laceration in his left eyebrow. Resident #3 stated he did not know what happened to his eyebrow.
On 03/05/2025 at 10:20 a.m., an observation and interview was conducted with Resident #4 about the incident with Resident #3. Resident #4 became agitated, his body became tense and he was speaking in a loud voice. With exaggerated hand movements, Resident #4 began shouting, It was a little accident. I don't want to talk about it. Leave. Getting on my nerves.
On 03/03/2025 at 3:00 p.m., an interview was conducted with S5LPN. S5LPN confirmed she worked on 02/23/2025 when Resident #3 and Resident #4 had the incident but did not witness it. S5LPN stated she observed Resident #3 visibly shaken, crying, and bleeding from his left eyebrow in the hallway after the incident. S5LPN stated she observed Resident #4 was standing with his fists balled up, stated he would punch or hit him, and stated, I swear to God I will kill him. S5LPN stated Resident #3 and Resident #4 were separated. S5LPN stated the charge nurse stayed with Resident #3 until he was sent to the hospital for the treatment of his behaviors. S5LPN stated Resident #4 was sent to the hospital for behaviors. S5LPN stated Resident #3 has been moved to a different hall.
On 03/05/2025 at 9:34 a.m., an interview was conducted with S13CNA. S13CNA stated Resident #3 would wander the halls after his meals and staff would redirect him to his room or the dining room. S13CNA stated once Resident #3 was brought to his room, he usually stayed there. S13CNA stated she received abuse training a week ago. S13CNA was knowledgeable on the types of abuse. S13CNA defined physical abuse as fighting and touching. S13CNA stated she would report abuse to the nurse or the supervisor immediately.
On 03/05/2025 at 10:17 a.m., an interview was conducted with S11CNA. S11CNA stated she did not witness the 02/23/2025 incident between Resident # and Resident #4. S11CNA stated she was in another resident's room and heard yelling and commotion down the hall. S11CNA stated she saw Resident #3 side-lying on the floor in the hall and bleeding from his eyebrow. S11CNA stated Resident #4 was standing over Resident #3 with his fist clenched, yelling for him to get out of his room. S11CNA stated Resident #3 was brought into another room and was provided nursing care until Emergency Medical Services (EMS) arrived. S11CNA stated Resident #3 required stitches. S11CNA denied any changes in Resident #3's behavior after the incident. S11CNA stated an in-service on abuse and neglect was provided after the incident. S11CNA confirmed that the incident between Resident #3 and Resident #4 was physical abuse.
On 03/03/2025 at 3:17 p.m., an interview was conducted with S1ADM. S1ADM stated he reviewed the video footage of the incident between Resident #3 and Resident #4 on 02/23/2025. S1ADM stated Resident #3 went into Resident #4's room and Resident #4 pushed Resident #3 out of the room and Resident #3 fell face forward into the hallway. S1ADM stated Resident #3 fell to his knees and hit his left forehead on the floor. S1ADM stated Resident #3 and #4 were placed on 1:1 supervision until they were sent to the hospital. S1ADM stated Resident #3 was sent to the hospital for stitches and returned the same day. S1ADM stated Resident #4 was sent to a psych hospital in excess of a week. S1ADM stated Resident #3 was moved to a different locked unit due to his wandering and to prevent further problems.
On 03/05/2025 at 10:32 a.m., an interview was conducted with S3ADON. S3ADON confirmed she responded to the incident with Resident #3 and Resident #4 on 02/23/2025. S3ADON stated staff were assisting Resident #3 when she arrived. S3ADON stated Resident #3's left forehead was bleeding. S3ADON confirmed Resident #3 was sent out to the hospital and received 9 sutures to the laceration. S3ADON stated Resident #4 stated Resident #3 came into his room and he wanted him out and he pushed him out.
On 03/05/2025 at 12:33 p.m., an interview was conducted with S2DON. S2DON confirmed on the video footage they saw Resident #4 physically push Resident #3 out of the room on 02/23/2025. S2DON confirmed the incident between Resident #3 and Resident #4 was an incident of resident to resident physical abuse. S2DON stated after the 02/23/2025 incident with Resident #3 and #4, staff ensured both residents were safe and separated until they were sent out of the facility. S2DON stated Resident #3 was moved to a different unit. S2DON stated the facility reported the 02/23/2025 incident between Resident #3 and #4 to the State Agency, notified the police, and opened a Quality Assurance and Performance Improvement (QAPI) on resident to resident altercations. S2DON stated staff were educated on abuse and received an abuse quiz. S2DON stated cognitive residents were also interviewed regarding abuse - abuse by staff and other residents, and were encouraged to report. S2DON stated Residents with BIMS less than 10 were assessed for any concerns related to abuse and behavioral changes - depression or being withdrawn. S2DON stated she has completed monitoring randomly on 3 cognitively impaired residents 3 three times a week. S2DON stated monitoring will continue until compliance is met.
2.
Resident #6
Review of Resident #6's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Dementia.
Review of Resident #6's Quarterly MDS with ARD of 11/05/2024 revealed the provider assessed the resident has having a BIMS of 7, which indicated cognitive impairment.
On 03/05/2025 multiple attempts were made to contact Resident #6's Responsible Party with no answer.
On 03/05/2025 at 10:00 a.m., an attempt to interview Resident #6 revealed he was unable to answer any historical questions regarding the incident on 02/14/2025.
Resident #5
Review of Resident # 5's Clinical Record revealed he was admitted to the facility on [DATE] with Diagnoses which included Chronic Kidney Disease and Chronic Schizoaffective Disorders.
Review of Resident #5's Annual MDS with ARD of 12/04/2024, revealed a BIMS of 15, which indicated the resident was cognitively intact.
Review of Resident #5's Care Plan, updated 02/14/2025 revealed, in part:
Mood State: Mood disorder related to diagnosis of Schizoaffective Disorder. 02/14/2025 - Resident's roommate reported that he was hit by this resident, aggressive with staff, PEC for behavioral hospital in house evaluation.
Interventions: assess for changes in mood status, assess for effectiveness of medication therapy, monitor for side effects of psychoactive therapy, (02/14/2025) remove from room immediately, send to behavioral hospital per PEC, 02/28/2025) room change upon return to facility.
Review of Resident #5's incident report, dated 2/14/2025 revealed the following, in part: at approximately 7:00 a.m. S12CNA heard a noise coming from Resident #5 and Resident #6's room. S12CNA went to the room and witnessed Resident #5 hitting Resident # 6.
On 03/05/2025 three attempts were made to contact S12CNA, she was unavailable.
On 03/05/2025 at 9:00 a.m., an interview was conducted with Resident #5. He stated he was sent out to the hospital on [DATE] for hitting his roommate, Resident #6.
On 03/05/2025 at 9:10 a.m., an interview was conducted with S4LPN. She stated on 02/14/2025 S12CNA summoned her to Resident #6's room. S4LPN stated S12CNA told her Resident #5 was hitting Resident #6. S4LPN stated they were separated and Resident #6 was brought to the nurse's station for 1:1 observation. S4LPN stated Resident #6 was examined and did not have any injury. S4LPN stated Resident #5 was placed on 1:1 observation until he was transferred to the behavioral hospital for evaluation. S4LPN stated Resident #5 hitting Resident #6 was resident to resident abuse.
On 03/05/2025 at 10:15 a.m., an interview was conducted with S2DON. S2DON stated on 02/14/2025 Resident #5 and Resident #6 were involved in an altercation. She stated S12CNA witnessed Resident #5 hitting Resident #6. S2DON stated Resident #6 did not have any injuries and was placed on 1:1 observation. S2DON stated Resident #5 was placed on 1:1 observation until admitted to the psychiatric hospital for evaluation and treatment. She confirmed Resident #5 was moved to another room upon return to the facility. S2DON confirmed on 02/14/2025 In-Service Training was conducted with all staff by S1ADM on Abuse and Neglect and Redirection of Residents with Aggressive Behaviors. S2DON confirmed Resident #5 hitting Resident #6 was abuse.
On 03/05/2025 at 3:10 p.m., an interview was conducted with S1ADM. He confirmed the incident on 02/23/2025 between Residents #3 and #4 was an incident of resident to resident abuse. He confirmed the incident on 02/14/2025 between Residents #5 and #6 were incidents of resident to resident abuse.
The facility had implemented the following corrective actions to correct the deficient practice:
Plan of Correction:
Resident to Resident Altercation/Abuse Allegation
On 02/14/2025 at 9:28 a.m. an altercation occurred between 2 residents. Resident #5 and Resident #6. S12CNA was making rounds on the hall when she heard Resident #5 yelling out. When she entered Resident #5's room she witnessed Resident #5 hitting Resident #6. She immediately intervened and separated the 2 residents and notified the nurse. Resident #5 was placed on 1:1 supervision. The NP (Nurse Practitioner) assessed Resident #6 and no injuries were found. Resident #5 remained on 1:1 supervision until the ambulance arrived at approximately 4:00 p.m.
On 02/14/2025, the Administrator and Director of Nursing held an in-service with the nursing staff and reviewed the following areas:
1-Abuse/Neglect, Reporting Abuse/Neglect to Immediate Supervisor, Administrator Director of Nursing, Assistant Director of Nursing, Charge Nurse, Weekend Registered Nurse, Floor Nurse.
2-Fall Incident/Accident Reporting, per facility Policy/Procedure.
A resident list was completed by the Clinical Care Coordinator for residents BIMS scores.
Residents with a BIMS of 10 or less were identified as Cognitive Impairment/Communication Impairment. A Quality Assurance Performance Improvement (QAPI) monitor was developed to assess random residents who are Cognitively Impaired for any indication of Abuse by direct observation of resident change in behavior (crying, withdrawn, decrease in activity participation, acting out at others). A QAPI monitor was developed by the Director of Nursing. The Quality Assurance (QA) Monitor will be completed tor 3 random residents that are cognitively impaired 3 times a week for 6 weeks and monthly thereafter.
A resident list for residents that are cognitively intact with a BIMS of 13 or greater was completed by the Director of Nursing. An additional QA Monitor was developed for Reporting of Alleged Violations. The QA monitor will be completed 5 times per week for 3 weeks and randomly thereafter.
The in-services were completed 02/25/2025. The PRN (As needed) staff will be in-serviced prior to working.
Jan 2025
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
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure resident privacy and confidentiality was maintained for 1 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure resident privacy and confidentiality was maintained for 1 (#1) of 10 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #R10) sampled residents. The facility failed to ensure S5A did not take and keep an unauthorized photograph of Resident #1. This deficient practice had the potential to affect all 130 residents on the current census.
Findings:
Review of the facility's policy titled, Resident's Rights dated 12/01/1991, revealed the following, in part:
A facility must protect and promote the rights of each resident, including each of the following rights:
(e) Privacy and Confidentiality
Review of Resident #1's Clinical Record revealed the resident was admitted on [DATE] with diagnoses, in part: Alzheimer's Disease, Dementia, Moderate with Other Behavioral Disturbances, Aphasia, Cognitive Communication Deficit, Attention and Concentration Deficit Following Other Cerebrovascular Disease, and Recurrent Depressive Disorder.
Review of Resident #1's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/03/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) of 99, which indicated the interview was incomplete, related to nonsensical responses, or no verbal or written responses to questions were provided by Resident #1.
Review of Resident #1's Consent to Photograph and Activities Consent Form, dated 06/07/2024 and signed by Resident #1's Responsible Party, revealed consent was not authorized for the attending physician or other designated person (s) to take:
2. Photographs of appropriate parts of the body of the resident in order to provide supporting documentation of my medical condition. (I understand any photographs taken will be placed in and remain part of the resident's medical record.)
3. Photographs of the resident for publicity, the facility newsletter or the birthday board.
4. Photographs of the resident for the purpose of (specify): blank
On 12/27/2024 at 11:59 a.m., an interview was conducted with S5A. S5A confirmed she had saved text messages on her phone and would provide them to the State Agency.
On 12/27/2024 at 1:56 p.m., review of screenshots of text messages provided by S5A revealed a photograph of Resident #1 in his room.
On 01/02/2025 at 2:59 p.m., an interview was conducted with S3DON and S4ADON. S3ADON and S4DON reviewed the text message/photograph and confirmed the photograph was of Resident #1 in his room. S3DON and S4DON confirmed staff should maintain resident's confidentiality and privacy at all times. S3DON and S4ADON confirmed when staff took and kept an unauthorized photograph of Resident #1, it was a violation of Resident #1's right to privacy and confidentiality.
On 01/02/2025 at 3:30 p.m., an interview was conducted with S1ADM and S2RD. S1ADM and S2RD reviewed the text message/photograph and S1ADM confirmed the photograph was of Resident #1 in his room. S1ADM and S2RD confirmed staff should maintain resident's confidentiality and privacy at all times. S1ADM and S2RD confirmed staff should not take and keep unauthorized photographs of residents, as it is a violation of their right to privacy and confidentiality.
Aug 2024
7 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident was treated with respect ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to 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 for 2 (#43 and #120) of 28 residents reviewed in the final sample. The facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over and sitting on Residents #43 and #120's beds while assisting them to eat.
Findings:
Review of the facility's undated policy titled, Feeding A Resident revealed the following, in part:
Procedure:
5. Sit in a chair to feed the resident.
Resident #43
Review of Resident #43's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Senile Degeneration of Brain and Dementia.
On 08/20/2024 at 7:35 a.m., an observation was made of Resident #43 in bed. S11CNA was observed feeding Resident #43 while standing next to his bed. S11CNA then sat on Resident #43's bed and continued feeding him the rest of the meal.
On 08/20/2024 at 1:30 p.m., an interview was conducted with S11CNA. She confirmed the aforementioned observations. She confirmed she should sit in a chair to feed a resident.
Resident #120
Review of Resident #120's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Dementia.
On 08/20/2024 at 7:43 a.m., an observation was made of Resident #120 in bed. S10CNA was observed standing next to the bed and then sat on Resident #120's bed to feed the resident.
On 08/20/2024 at 1:25 p.m., an interview was conducted with S9LPN. She confirmed CNA's should not stand while feeding residents or sit on the resident's bed, they should sit in a chair.
On 08/20/2024 at 2:05 p.m., an interview was conducted with S10CNA. She confirmed the aforementioned observations. She confirmed she should sit in a chair to feed a resident.
On 08/20/2024 at 4:50 p.m., an interview was conducted with S2DON. She confirmed CNA's should not be standing or sitting in the resident's beds while feeding a resident, they should be seated in a chair next to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported immediately but ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported immediately but no later than 2 hours after the allegation was made to the State Survey Agency for 1 (#33) of 8 (#1, #5, #15, #33, #46, #47, #73, and #106) residents interviewed during the initial pool and reviewed for abuse.
Findings:
Review of the facility's document titled Abuse/Neglect Policy Statement dated March 2016 revealed in part, the following:
Definitions:
Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
Alleged Violation - the terminology used when a verbal allegation of resident abuse has been made either by a resident, family member, visitor, or employee .
Verbal Abuse - the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability .
Physical Abuse - includes hitting, slapping, pinching, and kicking .
Review of the facility's Policy titled Abuse/Neglect Investigation, Protection, and Reporting dated March 2016 revealed in part, the following:
In the event of any evidence involving abuse .an occurrence will be immediately reported to the Administrator or designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines .
Review of Resident #33's clinical record revealed the resident was admitted to the facility on [DATE].
Review of the incident reports for Resident #3 revealed no report regarding alleged verbal abuse by S17CNA.
Review of Resident #33's Quarterly MDS with an ARD of 06/11/2024 revealed Resident #33 had a BIMS of 15, which indicated the resident was cognitively intact.
On 08/19/2024 at 10:00 a.m., an interview was conducted with Resident #33. Resident stated S17CNA yelled and cursed at him on Saturday. Resident #33 stated he reported what S17CNA had done to S16LPN and S1ADM on the morning of 08/19/2024.
On 08/19/2024 at 10:00 a.m., an interview was conducted with Resident's roommate. He stated he saw and heard S17CNA yelling and cursing at Resident #33. Resident #33.
On 08/19/2024 at 10:48 a.m., an interview was conducted with S16LPN. She stated Resident #33 told her this morning S17CNA had yelled and cursed at him. She stated she immediately notified S2DON and S1ADM.
On 08/20/2024 at 2:00 p.m., an interview was conducted with S2DON. She stated S16LPN notified her on the morning of 08/19/2024 Resident #33 reported S17CNA had yelled and cursed at him. She stated any allegations of staff yelling or cursing at residents would be considered abuse.
On 08/20/2024 at 2:30 p.m., an interview was conducted with S1ADM. S1ADM confirmed he was informed of S17CNA yelling and cursing at Resident #33 on 08/19/2024 by S16LPN and confirmed he had not reported it to the state survey agency. S1ADM stated staff yelling or cursing at a resident was considered abuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge Status for 1 (#130) of 28 residents reviewed in the final sample.
Findings:
Review of Resident #130's Clinical Record revealed she was admitted to the facility on [DATE].
Review of Resident #130's Discharge MDS, with an ARD of 07/09/2024, indicated, in part, the following;
Section A:
Planned/Unplanned discharge: 1. Planned.
discharge date : [DATE].
Discharge Status: 4. Short Term General Hospital.
Assessment Reference Date: 07/09/2024.
Review of Resident #130's Physician Orders revealed, in part, an order written on 07/09/2024 to discharge to a private facility.
Review of Resident #130's Nurses Notes revealed, in part, a note written on 07/09/2024 at 5:50 p.m. by S8LPN indicating Resident #130's son has arrived to transport this resident to a group home .
On 08/20/2024 at 4:00 p.m., an interview was conducted with S7SSD. She stated Resident #130 discharged from the facility to a group home.
On 08/20/2024 at 4:20 p.m., an interview was conducted with S6RN. She confirmed she was responsible for entering MDS Assessments for the facility. She reviewed Resident #130's Discharge MDS and Nurses Notes dated 07/09/2024. She confirmed the resident was discharged to a group home, not a short term hospital and the MDS was coded incorrectly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement an effective discharge planning process whic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement an effective discharge planning process which focused on the resident's discharge goals for 1 (#71) of 1 residents reviewed for choices. The facility failed to update the discharge plan to accurately reflect the discharge wishes of the resident.
Findings:
Review of the facility's undated policy titled Discharge Planning revealed the following:
Policy: It is the policy of this facility that discharge planning and evaluating services be provided by the Department of Social Services for each resident. Discharge planning involves the resident, the family and/or representative, interdisciplinary staff, and other resources as needed.
Review of Resident #71's clinical record revealed he was admitted to the facility on [DATE].
Review of Resident #71's quarterly MDS with an ARD of 07/03/2024 revealed he had a BIMS of 12, which indicated he had moderate cognitive impairment.
Review of Resident #71's facility facesheet revealed he was his own responsible party.
Review of Resident #71's care plan revealed the following:
Onset: 04/30/2024
Problem: Discharge plans - Resident and RP plans are for the resident to remain in the facility
Intervention: Assess residents and responsible party's feelings and desires toward discharge; Support and assist resident in making own choices
Review of Resident #71's care team notes dated April 2024 to August 2024 revealed the following:
04/04/2024 at 3:16 p.m. - He is understood when making request and needs known . Resident scored 12 on BIMS scale which indicates that he is moderately impaired. Resident does not care for this facility and desires to transfer to a facility closer to his home. Signed by: S7SSD
04/04/2024 at 5:03 p.m.-Resident is new to facility and lives out in general population .No plans for discharge at this time. Signed by: S12AD
05/10/2024 at 10:52 a.m. - He is understood when making request and needs known . Resident expects to transfer to other facility . Signed by: S7SSD
05/15/2024 at 12:13 p.m. - Resident is new admit to facility .No plans for discharge at this time. Signed by: S12SSD
On 08/19/2024 at 9:48 a.m., an interview was conducted with Resident #71. He stated he requested to be transferred to a facility closer to his family. He stated he talked with S7SSD about this, but nothing had been done about it.
On 08/20/2024 at 9:58 a.m., an interview was conducted with S4LPN. She stated Resident #71 was able to communicate and make his needs known. She stated he had voiced to her he wanted to leave the facility, but never stated or specified he wanted to be moved to another facility closer to home.
On 08/20/2024 at 10:18 a.m., an interview was conducted with S13CNA. She stated Resident #71 had mentioned to her his desire to be transferred to another facility closer to his family.
On 08/20/2024 at 11:10 a.m., an interview was conducted with S7SSD. She stated Resident #71 was a new resident at the facility and was admitted in March. She stated he told her he wanted to be transferred to a facility closer to where his family was located. She confirmed she had not sent any documents for approval of transfer to another facility closer to his home because he was newly admitted to this facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0807
(Tag F0807)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide drinks consistent with resident preferences....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide drinks consistent with resident preferences. The facility failed to ensure staff passed ice and water to 2 (#10 and #112) of 33 residents reviewed in the initial pool.
Findings:
Review of the facility's undated policy titled, Hydration Management revealed the following, in part:
Procedure:
1. A pitcher of ice water will be available to all residents in their rooms . Efforts will be made to keep water pitchers within the resident's reach .
2. Water pitchers will be filled with ice not less than three times per 24 hours.
Resident #10
Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #10's admission MDS with ARD of 06/26/2024 revealed Resident #10 had a BIMS of 14, which indicated he was cognitively intact.
Review of Resident #10's current Physician Orders revealed the following, in part:
Start date: 08/01/2024- Low Concentrated Sweets/Controlled Carbohydrate Diet, Regular texture.
On 08/19/2024 at 9:11 a.m., an interview was conducted with Resident #10. Two plastic pink cups were observed sitting on the air conditioning unit by his bed. Resident #10 removed the lids off both cups and they were observed empty. He stated he had no ice or water and was lucky to get his cup filled once a day.
On 08/19/2024 at 2:15 p.m., an interview was conducted with Resident #10. Two plastic pink cups were observed sitting on the air conditioning unit by his bed. Resident #10 removed the lids off both cups and they were observed empty. He stated staff had not filled his cup with water and ice for 2 weeks and he would like some.
On 08/20/2024 at 8:30 a.m., an observation was made of Resident #10 room. Two plastic pink cups were observed empty sitting on the air conditioning unit by Resident #10's bed.
Resident #112
Review of Resident #112's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #112's Quarterly MDS with an ARD of 05/24/2024 revealed Resident #112 had a BIMS of 3, which indicated he was severely cognitively impaired.
Review of Resident #112's current Physician Orders revealed the following, in part:
Start date: 08/01/2024- Regular diet, Regular texture, Regular/thin consistency.
On 08/19/2024 at 2:18 p.m., an interview was conducted Resident #112. No ice or water was observed on his bedside table. A pink cup was observed empty on the cabinet shelf out of the resident's reach. Resident #112 stated no ice or water were passed or offered by the CNA's. He stated he used to ask the CNA's for ice and water, but they never bring any, so he quite asking them because it was a waste of time.
On 08/20/2024 at 8:30 a.m., an observation was made of Resident #112's room. A pink cup was observed empty on the cabinet shelf out of Resident #112's reach. No ice or water was observed on Resident #112's bedside table.
On 08/20/2024 at 12:48 p.m., an interview was conducted S9LPN. She stated the plastic pink cups in the resident rooms should have ice and water in them. She stated the CNA's should pass ice and water to the residents every shift and as requested.
On 08/20/2024 at 1:30 p.m., an interview was conducted with S11CNA. She stated the plastic pink cups in the resident rooms should be filled up with ice and water. She stated the CNA's had not passed ice and water to Resident #10 and Resident #112's room this week and should have.
On 08/20/2024 at 1:50 p.m., an interview was conducted with S10CNA. She stated she was assigned to Resident #10 and Resident #112 today, 08/20/2024. She confirmed she did not pass ice or water to Resident #10 or Resident #112 during her shift and should have. She stated ice and water should be offered to residents each shift and as requested.
On 08/20/2024 at 4:50 p.m., an interview was conducted with S2DON. She stated the CNA's should pass ice and water once to twice a shift and as requested by residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices. The facility failed to ensure Physician Orders for monitoring of behaviors and side effects for a psychotropic medication were obtained and documented for 1 (#124) of 28 residents reviewed in the final sample.
Findings:
Review of Resident #124's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Other Specified Depressive Episodes and Severe Vascular Dementia with Other Behavioral Disturbance.
Review of Resident #124's current Physician Orders revealed the following, in part:
Revision Date: 08/01/2024 Sertraline HCl Tab 100 mg give 1 tablet by mouth one time a day.
Further review revealed no orders pertaining to monitoring for behaviors or side effects of psychotropic medications.
Review of Resident #124's MAR dated June 2024-August 2024 revealed the following, in part:
Start date: 04/24/2024 Sertraline 100 mg tablet administer 1 tablet by mouth one time a day.
Further review revealed no documentation pertaining to monitoring for behaviors and side effects of psychotropic medications.
On 08/20/2024 at 12:38 p.m., an interview was conducted with S9LPN. She stated she was assigned to Resident #124. She reviewed Resident #124's physician orders and MAR and verified he received the antidepressant medication Sertraline daily. She confirmed there was no physicians order or task assigned to the nurses to monitor Resident #124 for behaviors or side effects related to the antidepressant and there should have been.
On 08/20/2024 at 4:30 p.m., an interview was conducted with S14LPN. She reviewed Resident #124's clinical record and confirmed he received psychotropic medications. She confirmed Resident #124 did not have orders for monitoring behaviors and side effects for psychotropic medication and should have.
On 08/20/2024 at 4:40 p.m., an interview was conducted with S2DON. She reviewed Resident #124's physician orders and MAR and confirmed he was prescribed Sertraline for depression. She confirmed a physician's order was not entered or a task assigned to the nurses for the monitoring of the psychotropic medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles by failing to:
1.
Ensure medications were in locked compartments permitting only authorized personnel to have access for 1 (#33) of 8 (#1, #5, #15, #33, #46, #47, #73, and #106) residents observed during the initial pool; and
2.
Ensure Schedule III-IV medications were stored in a permanently affixed compartment and/or a single unit package drug distribution system for 1 (Room A) of 1 Medication Storage Room reviewed.
Findings:
Review of the facility's undated Policy titled, Medication Storage in the Facility revealed the following:
Policy Statement:
Medication and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel.
Procedure:
2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications .
1.
Resident #33
Review of Resident #33's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Glaucoma.
Review of Quarterly MDS with ARD of 6/11/2024 that resident had a BIMS of 15 which revealed resident was cognitively intact.
Review of Resident #33's August 2024 Physician Orders revealed the following, in part:
Start date: 01/01/2022- Brimonidine Tartratetimolol Maleate 0.2%-0.5% eye drops. Instill 1 drop in right eye two times a day.
Start date: 01/01/2022 - Latanoprost 0.005% Eye drops. Instill 1 drop in both eyes at bedtime.
Review of Resident #33's August 2024 MAR revealed the following, in part:
Brimonidine Tartratetimolol 0.2-0.5% was administered on 08/19/2024 at 8:00 p.m.
Latanoprost 0.005% was administered on 08/19/2024 at 8:00 p.m.
On 08/20/2024 at 8:52 a.m., an observation was made of two bottles of eye drops, Latanaprost 0.005% and Brimonidine 0.2-0.5%, at Resident #33's bedside. Resident #33 stated the eye drops were his and were left last night by the nurse.
On 08/20/2024 at 8:59 a.m., an observation and interview was conducted with S12LPN. She confirmed eye drops, Latanaprost 0.005% and Brimonidine 0.2-0.5%, had been left at Resident #33's bedside. She stated medications, including eye drops, should not have been left at Resident #33's bedside.
On 08/20/2024 at 10:35 a.m., an interview was conducted with S3ADON. She confirmed nurses should never leave medications at a resident's bedside, including eye drops.
2.
On 08/19/2024 at 9:40 a.m., an observation was made of Room A with S4LPN. There was a small tan colored box, Controlled Substance Emergency Kit, present in Room A on a corner shelf. The Controlled Substance Emergency Kit was not permanently affixed. S4LPN picked the entire Controlled Substance Emergency Kit up and held it in her hands. An interview was conducted with S4LPN at that time. S4LPN confirmed the Controlled Substance Emergency Kit contained Schedule III-IV medications and was not permanently affixed. Review of the list of medications present in the Controlled Substance Emergency Kit revealed the following Schedule III - IV medications were present in the kit:
1.
Alprazolam 0.25mg tablet - Quantity 8 tablets
2.
Clonazepam 0.5mg tablet - Quantity 8 tablets
3.
Lorazepam 0.5mg - Quantity 8 tablets
4.
Tramadol HCL 50mg - Quantity 8 tablets
5.
Tramadol/APAP 37.5mg/325mg tablet - Quantity 8 tablets
6.
APAP/Codeine 300/30mg tablet - Quantity 8 tablets
7.
APAP/Codeine 300/60mg tablet - Quantity 8 tablets
On 08/19/2024 at 2:44 p.m., an interview was conducted with S2DON and S3ADON in Room A. S2DON and S3ADON both reported every floor nurse and administrative nurse had keys to Room A and had access to the Controlled Substance Emergency Kit. S2DON picked up the Controlled Substance Emergency Kit containing Schedule III-IV medications and held it in her hands. Both S2DON and S3ADON confirmed the Controlled Substance Emergency Kit box was not permanently affixed and could easily be removed from Room A. S2DON and S3ADON both confirmed the Controlled Substance Emergency Kit was not a single unit dose distribution system and contained Scheduled III-IV medications. S2DON stated she was unaware the Controlled Substance Emergency Kit should have been stored in a permanently affixed compartment.
On 08/20/2024 at 10:00 a.m., an interview was conducted with S1ADM who confirmed he was unaware controlled medications should have been in a permanently affixed compartment or a single unit dose distribution system.
Sept 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure a resident who was unable to carry out activiti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for 1 (# 97) of 3 (#22, #71, and # 97) residents reviewed for nail care.
Findings:
Review of the facility's policy titled Nail Management revealed, in part:
Policy:
Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury form scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath.
Essential Points:
Nails that are ingrown, thickened, or infected should be cared for by a podiatrist or physician.
Review of Resident #97's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included; Dementia, Alzheimer's Disease, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-dominant Side.
Review of Resident #97's Plan of Care revealed, in part:
Problem: Self-care ADL Deficit: Resident will receive person-centered care; needs assist with bathing, hygiene, dressing and grooming related to neurocognitive disorder.
Approach: Assist with hygiene, dressing and grooming as needed, encourage resident to assist with all tasks as able, fingernails cleaned and trimmed as needed.
Review of Resident #97's Physician Progress Notes revealed no documentation of Resident #97 needing a podiatry consult due to toenail length and thickness.
Review of Resident #97's Nurse Notes revealed no documentation of Resident #97 needing a podiatry consult due to toenail length and thickness.
Review of Resident #97's Skin Inspection Report, dated 9/02/2023, revealed no documentation of Resident # 97's toenails requiring a podiatry consult due to nail length and thickness.
An observation was made on 09/11/2023 at 9:30 a.m. of Resident # 97 lying in bed with his feet exposed. His toenails extended half an inch beyond the tip of his toes and were thick and brown in color.
An interview was conducted on 09/12/2023 at 10:45 a.m. with S18LPN. She confirmed she should have notified the Nurse Practitioner a podiatry consult was needed for Resident #97 but she had not.
An interview was conducted on 09/12/2023 at 11:00 a.m. with S8TLPN. She stated if a resident's nails were too thick for staff to use clippers, and podiatry should have been consulted. She confirmed she was not aware Resident #97 needed a toenail trim but should have been.
An observation and interview was conducted on 09/12/2023 at 1:45 p.m. with S19CNA. She confirmed Resident #97's toenails were extended half an inch beyond the tip of his toes and were jagged, thick and brown in color. She confirmed she could not trim his toenails due to their condition and could not recall having reported his need for a toenail trim to the nurse. She confirmed his toenails should have been trimmed but had not been.
An interview was conducted on 09/12/2023 at 2:05 p.m. with S18LPN. She confirmed Resident #97's toenails were extended half an inch beyond the tip of his toes and were jagged, thick and brown in color. She confirmed his toenails would require a podiatry consult. She confirmed a podiatry consult had not been requested but should have been.
An interview was conducted on 09/13/23 at 02:03 p.m. with S3DON She confirmed if a resident needed a podiatry consult ordered, she would expect her nurses to inform the nurse practitioner immediately. She confirmed Resident's 97's toenails should not have extended a half inch past his toes. She confirmed the staff had not provided nail care/management and they should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a resident's right to request, refuse and/or discontinue tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a resident's right to request, refuse and/or discontinue treatment, and to formulate an advanced directive was properly reflected in the resident's record as evidenced by:
1. Failure to ensure all records regarding code status consistently reflected the residents wishes for 1 (#8) of 3 (#8, #71 and #78) residents reviewed for advanced directives in the final sample; and
2. Failure to ensure a completed advanced directive was placed on the chart for 2 (#71 and #78) of 3 (#8, #71 and #78) residents reviewed for advanced directives in the final sample.
This deficient practice had the potential to affect 121 residents currently residing in the facility.
Findings:
A review of the facility's Advanced Directive Policy revealed, in part, the following:
Purpose:
To outline the mechanism whereby requests not to administer cardiac resuscitation can be brought to the attention of those who might be required to respond.
Authority:
Each patient/resident shall be given the opportunity to refuse treatment. If a terminally ill patient/resident is comatose, incompetent, or is physically/mentally incapable of communication, certain other individuals may make the request on his/her behalf. The following procedure shall be complied with in handling the request not to administer cardiac resuscitation.
Procedure:
2. The physician shall have prescribed a plan regimen of total care for the patient/resident which shall include special exceptions to the treatment regimen.
3. If the patient/ resident has elected to appoint or designate an individual to make the request to refuse treatment, then that request must be evidenced by a witnessed document, statement or expressions, voluntarily made by the patient/ resident authorizing the withholding or withdrawal of life sustaining procedures in accordance with the requirements of Louisiana law. This declaration may be in writing, orally, or by other means of non-verbal communication.
4. The facility attorney shall have certified in a written statement that the patient/ residents declaration is valid and that the patient/resident is a qualified patient as documented by the two physicians as set forth hereinabove.
1.
Resident #8
Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE].
A review of Resident #8's current Medication Administration Record (MAR) revealed DNR code status with a start date of [DATE].
A review of Resident #8's current Physician's Orders revealed an order written on [DATE] for DNR.
Review of Resident #8's Louisiana Physician Orders for Scope of Treatment (LAPOST) advanced directive in the paper chart revealed, in part, the following:
A. CPR/Attempt Resuscitation: Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Blank.
Physician Phone Number: Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #8's responsible party.
Date (Mandatory): [DATE].
An interview was conducted on [DATE] at 10:13 a.m. with Resident #8's responsible party. She stated she discussed making Resident #8 a DNR with his physician roughly a year prior but did not recall signing any paperwork to make it happen.
An interview was conducted on [DATE] at 8:56 a.m. with S3LPN. She stated in the event of an emergency, she would immediately check the Advance Directive section of a resident's paper chart. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and stated he was a full code and should receive CPR in the event of an emergency. She confirmed she would perform CPR on Resident #8 based on his LAPOST advanced directive. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status so she should not perform CPR in the event of an emergency. She confirmed there was a discrepancy and she was not sure which code status she should honor.
An interview was conducted on [DATE] at 9:14 a.m. with S12LPN. She stated in the event of an emergency, she would immediately check the Advance Directive section of a resident's paper chart. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and stated he was a full code and should receive CPR in the event of an emergency. She confirmed she would perform CPR on Resident #8 based on his LAPOST advanced directive. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status so she should not perform CPR in the event of an emergency. She confirmed there was a discrepancy and she was not sure which code status she should honor.
An interview was conducted on [DATE] at 9:22 a.m. with S14CNA. She stated in the event of an emergency, she would immediately check the Advance Directive section of a resident's paper chart. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and stated he was a full code and should receive CPR in the event of an emergency. She confirmed she would perform CPR on Resident #8 based on his LAPOST advanced directive. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status so she should not perform CPR in the event of an emergency. She confirmed there was a discrepancy and she was not sure which code status she should honor.
An interview was conducted on [DATE] at 9:15 a.m. with S9MR. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and confirmed it indicated full code. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status. She confirmed there was a discrepancy for Resident #8's advanced directive. She confirmed Resident #8's most up to date, completed advanced directive was not on his chart and should have been.
An interview was conducted on [DATE] at 11:38 a.m. with S20LPN. She confirmed she was responsible for ensuring the accuracy and completeness of advanced directives for the residents of the facility. She confirmed Resident #8's LAPOST advanced directive did not match his electronic orders in the computer but should.
An interview was conducted on [DATE] at 2:20 p.m. with S3DON. She reviewed Resident #8's LAPOST advanced directive present on his paper chart and confirmed it indicated full code. She reviewed Resident #8's EMR and confirmed his MAR and Physician Orders revealed he was a DNR code status. She confirmed there was a discrepancy for Resident #8's advanced directive. She confirmed all resident charts should contain the most up to date, accurate and complete advanced directive at all times and Resident #8's did not.
2.
Resident #71
Review of Resident #71's Clinical Record revealed she was admitted to the facility on [DATE].
Review of Resident #71's LAPOST advanced directive in the paper chart revealed, in part, the following:
A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #71's responsible party.
Date (Mandatory): [DATE].
Resident #78
Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #78's LAPOST advanced directive in the paper chart revealed, in part, the following:
A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Illegible loops present, not on the signature line, in purple ink.
Physician Phone Number: Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #78's responsible party.
Date (Mandatory): [DATE].
An interview was conducted on [DATE] at 12:55 p.m. with S18LPN. She reviewed Resident #71 and #78's LAPOST advanced directive present on their paper chart and stated she would not perform CPR in the event of an emergency. She confirmed she did not verify Resident #71 and Resident #78's LAPOST advanced directives contained all of the information required to make the forms valid.
An interview was conducted on [DATE] at 3:46 p.m. with S21LPN. She reviewed Resident #71 and #78's LAPOST advanced directive present on their paper chart and stated she would not perform CPR in the event of an emergency. She confirmed she did not verify Resident #71 and Resident #78's LAPOST advanced directives contained all of the information required to make the forms valid.
An interview was conducted on [DATE] at 2:20 p.m. with S3DON. She confirmed Resident #71 and Resident #78's LAPOST Advanced Directives did not contain the required information for them to be complete and valid and should have. She confirmed all resident charts should contain the most accurate, complete advanced directive at all times.
An interview was conducted on [DATE] at 9:15 a.m. with S9MR. She confirmed Resident #71 and Resident #78's most up to date, accurate and complete advanced directives were not on their paper chart and should have been.
An interview was conducted on [DATE] at 11:38 a.m. with S20LPN. She confirmed Resident #71's LAPOST advanced directive did not have the required physician's signature to make the form valid but should. She confirmed Resident #78's LAPOST advanced directive did not have the required date to accompany the physician's signature to make the form valid but should. She confirmed all resident charts, paper and electronic, should contain a valid, accurate and complete advanced directive at all times.
An interview was conducted on [DATE] at 12:04 p.m. with S5NP. She confirmed an LAPOST advanced directive required a physician's signature and date to be considered valid. She confirmed a resident's LAPOST advanced directive should match the electronic orders present in a resident's chart. She confirmed she was never made aware by the facility of any issues or concerns regarding incomplete or inaccurate Advanced Directives.
An interview was conducted on [DATE] at 1:55 p.m. with S4MD. He confirmed he was the Medical Director for the facility. He confirmed an LAPOST advanced directive required a physician's signature and date to be considered valid. He confirmed a resident's LAPOST advanced directive should match the electronic orders present in the resident's chart. He confirmed he was never made aware by the facility of any issues or concerns regarding incomplete or inaccurate Advanced Directives.
An interview was conducted on [DATE] at 2:14 p.m. with S1ADM. He confirmed all resident charts, paper and electronic, should contain a valid, accurate and complete advanced directive at all times.
An interview was conducted on [DATE] at 2:14 p.m. with S17CRN. She confirmed all resident charts, paper and electronic, should contain a valid, accurate and complete advanced directive at all times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure notifications of changes in resident conditi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure notifications of changes in resident conditions were made. The facility failed to ensure:
1. S11LPN reported a yeast skin condition on a resident's underarms and trunk to the wound care nurse to initiate treatment for 1 (#45) of 2 (#45 and #98) residents reviewed for skin conditions; and
2. Clinical staff reported to the NP Resident #45's urinalysis specimen was not collected per physician's orders for 1 of 1 (#45) residents reviewed for urinary tracts infections.
Findings:
1.
Review of Resident #45's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Cystitis, Major Depressive Disorder, and Morbid Obesity
Review of Resident #45's most recent MDS with an ARD of 09/08/2023, revealed Resident #45 had a BIMS of 12, which indicated she had mild cognitive impairment. Further review revealed the resident required extensive assistance for ADL's and was always incontinent of bowel and bladder.
Review of Resident #45's September 2023 TAR revealed the resident was not receiving treatment for a yeast skin infection.
An interview was conducted with S15CNA on 09/12/2023 at 12:53 p.m. She stated Resident #45 currently had a yeast skin infection under her arms and under her breast and the treatment nurse was responsible for the medicated powder treatment.
An observation was conducted on 09/12/2023 at 12:53 p.m. of Resident #45 and S11LPN at bedside. Resident #45 showed S11LPN the yeast infection under her arms. Resident #45's skin was bright red and irritated under both arms and down both sides of her trunk.
An interview was conducted with S8TLPN on 09/13/2023 at 10:14 a.m. She confirmed she was not notified Resident #45's yeast infection returned and was not currently on her treatment list. She stated if the yeast skin infection returned she would expect to be notified by the nurse. She confirmed she was not notified and should have been notified to initiate the treatment.
An interview was conducted with S11LPN on 09/13/2023 at 11:31 a.m. She confirmed she was aware Resident #45 currently had a yeast skin infection and did not inform the wound care nurse because it was an ongoing problem. She confirmed she did not have an active order for treatment of the yeast skin infection.
An interview was conducted with S3DON on 09/13/2023 at 1:14 p.m. She was made aware of the aforementioned findings. She confirmed nursing staff should report new skin concerns to the wound care nurse immediately for treatment to begin.
2.
Review of Resident #45's current Physician Orders revealed
08/17/2023 Sterile Cath UA C&S c/o dysuria and pain.
Review of Resident #45's lab work revealed no results from the 08/17/2023 UA order.
Review of Resident #45's Nurse's Notes dated 07/17/2023 through 09/08/2023, revealed the following:
08/17/2023 - Resident #45 complained about pain and discomfort when urinating. Received order for sterile Cath UA with C&S. Reported to oncoming nurse.
An interview was conducted with S11LPN on 09/12/2023 at 1:10 p.m. She stated she received the order for a urine specimen on 08/17/2023 at shift change and reported it to the oncoming shift.
An interview was conducted with S9MR on 09/12/2023 at 1:20 p.m. She stated two nurses attempted to collect the urine from the resident for a UA and were not able to obtain it so the order was cancelled. She did not know why the order was cancelled.
An interview was conducted with S10LPN on 09/12/2023 at 4:37 p.m. She stated on 08/17/2023 she received report that Resident #45 needed a sterile urine specimen for a UA. She stated she had a busy night, was not able to obtain the specimen, and placed it on the 24 hour report.
An interview was conducted with S5NP on 09/13/2023 at 2:41 p.m. She stated she reviewed her notes and was not notified the sterile urine specimen for a UA was not collected on 08/17/2023. She confirmed she should have been notified if staff could not obtain the urine specimen. She confirmed she did not cancel the order and the specimen should have been obtained by the nursing staff. She stated on 08/31/2023 she looked for Resident #45's U/A results from 08/17/2023, did not find any results and ordered a stat UA.
An interview was conducted with S3DON on 09/13/2023 at 3:45 p.m. She confirmed Resident #45 had an order for a UA on 08/17/2023 and expected the nursing staff to follow the physicians order to obtain the specimen. She stated if staff could not obtain the specimen the NP should be notified.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 4 (#8, #72, #96, and #109) of 5 (#8, #72, #96, and #109) residents reviewed for MDS.
Findings:
Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease.
Review of Resident #8's annual MDS with an ARD of 07/13/2023 revealed Chronic Obstructive Pulmonary Disease was not coded as an active diagnosis in Section I.
Review of Resident #72's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Traumatic Brain Injury and Aphasia.
Review of Resident #72's annual MDS with an ARD of 05/17/2023 revealed Traumatic Brain Injury and Aphasia were not coded as active diagnoses in Section I.
Review of Resident #96's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Viral Chronic Hepatitis C.
Review of Resident #96's quarterly MDS with an ARD of 07/26/2023 revealed Viral Chronic Hepatitis C was not coded as an active diagnosis in Section I.
Review of Resident #109's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Unspecified Dementia and Major Depressive Disorder.
Review of Resident #109's admission MDS with an ARD of 06/22/2023 revealed Unspecified Dementia and Major Depressive Disorder were not coded as active diagnoses in Section I.
On 09/12/2023 at 1:40 p.m., an interview was conducted with S7MDS. She stated she was responsible for resident's MDS assessments. She stated when a MDS assessment is performed, all diagnoses should be coded accurately for every resident. She reviewed the admission MDS for Residents #8, #72, #96, and #109 and confirmed their MDS' were not coded accurately for active diagnoses in Section I.
On 09/12/2023 at 1:44 p.m., an interview was conducted with S3DON. She confirmed if a resident had an active diagnosis, the MDS should be coded correctly with those diagnoses.
On 09/13/2023 at 2:14 p.m., an interview was conducted with S1ADM. He confirmed if a resident had an active diagnosis, the MDS should be coded correctly with those diagnoses.
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 observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 12% during the medication administra...
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Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5% by having a medication error rate of 12% during the medication administration observation. A total of 33 opportunities were observed, which included 4 medication errors with Resident #10 and Resident #79. This failed practice had the potential to affect any of the 121 residents currently residing in the facility.
Findings:
A review of the facility's policy, General Guidelines, revealed the following, in part:
Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by person legally authorized to do so.
2. Medications are administered in accordance with written orders of a physician.
19. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.
Resident #10:
Review of September 2023 Physician's Orders for Resident #10 revealed the following:
Zinc Sulfate 220mg give one by mouth at 8:00 a.m.
Acidophilus give one by mouth at 8:00 a.m.
Trelegy Ellipta 100-62.5-25 give one puff 8:00 a.m.
On 09/12/2023 at 7:37 a.m., an observation was made of S12LPN during medication administration. She was observed not giving Resident #10 his ordered medication of Acidophilus or Trelegy Ellipta. Further observations revealed S12LPN giving Zinc Sulfate 50mg by mouth, instead of his ordered medication Zinc Sulfate 220mg.
An interview was conducted on 09/12/2023 at 9:00 a.m. with S12LPN. She confirmed Acidophilus and Trelgey Ellipta were not given at the time of medication administration, and should have been. She confirmed she gave Resident #10 Zinc Sulfate 50mg instead of his ordered medication of Zinc Sulfate 220mg.
Resident #79
Review of September 2023 Physician's Orders for Resident #79 revealed the following:
Aspirin 81mg give one by mouth daily at 8:00 a.m.
On 09/12/2023 at 7:26 a.m., an observation was made of S12LPN during medication administration. She was observed not giving Resident #79 his ordered medication of Aspirin 81mg.
An interview was conducted on 09/12/2023 at 9:00 a.m. with S12LPN. She confirmed Aspirin was not given at the time of medication administration and should have been.
An interview was conducted on 09/13/2023 at 11:34 a.m. with S3DON. She stated S12LPN informed her of missed medications during medication administration yesterday. She confirmed all medications should be administered according to the physician orders.
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 observations, interviews, and policy review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles by having e...
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Based on observations, interviews, and policy review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles by having expired medications available for use in 1 of 1 (Medication Storage Room).
Findings:
A review of the facility's policy, Medication: Stock, revealed the following, in part:
Policy: Stock medications are any over the counter medication, which can be administered to any resident having a medical doctor order.
b. Monthly inspections of these supplies are made by the pharmacist to assure that supply levels are correctly maintained and that expiration dates are closely monitored.
A review of the facility's policy, Medication Storage in the Facility, revealed the following, in part:
Policy: Medications and biologicals are stored safely, securely, and properly following manufacture's recommendations or those of the supplier.
Procedure:
13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists.
An observation was made on 09/12/2023 at 9:05 a.m. of the facility's medication storage room. The observation was conducted with S3DON. She confirmed the following expired medications
- (2) bottles of Calcium Carbonate with Vitamin D 600mg expired 08/2023
- (1) bottle of Calcium 600 mg expired 05/2023
- (9) bottles of Vitamin B-12 500mcg expired 07/2023
An interview was conducted on 09/12/2023 at 9:10 a.m. with S3DON. She confirmed all expired medications and supplies should be disposed of properly, and had not been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on an observation, interviews, and record review, the facility failed to ensure garbage and refuse was disposed of properly.
Findings:
Review of the facility's policy, Infectious Material Dispo...
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Based on an observation, interviews, and record review, the facility failed to ensure garbage and refuse was disposed of properly.
Findings:
Review of the facility's policy, Infectious Material Disposal revealed the following, in part:
Policy: All infectious material will be disposed of as follows:
Procedure:
1. All disposables such as dressings, contaminated briefs, contaminated gloves, etc. shall be placed in a red plastic bag and taken immediately to the infectious waste container.
4. Infectious waste will be picked up by a licensed medical waste disposal provider as needed.
An observation of the outdoor garbage bins was conducted on 09/11/2023 at 9:00 a.m. with S6HC. She confirmed the following observations around the garbage bins:
- 1 soiled adult brief
- 32 rubber gloves
- 13 silverware utensils
- 4 sugar packets
- 3 paper straw papers
- 4 Styrofoam cups
- 1 plastic cup
- 3 cracker wrappers
- 1 Styrofoam food container
An interview was conducted on 09/11/2023 at 9:00 a.m. with S6HC. She confirmed garbage should not be on the ground at any time. She stated maintenance was responsible for cleaning the area but had been out of town the last week.
An interview was conducted on 09/11/2023 at 11:45 a.m. with S1ADM. He confirmed garbage should not be on the ground at any time. He stated maintenance was responsible for cleaning the area but was out of town last week. S1ADM stated he was responsible for cleaning up the garbage bin area when maintenance was not available. He confirmed he did not clean it on Friday or over the weekend as he should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to coordinate hospice care services to ensure a system was in place ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to coordinate hospice care services to ensure a system was in place to update hospice binders with completed Advanced Directives for 2 of 2 (#8 and #78) residents reviewed for hospice care.
Findings:
Cross Reference F578.
Resident #8
Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #8's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2023, indicated the resident had a Brief Interview for Mental Status (BIMS) of 8, which indicated moderate cognitive impairment.
Review of Resident #8's Louisiana Physician Orders for Scope of Treatment (LAPOST) advanced directive in the paper chart revealed, in part, the following:
A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Blank,
Physician Phone Number: Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #8's responsible party.
Date (Mandatory): 02/11/2019.
Review of Resident #8's hospice binder revealed no LAPOST advanced directive.
Resident #78
Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #78's most recent MDS, with an ARD of 08/14/2023, indicated the resident had a BIMS of Blank, which indicated he was unable to participate in the assessment.
Review of Resident #78's LAPOST advanced directive in the paper chart revealed, in part, the following:
A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Illegible loops present, not on the signature line, in purple ink.
Physician Phone Number: Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #78's responsible party.
Date (Mandatory): 10/14/2022.
Review of Resident #78's hospice binder revealed no LAPOST advanced directive.
An interview was conducted on 09/13/2023 at 3:27 p.m. with the Director of Nursing for the local hospice agency. She confirmed the hospice agency had a completed LAPOST on file signed by Resident #8's responsible party and the physician on 08/09/2022 indicating a DNR status. She confirmed the hospice agency had a completed LAPOST on file signed by Resident #78's responsible party and physician on 11/09/2022 indicating a DNR status. She confirmed Residents #8 and #78's facility hospice chart did not contain a completed LAPOST and should.
An interview was conducted on 09/13/2023 at 2:20 p.m. with S3DON. She confirmed Resident #8 and Resident #78's charts did not contain completed advanced directives. She confirmed all resident's hospice charts should contain the most up to date and complete advanced directives.
An interview was conducted on 09/13/2023 at 9:15 a.m. with S9MR. She confirmed she was responsible for maintaining hospice charts within the facility. She confirmed Resident #8 and Resident #78's most up to date, complete advanced directives were not on their hospice chart and should have been.
An interview was conducted on 09/13/2023 at 4:03 p.m. with S7MDS. She confirmed Resident #8 and Resident #78's most up to date, complete advanced directives were not on their hospice charts and should have been. She confirmed all hospice residents should have a valid and complete Advanced Directive located in their charts.
An interview was conducted on 09/13/2023 at 2:14 p.m. with S1ADM. He confirmed all hospice residents should have a completed Advanced Directive located in their charts.
An interview was conducted on 09/13/2023 at 2:14 p.m. with S17CRN. She confirmed all hospice residents should have a completed Advanced Directive located in their charts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement an effective Quality Assurance system to correct identi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement an effective Quality Assurance system to correct identified quality deficiencies for 3 of 3 (#8, #71 and #78) residents reviewed for advance directives.
This deficient practice had the potential to affect 121 residents currently residing in the facility.
Findings:
Cross Reference F578 and F849.
Review of the facility's policy Quality Assurance and Performance Improvement (QAPI) Guidelines revealed, in part, the following:
Policy:
To establish procedures within the facility for the QAPI by incorporating the Five Elements including:
1. Design and Scope:
a. A QAPI program must be ongoing and comprehensive, dealing with the full range of services offered by the facility, including the full range of departments. When fully implemented, the program should address all systems of care and management practices, which include clinical care, quality of life, and resident choice. It aims for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident agents). It utilizes the best available evidence to define and measure goals. Nursing homes will have in place a written QAPI plan adhering to these principles.
3. Feedback, Data Systems and Monitoring:
a. The facility puts in place systems to monitor care and services, drawing data from multiple sources. Feedback systems actively incorporate input from staff, residents, families, and others as appropriate. This element includes using Performance Indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or targets the facility has established for performance. It also includes tracking, investigating, and monitoring Adverse Events that must be investigated every time they occur, and action plans implemented to prevent recurrences.
5. Systematic Analysis and Systemic Action
a. The facility uses a systemic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered.
Procedure:
The committee will identify any issues which negatively affect quality of care and services provided to residents. In addition, the committee will develop and implement plans of action to correct identified deficient practices.
Review of the facility's Baseline Advanced Directive QA Monitoring Tool revealed, in part, the following:
1. Resident Name: Resident #8
If an advanced directive was executed, what follow up document does the chart contain? LAPOST on chart, not complete, no MD signature.
Corrective Actions Needed: Blank.
2. Resident Name: Resident #71
If an advanced directive was executed, what follow up document does the chart contain? LAPOST on chart, not complete.
Corrective Actions Needed: Blank.
Resident #8
Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE].
A review of the current Medication Administration Record (MAR) revealed DNR code status with a start date of [DATE].
A review of the current Physician's Orders revealed in part an order written on [DATE] for DNR.
Review of Resident #8's Louisiana Physician Orders for Scope of Treatment (LAPOST) revealed, in part, the following:
A. Cardiopulmonary Resuscitation (CPR): Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Blank.
Physician Phone Number: Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #8's responsible party.
Date (Mandatory): [DATE].
Resident #71
Review of Resident #71's Clinical Record revealed she was admitted to the facility on [DATE].
Review of Resident #71's Louisiana Physician Orders for Scope of Treatment (LAPOST) revealed, in part, the following:
A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #71's responsible party.
Date (Mandatory): [DATE].
Resident #78
Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #78's LAPOST revealed, in part, the following:
A. DNR/Do Not Attempt Resuscitation (Allow Natural Death): Selected.
Print Physician's Name: Blank.
Physician Signature (Mandatory): Illegible loops present, not on the signature line, in purple ink.
Physician Phone Number: Blank.
Date (Mandatory): Blank.
PHCR Signature (Mandatory): Signature by Resident #78's responsible party.
Date (Mandatory): [DATE].
An interview was conducted on [DATE] at 11:38 a.m. with S20LPN. She confirmed she was responsible for ensuring the accuracy and completeness of advanced directives for the residents of the facility. She stated in July of 2023 she audited advanced directives and identified concerns with several residents. She referenced her monitoring tool she created and confirmed Resident #8 and Resident #71 were identified in July of 2023 to have advanced directive concerns. She confirmed Resident #8's paper advanced directive did not match his electronic orders in the computer and should have. She confirmed Resident #71's LAPOST advanced directive did not have the required physician's signature making the form invalid. She confirmed both Resident #8 and Resident #71's advanced directive concerns were not corrected when identified in July of 2023 and remained invalid at this time. She confirmed Resident #78's LAPOST advanced directive did not have the required date to accompany the physician's signature making the form invalid. She confirmed Resident #78 was not identified in July of 2023 and remained invalid at this time. She stated she did not look at Resident #78's chart for an accurate LAPOST.
An interview was conducted on [DATE] at 12:04 p.m. with S5NP. She confirmed an LAPOST advanced directive would require a physician's signature and date to be considered valid. She confirmed a resident's LAPOST advanced directive should match the electronic orders present in the resident's chart. She confirmed she was never made aware by the facility of any issues or concerns regarding incomplete Advanced Directives and should have been.
An interview was conducted on [DATE] at 1:55 p.m. with S4MD. He confirmed he was the Medical Director for the facility. He confirmed an LAPOST advanced directive would require a physician's signature and date to be considered valid. He confirmed a resident's LAPOST advanced directive should match the electronic orders present in the resident's chart. He confirmed he was never made aware by the facility of any issues or concerns regarding incomplete Advanced Directives and should have been.
An interview was conducted on [DATE] at 11:10 a.m. with S2AADM. She confirmed she was in charge of monitoring the effectiveness of QAPI for the facility. She confirmed the facility should follow their policy and procedure for their QAPI process. She confirmed she was not involved in any QAPI process involving resident advanced directives and was not aware anyone was working on one.
An interview was conducted on [DATE] at 2:20 p.m. with S3DON. She confirmed she was in charge of monitoring and managing open/active QAPI's for the facility. She confirmed the facility should follow their policy and procedure for their QAPI process. She confirmed she was not involved with managing resident advanced directives for the facility. She stated S20LPN was the person responsible. She confirmed she did not have any knowledge of or documentation regarding an open QAPI for resident advanced directives. She confirmed given the advanced directive concerns identified by a facility employee in July of 2023, she felt an official QAPI should have been opened which would have ensured the Medical Director was aware. She confirmed when any member of their staff identified concerns with the functionality of the facility systems/programs, she would expect them to immediately bring it forward to the administrative team so it could be formally addressed through things like QAPI.
An interview was conducted on [DATE] at 2:14 p.m. with S1ADM. He confirmed the facility identified problems with advanced directives in July of 2023. He confirmed current inaccurate or incomplete advanced directives were identified for Residents #8, #71, and #78. He confirmed continued problems with advanced directives would indicate the facility's QAPI process was ineffective.
Jul 2023
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours to the state agency for 1 (#2) of 5 (#1, #2, #3, #4, #5) residents reviewed for abuse.
Findings:
Review of the Facility's policy Abuse/Neglect Prevention Program revealed, in part:
This facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse.
In the event of any evidence involving mistreatment, exploitation, neglect or abuse including injuries of an unknown source, an occurrence will be reported immediately to the Administrator or his or her designee of the facility, who will immediately notify corporate office and the appropriate state officials per state guidelines.
Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included: Anxiety disorder, Psychosis, and Cerebral Vascular Accident.
Review of the facilities Grievance Log revealed Resident #2 filed a grievance on 06/05/2023 alleging staff hit him.
Review of the Facility's Reportable Incidents from January 2023 to July 2023 revealed no entries for Resident #2.
Review of Facility Investigation Report for Resident #2 revealed the following:
On 06/07/2023 at 9:00 a.m.- S2DON interviewed Resident #2. Resident #2 stated a male staff hit him behind the head 2 weeks ago. S2DON completed a body audit with no abnormal findings. Resident #2 was unable to identify a specific staff.
Review of Quarterly MDS with ARD of 05/24/2023 revealed the resident had BIMS 6, indicating severe cognitive impairment.
On 07/25/2023 at 9:34 a.m. an interview was conducted with Resident #2. He was oriented to person and place, and time. He stated that he was hit in the head twice very hard by a black CNA, wearing blue scrubs. Resident stated that this happened a month or two ago.
On 07/24/2023 at 3:20 p.m., an interview was conducted with S3SW. S3SW stated on 06/06/2023, Resident #2's sister reported that during a phone call with Resident #2, he alleged a staff member hit him. S3SW stated when she spoke with Resident #2, he was only able to recall the person who hit him was big and he was hit in the head. S3SW stated she reported these allegations to S4AADM and S1ADM.
On 07/24/2023 at 3:48 p.m., an interview was conducted with S1ADM. S1ADM stated on 06/06/2023, S3SW reported Resident #2 stated that staff hits him to his sister. S1ADM stated that an employee hitting a resident was considered abuse. He stated S4AADM was responsible for reporting allegations of abuse to the state. He confirmed Resident #2's allegation of physical abuse was not reported to the state agency.
On 07/25/2023 at 1:06 p.m., an interview was conducted with S4AADM. She confirmed that she was responsible for reporting abuse allegations to the state and she did not complete a report for Resident #2.
Feb 2023
1 deficiency
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain an infection prevention and control program designed to prevent or contain the spread of COVID-1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain an infection prevention and control program designed to prevent or contain the spread of COVID-19 as evidenced by staff failure to implement the appropriate use of Personal Protective Equipment (PPE) for Resident #1 while on transmission-based precautions for COVID-19. This deficiency had the potential to affect all 108 residents currently residing in the facility.
Review of the facility's COVID-19 Policy When Resident Tests Positive indicated, in part, the following:
Policy:
It is the policy of this Long Term Care Facility to ensure that all measures are properly followed once a resident tests positive for COVID-19.
Review of the CDC Guidance provided by the facility and indicated as their most current policy and procedure regarding the Isolation of COVID-19 Residents revealed, in part, the following: CDC's Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/23/2022.
The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions.
2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection:
Placement:
Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed.
Personal Protective Equipment:
Healthcare Providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
Review of the facility's CDC Isolation Signage for Contact and Droplet Precautions revealed, in part, the following:
Contact Precautions:
Stop.
Everyone must:
Clean hands before entering and when leaving room.
Put on gloves before entering and discard before exiting the room.
Put on gown before entering and discard before exiting the room.
Do not wear same gown and gloves for care of more than one person.
Use dedicated or disposable equipment or clean and disinfect reusable equipment before use on the next person.
Droplet Precautions:
Stop.
Everyone must:
Clean hands before entering and when leaving room.
Cover eyes, nose and mouth before entry and remove face protection before exiting the room.
Put on gloves before entering and discard before exiting the room.
Put on gown before entering and discard before exiting the room.
Do not wear same gown and gloves for care of more than one person.
Use dedicated or disposable equipment or clean and disinfect reusable equipment before use on the next person.
Resident #1
Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #1's Lab Results revealed he tested positive for COVID-19 on 01/22/2023.
Review of Resident #1's Physician Orders revealed an order written on 01/22/2023 to place resident on transmission based precaution isolation (contact and droplet) until meets criteria to discontinue isolation per CDC Guidelines.
On 01/30/2023 at 8:40 a.m., an observation was conducted of Resident #1 with no mask in use while seated in his wheelchair inside of his bedroom approximately 8 feet from the entrance to his bedroom door with the door open to hallway A.
On 01/30/2023 at 8:42 a.m., an interview was conducted with Resident #1. He confirmed he recently tested positive for COVID-19.
On 01/30/2023 at 10:35 a.m., an observation was conducted of Resident #1 with no mask in use while seated in his wheelchair inside of his bedroom approximately 8 feet from the entrance to his bedroom door with the door open to hallway A. CDC Isolation Guidance for Contact and Droplet Precautions was noted on the exterior of the resident's door.
On 01/30/2023 at 10:45 a.m., an interview was conducted with S4CNA. She confirmed Resident #1's bedroom door was open but should not be due to his isolation status for COVID-19.
On 01/30/2023 at 2:15 p.m., an observation was conducted of Resident #1 lying in bed approximately 6 feet from the entrance to the room with his bedroom door left open to hallway A. CDC Isolation Guidance for Contact and Droplet Precautions was noted on the exterior of the resident's door. Isolation Cart located in hallway outside the entrance to bedroom observed to be empty with no PPE inside.
On 01/30/2023 at 2:15 p.m., an interview was conducted with S6CNA. She confirmed she was working the 2:00 p.m. to 6:00 p.m. shift and was assigned to residents on Hall A. She stated she was not aware of any residents on hall A on isolation precautions for COVID-19. She then confirmed Resident #1's bedroom door was open to the hallway but was not sure if it should be. She also confirmed there was no PPE present in the Isolation Cart so she assumed Resident #1 was no longer on isolation precautions.
On 01/30/2023 at 3:00 p.m., an observation was conducted of Resident #1 seated in his wheelchair inside of his bedroom drinking a steaming cup of coffee with a snack on the bedside table. He was located approximately 8 feet from the entrance to the room with his bedroom door left open to hallway A. CDC Isolation Guidance for Contact and Droplet Precautions was noted on the exterior of the resident's door. Isolation Cart located in hallway outside the entrance to bedroom observed to be empty with no PPE inside.
On 01/30/2023 at 3:00 p.m., an interview was conducted with S5CNA. She confirmed she was working the 2:00 p.m. to 6:00 p.m. shift and was assigned to residents on Hall A. She stated she was not aware of any residents on hall A on isolation precautions for COVID-19. She confirmed there was signage on Resident #1's door, which indicated he should be on isolation precautions for COVID-19. She stated the information was not up to date and Resident #1 was no longer on isolation precautions because the isolation cart was empty. She stated someone should have taken the signs down but had not. She then confirmed she had just finished passing snacks and coffee with the assistance of S6CNA to the residents on Hall A.
On 01/30/2023 at 3:05 p.m., an interview was conducted with S1DON. She confirmed Resident #1 remained on isolation precautions for COVID-19 at this time. She confirmed the CNAs and nurses working that hall should be aware of his COVID-19 status, should be keeping his door closed, should be utilizing the proper PPE when entering the room and should be keeping the PPE cart stocked at all times. She stated if there were isolation signs on the doors, she would expect her staff to observe those guidelines. She confirmed she would expect an isolated resident to have their door closed at all times per the facility's Isolation Precautions for COVID-19 policy. She also confirmed the facility utilized the CDC's Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 09/23/2022) as their policy and procedure for isolating their COVID-19 residents.
On 02/01/2023 at 9:50 a.m., an interview was conducted with S2ADON. He confirmed Resident #1 was COVID-19 positive and on isolation as of 01/30/2023. He confirmed if an isolation sign was present on a resident's door, he would expect all staff and visitors to don and doff PPE as indicated on the isolation sign. He then confirmed staff should never enter an isolation room without the proper PPE. He confirmed if a staff member thought isolation signs were not current, they should not proceed into the room without the proper PPE until they spoke with their supervisor or assigned nurse. He also confirmed he would expect a COVID-19 isolated resident to have their bedroom door closed to the hallway at all times. He stated if a resident were resistant to leaving it closed, he would expect the staff to notify their supervisor or someone in Administration so they could speak with the resident about it.
On 02/01/2023 at 10:40 a.m., an interview was conducted with S3CNAS. She confirmed Resident #1 was COVID-19 positive and on isolation as of 01/30/2023. She stated if staff were unsure of a resident's COVID-19 status, she would expect them to find out before they assumed the care of their assigned residents. She confirmed a CNA should not enter a resident's room if an isolation sign were present on the door without utilizing the proper PPE. She confirmed if a staff member thought isolation signs were not current, they should not proceed into the room without the proper PPE until they spoke with their supervisor or assigned nurse. She also confirmed she would expect her staff to keep the doors closed for resident rooms on isolation precautions and to let their nurse or supervisor know if they had difficulty with compliance from a resident.
On 02/01/2023 at 10:52 a.m., an interview was conducted with S1DON. She confirmed the facility was currently in COVID-19 Outbreak Status. She stated if staff were unsure of resident COVID-19 status, she would expect them to find out before they assumed the care of their assigned residents. She confirmed she had reviewed the facility's camera footage from the afternoon of 01/30/2023 and saw S5CNA and S6CNA entering Resident #1's room to pass afternoon snacks and coffee without the required PPE. She stated staff had not made her aware of Resident #1's recent noncompliance with keeping his door closed. She confirmed she would have expected the staff members to notify her or someone in administration.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
- • 25 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is River Oaks Nursing & Rehabilitation Center Llc's CMS Rating?
CMS assigns RIVER OAKS NURSING & REHABILITATION CENTER LLC 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 River Oaks Nursing & Rehabilitation Center Llc Staffed?
CMS rates RIVER OAKS NURSING & REHABILITATION CENTER LLC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 41%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at River Oaks Nursing & Rehabilitation Center Llc?
State health inspectors documented 25 deficiencies at RIVER OAKS NURSING & REHABILITATION CENTER LLC during 2023 to 2025. These included: 1 that caused actual resident harm and 24 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates River Oaks Nursing & Rehabilitation Center Llc?
RIVER OAKS NURSING & REHABILITATION CENTER LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CENTRAL MANAGEMENT COMPANY, a chain that manages multiple nursing homes. With 132 certified beds and approximately 129 residents (about 98% occupancy), it is a mid-sized facility located in BAKER, Louisiana.
How Does River Oaks Nursing & Rehabilitation Center Llc Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, RIVER OAKS NURSING & REHABILITATION CENTER LLC's overall rating (3 stars) is above the state average of 2.4, staff turnover (41%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting River Oaks Nursing & Rehabilitation Center Llc?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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 substantiated abuse finding on record.
Is River Oaks Nursing & Rehabilitation Center Llc Safe?
Based on CMS inspection data, RIVER OAKS NURSING & REHABILITATION CENTER LLC has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at River Oaks Nursing & Rehabilitation Center Llc Stick Around?
RIVER OAKS NURSING & REHABILITATION CENTER LLC has a staff turnover rate of 41%, which is about average for Louisiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was River Oaks Nursing & Rehabilitation Center Llc Ever Fined?
RIVER OAKS NURSING & REHABILITATION CENTER LLC has been fined $8,278 across 1 penalty action. This is below the Louisiana average of $33,162. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is River Oaks Nursing & Rehabilitation Center Llc on Any Federal Watch List?
RIVER OAKS NURSING & REHABILITATION CENTER LLC 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.