Center Point Health Care and Rehab
For profit - Limited Liability company
172 Beds
Independent
Data: November 2025
Trust Grade
40/100
#190 of 264 in LA
Photo by Lace “Lace” Meyers
Photo by Lace “Lace” Meyers
Photo by Center Point Healthcare and Rehabilitation
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Center Point Health Care and Rehab has a Trust Grade of D, which indicates below-average performance with some significant concerns. They rank #190 out of 264 nursing homes in Louisiana, placing them in the bottom half, and #17 out of 25 in East Baton Rouge County, meaning there are better local options available. The facility is worsening over time, with issues increasing from 19 in 2024 to 22 in 2025. Staffing is a weakness, scoring just 1 out of 5 stars and experiencing a 50% turnover rate, which is average for the state. While they have not incurred any fines, they have concerningly low RN coverage compared to 93% of other facilities, which could affect the quality of care. Specific incidents noted by inspectors include dietary staff being inadequately trained, leading to unsanitary dishwashing practices that could potentially affect residents' meals, and meals being served late due to insufficient staffing. Additionally, the facility failed to consistently post nurse staffing data, which could hinder transparency for residents and their families. Overall, while there are no fines and some aspects like staffing transparency need improvement, families should weigh these strengths against the significant concerns highlighted in the inspection findings.
- Trust Score
- D
- In Louisiana
- #190/264
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 6 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 29%
No red flags
19 → 22 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 22 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 50%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
The Ugly 48 deficiencies on record
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0627
(Tag F0627)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post discharge care and the reduction of factors leading to preventable readmissions for 1 (#1) of 2 (#1 and #3) residents reviewed for discharge. The facility failed to ensure: 1. The discharge needs of the resident were identified and resulted in the development of a discharge plan;2. Involve the interdisciplinary team in the ongoing process of developing the discharge plan;3. Document the resident had been asked about their interest in receiving information regarding returning to the community; and 4. Create a discharge summary that included a post-discharge plan indicating where the resident planned to reside, any arrangements that had been made for the resident's follow-up care and any post-discharge medical and non-medical services.Review of the facility's policy titled, Transfer and Discharge (Including AMA) and dated 04/2025 revealed the following, in part:Policy Explanation and Compliance Guidelines:12. Anticipated Discharges to the Communitya. Facility will obtain a physician's order for transfer or discharge and instructions or precautions for ongoing care. b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results.ii. A final summary of the resident's statusiv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative which will assist the resident to adjust to his or her new living environment.e. The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge.f. Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative.Review of Resident #1's clinical record revealed he was initially admitted to the facility on [DATE] and discharged from the facility on 07/22/2025. Further review of his clinical record revealed no documentation of Resident #1's discharge planning process and an adequate, discharge summary. Review of Resident #1's Discharge MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/22/2025 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicted he was cognitively intact. On 09/10/2025 at 4:34 p.m., an interview was conducted with Resident #1. He stated he did not voice interest to staff pertaining to living within the community independently. He stated the facility was his home. He stated he did voice interest in going to rehab, but thought he would return to the facility after his treatment program was completed. On 09/10/2025 at 11:00 a.m., an interview was conducted with S2FADM. She stated Resident #1 resided at the facility for several years. She stated he was very independent and expressed to staff an interest in discharging from the facility to live within the community independently. She stated due to his history of alcohol abuse, he was discharged from the facility to Avenues Recovery Center with the understanding that he would then transition to community living. She stated she expected Avenues Recovery Center to assist Resident #1 with securing a permanent placement after his 45-day treatment program was completed. On 09/10/2025 at 11:19 a.m., an interview was conducted with S4SW. She stated during Resident #1's stay at the facility, he voiced interest in going to rehab and living within the community independently. She stated on 07/22/2025, she and Resident #1 participated in a phone call conference with an admission coordinator from Avenues Recover Center regarding their detox and rehabilitation program. She stated Resident #1 gave consent to admit to Avenues Recovery Center and was discharged from the facility effective on 07/22/2025. She stated she expected Avenues Recovery Center to assist Resident #1 with securing a permanent placement after his 45-day treatment program was completed.On 09/11/2025 at 10:02 a.m., an interview was conducted with S5NP. She stated she began working at the facility after Resident #1's discharge. She stated, however, if a resident wished to voluntarily discharge from the facility, their intent to discharge would need to be documented, an assessment would need to be completed by either the Nurse Practitioner or Physician to determine their capability to care for self and determine post-discharge needs. She further stated the resident's medical record should also feature a discharge order and an adequate, discharge summary to indicate the end of care at the facility and transition to the next level of care. On 09/11/2025 at 10:27 a.m., an interview was conducted with S3DON. She confirmed no documentation could be provided to reflect Resident #1's intent to discharge from the facility and return to living within the community independently. She further confirmed no documentation could be provided to reflect Resident #1 was involved in an ongoing process to develop an effective, discharge plan. Lastly, she confirmed Resident #1's medical record did not contain a discharge order or an adequate, discharge summary that would indicate the end of care at the facility and transition to next level of care. On 09/11/2025 at 11:27 a.m., an interview was conducted with S1ADM. She confirmed the facility failed to develop and implement an effective discharge planning process with Resident #1 and should have.
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 F0628
(Tag F0628)
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 provide the resident or RP (Responsible Party) with written notic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide the resident or RP (Responsible Party) with written notice, which specifies the duration of the bed-hold policy at the time of transfer to the hospital for 2 (#2 and #3) of 3 (#1, #2, and #3) sampled residents.Review of the facility's Bed Hold and Returns policy, revised on 04/2025, revealed, in part:Policy:It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave.Policy Explanation and Compliance Guidelines:1. The facility will issue (2) written notice of bed hold policy to the resident/or resident representative as follows:1. As part of the admission packet and2. At the time of a transfer to the hospital or a therapeutic leave.The facility will provide the resident and/or the resident representative written information that specifies:a. the duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;b. The reserve bed payment policy in the state plan policy, if any.c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed.d. Conditions upon which the resident would return to the facility:i. The resident requires the services which the facility provides;ii. The resident is eligible for Medicare skilled services or Medicaid nursing facility services.4. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. Resident #2Review of Resident #2's Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses, which included Unsteadiness on Feet, Abnormalities of Gait and Mobility, Morbid Obesity, Unspecified Lack of Coordination, and Need for Assistance with Personal Care. Review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Review of Physician Orders dated 07/10/2025 through 09/09/2025 revealed the following:07/10/2025- Okay to transfer to Rehabilitation for evaluation and treatment. Review of Resident #2's record revealed no documented evidence, and the facility was unable to present any documentation showing Resident #2 or Resident #2's RP had received written notification of the bed hold policy when Resident #2 was transferred to the Rehabilitation hospital on [DATE]. Review of the facility's Emergency Transfer Log revealed Resident #2 was transferred to a local Rehabilitation hospital for therapy on 07/10/2025 with a return to facility date of 07/29/2025. On 09/10/2025 at 9:20 a.m., an interview was conducted with Resident #2. Resident #2 confirmed she was transferred to a local Rehabilitation hospital in July 2025, and stayed there for about 2 weeks for exercise, and to get stronger. Resident #2 confirmed she was not given any written information or notice, which specified the duration of the bed hold policy. She further confirmed she did not sign any forms related to a bed hold policy prior to her transfer on 07/10/2025. Resident #3Review of Resident #3's Clinical Record revealed Resident #3 as admitted to the facility on [DATE] with diagnoses, which included Displaced Bimalleolar Fracture of Right Lower Leg, and Other Abnormalities of Gait and Mobility. Review of Resident #3's admission Minimum Data Set (MDS), dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Review of Physician Orders dated 07/11/2025 through 08/08/2025 revealed the following:08/08/2025- Resident to be transferred to local hospital for surgery to right foot. Review of Resident #3's record revealed no documented evidence, and the facility was unable to present any documentation showing Resident #3 or Resident #3's RP had received written notification of the bed hold policy when Resident #3 was transferred to the local hospital on [DATE]. Review of the facility's Emergency Transfer Log revealed Resident #3 was transferred to a local hospital for surgery on 08/08/2025. On 09/11/2025 at 10:27 a.m., an interview was conducted with S3DON. S3DON confirmed Residents #2 and #3 were transferred from the facility on the aforementioned dates. S3DON confirmed there was no documented evidence the facility provided Residents #2, #3 or their RPs with a dated and signed written notice, which specified the duration of the bed-hold policy at the time of their transfers to the hospital, and there should have been. On 09/11/2025 at 11:27 a.m., an interview was conducted with S1ADM. S1ADM confirmed there was no documented evidence the facility provided Residents #2, #3 or their RPs with a dated and signed written notice, which specified the duration of the bed-hold policy at the time of their transfers to the hospital, and there should have been.
May 2025
17 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
Deficiency F0645
(Tag F0645)
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 with a mental disorder had an accurate Pre-admis...
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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 with a mental disorder had an accurate Pre-admission Screening for 1 (#138) of 6 (#9, #19, #36, #53, #92, and #138) residents reviewed for PASSAR.
Findings:
Review of the facility's policy titled Resident Assessment-Coordination with PASSAR Program dated 05/2023, revealed in part, the following:
1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening.
6. The social services director shall be responsible for keeping track of each resident's PASSAR screening status, and referring to the appropriate authority.
Review of Resident #138's Medical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Post-Traumatic Stress Disorder and Schizophrenia.
Review of Resident #138's Level 1 Pre-admission Screening completed by a social worker at a local hospital dated 03/12/2025 revealed in part, the following:
No Level II Required.
No mental health diagnosis is known or suspected.
An interview was conducted on 05/07/2025 at 9:05 a.m. with Program Manager for Office of Behavioral Health. She stated the facility is responsible for ensuring Level I PASSAR prescreens are accurate. She stated if a resident is admitted and the facility is made aware of mental health diagnoses, they should resubmit a new resident review.
An interview was conducted on 05/07/2024 at 10:00 a.m. with S9SW. S9SW confirmed Resident #138's Pre-admission Level I PASSAR Screen dated 03/12/2025 did not contain his diagnoses of Post-Traumatic Stress Disorder and Schizophrenia. She confirmed the facility did not resubmit a new resident review, and should have.
An interview was conducted on 05/07/2025 at 11:08 a.m. with S2DON. He reviewed Resident #138's Pre-admission Level I PASSAR Screen dated 03/12/2025. He confirmed it did not contain his diagnoses of Post-Traumatic Stress Disorder and Schizophrenia. He confirmed the facility did not resubmit a new resident review, and should have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 1 (#30) of 30...
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Based on observations, interviews, and record review, the facility failed to implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 1 (#30) of 30 residents reviewed for comprehensive care plans in the final sample.
Findings:
Review of Facility's Policy titled Oxygen Administration, revised 06/2023 revealed the following, in part:
Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice and the comprehensive person-centered care plan.
1. Oxygen is administered under orders of a physician.
Review of Resident #30's Clinical Record revealed an admission date of 08/19/2022 and diagnoses, which included Anxiety, Parkinson's Disease, Depression, and Dementia.
Review of Resident #30's Current Physician Orders dated 05/05/2025 revealed the following, in part:
Start date: 06/01/2024 - O2(Oxygen) @2L per NC (Nasal Cannula) to maintain Sp02 (Oxygen Saturation) >92% every 24 hours as needed.
Review of Resident #30's Quarterly MDS revealed, in part, a BIMS summary score of 7, which indicated she was cognitively impaired.
Review of Resident #30's Progress Note, dated 03/25/2025, entered by S5LPN, revealed the following, in part:
Resident up and about in halls and to dining area for all meals. Pt complained of shortness of breath, Sa02 98%, 02 started at 2L for comfort measures.
On 05/06/2025 at 3:00 p.m., an interview was conducted with S5LPN. S5LPN stated on 03/25/2025 at 6:00 p.m. Resident #30 was anxious and stating she could not breathe. S5LPN stated Resident #30's Sp02 was 98% and showed no signs of respiratory distress. S5LPN stated she started O2 @ 2L to appease her. She reviewed the Physician's order for oxygen and confirmed the order was O2@2L per NC to maintain Sp02 >92% every 24 hours as needed. She confirmed she did not follow the physician's order, and should have.
On 05/06/2025 at 3:15 p.m., an interview was conducted with S4ADON. S4ADON reviewed clinical documentation that S5LPN initiated O2 @ 2L for Resident #30 with Sp02 of 98%.
S4ADON reviewed Resident #30's Physician orders, and confirmed that the order stated to keep Sp02 >92%. S4ADON stated starting oxygen with a Sp02 98% was not following physician's orders, and staff should follow physician's orders.
On 05/07/2025 at 9:00 a.m., an interview was conducted with S7NP. S7NP reviewed the orders for Resident #30, confirmed the order for Oxygen was to keep Sp02 > 92%, and administering Oxygen with Sp02 of 98% would not be following physician's orders, and should not have been administered.
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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality profe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were administered safely and timely by leaving the medications at the bedside for 1(#19) of 31 residents observed in the final sample.
Findings:
Review of the facility's Policy titled Medication Storage and dated 12/2024 revealed the following, in part:
Policy Explanation and General Guidelines
1. General Guidelines:
a. All drugs and biologicals will be stored in locked compartments ( i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.
b. Only authorized personnel will have access to the keys to locked compartments.
c. During medication pass, medications must be under the direct supervision of the person administering medications or locked in the medication storage area/cart.
Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, Shortness of Breath and Chronic Obstructive Pulmonary Disease.
Review of Resident #19's current Physician's Orders revealed the following:
Albuterol Sulfate HFA Inhalation Aerosol Solution 108 MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for SOB - Start date 03/06/2025
On 08/07/22 at 10:21 a.m., an observation was made of Resident #19 awake and alert sitting in his chair. Observed on his bedside table was a box containing his albuterol inhaler. At this time an interview was conducted with Resident #19, he verified the inhaler was his. He stated he kept one inhaler in his room and the nurse kept the second inhaler and would administer it himself if he needed.
On 05/06/25 at 8:46 a.m., an observation and interview was conducted with S25LPN. She entered Resident #19's room with surveyor and confirmed Resident #19's albuterol inhaler was on the bedside table in his room. She further confirmed there was no order for Resident #19 to keep the Albuterol Sulfate inhaler in his room.
On 05/06/25 at 9:36 a.m., an observation was made with S3ADON of Resident #19's Albuterol inhaler on the bedside table in Resident #19's room. She confirmed medications should not be left at a resident's bedside unless there was a physician's order to leave medication with the resident.
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
Tube Feeding
(Tag F0693)
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 ensure a resident who was fed by enteral means rece...
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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 ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#111) of 5 (#104, #111, #208, #337, #342) residents reviewed for enteral feedings. The facility failed to ensure:
1. The enteral feeding flush bag was appropriately labeled with a date and time; and
2. The enteral feeding pole was kept clean and free of dried formula.
Findings:
Review of the Manufacturer's Insert for Kangaroo ePump ENPlus Spike with revealed the following:
Note: It is recommended that this device be replaced every 24 hours.
Review of the facility's policy titled, Tube Feeding, and dated 05/2023 revealed the following:
K. Pre-filled closed system containers will be used to provide enteral nutrition utilizing an enteral feeding pump. A new administration set will be used with each new container, and containers will be changed when empty, or every 48 hours according to the manufacturer's recommendations.
Review of the clinical record for Resident #111 revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status, Traumatic Brain Injury, Dysarthria and Gastro-Esophageal Reflux Disease.
Review of the current Physician Orders for Resident #111, revealed, in part, the following: Start date: 05/06/2025 - TwoCal HN Enteral feeding 55 ml/hr continuous with 200 cc free water flushes set at every 4 hours.
An observation was made on 05/06/2025 at 8:30 a.m. of Resident #111 in his room. Resident #111's enteral feeding solution of TwoCal HN was infusing with a hanging next to it on the pole with no labeling of date or time. Further observation revealed multiple formula drip areas along the length of the pole including an area of dried formula, approximately 4 inches in length, on the foot of the pole.
An interview was conducted on 05/06/25 at 8:40 a.m. with S6LPN in Resident #111's room. She confirmed the hanging bag of free water should have been labeled with a date and time and was not. She further observed and confirmed the multiple drip areas of formula and dried formula on the tube feeding pole. She stated the pole should have been kept clean.
An interview was conducted on 05/06/25 at 9:44 a.m. with S3ADON. S3ADON confirmed a hanging flush bag should be labeled with the date and time of the start of infusion. She stated she expected the nursing staff to ensure this was done when the solution was started. S3ADON further confirmed the tube feeding pole should be kept clean and remain free of dried formula.
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 F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1 of 1 (#138) resident reviewed for IV (Intravenous) fluid therapy. The facility failed to monitor and flush according to professional standards.
Findings:
Review of Resident #138's Medical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #138 acquired a new diagnosis of Pneumonia on 05/02/2025 requiring central line device placement.
Review of Resident #138's physician orders, dated May 2025, revealed an order on 05/02/2025 for Cefepime Intravenous Solution 2 grams per 100 milliliters. Use 2 grams intravenously three times a day for pneumonia for 7 Days. Further review revealed no physician orders for an assessment daily, dressing changes, or flushing schedule for Resident #138's maintenance of PICC line.
Review of Resident #138's Medication Administration Record (MAR), dated May 2025, revealed no documented evidence of an assessment daily or flushing for Resident #138's PICC line maintenance.
On 05/06/2025 at 8:55 a.m., an observation was made of Resident #138's PICC line site to his right upper arm.
On 05/06/2025 at 10:45 a.m., an interview was conducted with S16ADON. He stated the admitting nurse is responsible for ensuring all appropriate orders for each resident are documented. He reviewed Resident #138's current physician orders and confirmed there was not an order for assessing daily or flushing his PICC line and should have been.
On 05/07/2025 at 11:08 a.m., an interview was conducted with S2DON. He reviewed Resident #138's current care plan and current physician orders. He confirmed there was not an order for assessing daily or flushing his PICC line and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
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 laboratory tests were completed as ordered by ...
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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 laboratory tests were completed as ordered by the physician for 1(#9) of 31 residents investigated in the final sample.
Findings:
Review of Resident #9's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder and Paranoid Schizophrenia.
Review of Resident #9's Physician's Orders revealed, in part:
Order date 04/24/2025- laboratory blood draw for Depakote level every three months in January, April, July ,October once every 3 months.
Review of Resident #9's clinical record revealed the last collected Depakote level was performed on 02/04/2025.
An interview was conducted on 05/07/2025 at 1:52 p.m. with S7NP. She confirmed the last collected lab on record for Depakote level for Resident #9 was collected on 02/04/2025. S7NP confirmed Physician Orders should have been followed and a Depakote level should have been drawn for Resident #9 in April 2025, and was not.
An interview was conducted on 05/07/2025 at 3:25 p.m. with S2DON. He reviewed Resident #9's clinical record and confirmed the last documented Depakote level collection was performed on 02/04/2025. S2DON confirmed physician orders should have been followed and a Depakote level should have been drawn for Resident #9 in April 2025, and was not.
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
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to dispose of garbage properly by failing to ensure:
1. Trash was contained in the facility's kitchen and outdoor dumpster; and
2. Garbage rece...
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Based on observation and interviews, the facility failed to dispose of garbage properly by failing to ensure:
1. Trash was contained in the facility's kitchen and outdoor dumpster; and
2. Garbage receptacles and dumpsters were covered.
Findings:
Review of the facility's policy titled Disposal of Garbage and Refuse and dated 05/2023, revealed in part, the following:
1. Garbage shall be disposed of in refuse containers with plastic liners and lids.
7. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.
On 05/05/2025 at 8:54 a.m., an observation was made of the kitchen garbage receptacle, which was uncovered with garbage present. Further observation revealed an empty box of fruit punch on the floor with left over residue to the left side of the garbage receptacle.
On 05/05/2025 at 10:26 a.m., an observation was made of the outside garbage area with S10DM. The dumpster was open and full with 1 bag of trash partially falling out of the receptacle. There were 7 soiled gloves near the base of the dumpster.
On 05/06/2025 at 9:45 a.m., an interview was conducted with S1ADM. S1ADM confirmed all garbage should have been contained and the garbage receptacles should have been covered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#84) of 7 (#9, #11, #49, #56, #84,#109, and #293) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing gastrostomy feeding to a resident who was on Enhanced Barrier Precautions (EBP).
Findings:
Review of the facility's policy titled Enhanced Barrier Precautions revised on 04/2025, revealed the following, in part:
For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities:
g. feeding tubes
Review of Resident #84's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included, in part: Encounter for Attention to Gastrostomy.
An observation was made on 05/05/2025 at 11:00 a.m., of the EBP sign posted on Resident #84's door. The signage revealed the following, in part:
Providers and staff must also:
Wear gloves and a gown for the following high-contact resident care activities.
In addition to standard precautions, everyone must gown and glove for these resident care activities: Feeding Tube.
An observation was made on 05/05/2025 at 11:00 a.m. of S5LPN providing enteral feeding to Resident #84. S5LPN did not wear a gown while administering enteral feeding to Resident #84.
An interview was conducted on 05/05/2025 at 11:15 a.m. with S5LPN. S5LPN verified Resident #84 was on EBPs due to his gastrostomy tube. She confirmed she did not wear a gown when providing enteral feeding via gastrostomy tube to Resident #84, and should have.
An interview was conducted on 05/06/2025 at 1:30 p.m. with S2DON. S2DON confirmed Resident #84 was on EBP for gastrostomy tube. S2DON confirmed when a resident was on EBPs, staff should wear a gown while providing enteral feedings via gastrostomy tube.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 2 (#19 and # 92) of 6 (#9, #19, #36, #53, #92 and #138) residents reviewed for PASRR.
Findings:
Resident #19
Review of Resident #19's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part, Schizoaffective Disorder with an onset date of 10/01/2020.
Review of Resident #19's most recent Level I PASRR Screening and Determination form revealed a previous assessment was performed on 07/05/2020.
Review was attempted of Resident #19's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 10/01/2020, with no documentation available for review.
An interview was conducted on 05/07/2025 at 2:15 p.m. with S9SW. S9SW confirmed Resident #19's Pre-admission Level I PASRR Screen and Determination was last submitted on 07/05/2020. She confirmed on 10/01/2020, Resident #19 received a new diagnosis of a relevant mental illness: Schizoaffective Disorder. She confirmed the facility did not resubmit a new Level I PASRR Screen and Determination with the onset of the new diagnosis.
Resident #92
Review of Resident #92's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Fracture of Head of Right Radius, Chronic Pain, Insomnia, and Cognitive Communication Disorder. Resident #92 had diagnosis of Post Traumatic Stress Disorder dated 05/30/2024.
Review of Resident #92's most recent Level I PASRR Screening and Determination form revealed her previous assessment was performed on 02/14/2024.
Review was attempted of Resident #92's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 05/30/2024, with no documentation available for review.
Review of Resident #92's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2025, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Further review revealed, in part, the following:
Section I: Diagnoses
I6100: Post Traumatic Stress Disorder - Checked.
An interview was conducted on 05/07/2025 at 10:00 a.m. with S9SW. S9SW confirmed Resident #96's Pre-admission Level I PASRR Screen and Determination was most recently submitted on 02/14/2024. She confirmed on 05/30/2024, Resident #96 received a new diagnosis of a relevant mental illness: Post Traumatic Stress Disorder. She confirmed the facility did not resubmit a new Level I PASRR Screen and Determination with the onset of the new diagnosis, and should have.
An interview was conducted on 05/07/2025 at 3:00 p.m. with S2DON. He confirmed if a resident received a new relevant mental illness diagnosis a resident review should be resubmitted.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 a resident who was unable to carry out ADLs ...
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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 a resident who was unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#11 and #111) of 4 (#9, #11, #30, and #111) residents reviewed for ADL's.
The facility failed to:
1. trim fingernails for Resident #111; and
2. provide incontinent care in a timely manner for Resident #11.
Findings:
Review of the facility's policy, Nail Care , with a revision date of 09/2017, revealed the following, in part:
Policy: Nail care should be included in a Patient's daily hygiene; the best time is during the Patient's bath.
Procedure:
-Cut nails immediately after bathing when they are the softest and easiest to cut.
-Cut nails straight across with a nail clipper.
1.
Resident #111
Review of the clinical record for Resident #111 revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status and Traumatic Brain Injury.
Review of the most recent MDS with ARD (Assessment Reference Date) of 04/13/2025 revealed a BIMS (Brief Interview for Mental Status) score of 3, which indicated severe cognitive impairment.
Review of Resident #111's current Care Plan revealed the following:
Problem: The resident has an ADL self-care performance deficit.
Interventions: Assist with ADLs
On 05/06/2025 at 8:30 a.m., an observation and interview was conducted with Resident #111. His fingernails were long and approximately 0.5 cm past the tips of all ten of his fingers. Resident #111 stated if he had clippers and if he was able, he would trim his own nails. He stated he would like for his fingernails to be trimmed. He stated he received a bath on 05/05/2025 and his nails were not trimmed at that time.
On 05/06/2025 at 9:00 a.m., an observation and interview was conducted with S6LPN. She stated CNAs were responsible for cleaning and trimming the fingernails of residents who do not have diabetes. She further stated nail care is usually provided along with a resident's bath. S6LPN observed and confirmed Resident #111's were too long and needed to be trimmed.
On 05/06/2025 at 9:36 a.m., an observation was made with S12CNAS of Resident #111's fingernails. Resident #111 informed S12CNAS he had received a bath on 05/05/2025 and had not been provided nail care. She stated CNAs were responsible for trimming the nails of residents that did not have diabetes. S12CNAS confirmed resident #111's nails were too long and needed to be trimmed.
On 05/06/2025 at 9:44 a.m., an interview was conducted with S3ADON. She confirmed that resident's nails should be kept clean and trimmed.
2.
Resident #11
Review of the clinical record for Resident #11 revealed he was admitted to the facility on [DATE] with diagnoses which included Morbid Obesity, Hemiplegia, and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side.
Review of the most recent MDS with ARD (Assessment Reference Date) of 01/28/2025 revealed BIMS (Brief Interview for Mental Status) score of 15, which indicated no cognitive impairment.
Review of Resident #11's current care plan revealed the following:
Problem: The resident has bowel incontinence related to immobility.
Goal: The resident will remain free from skin breakdown due to incontinence and brief use.
Intervention: Check resident every two hours and assist with toileting as needed; provide pericare after each incontinent episode.
On 05/06/2025 at 9:00 a.m., an interview was conducted with Resident #11. He stated he was currently soiled with urine and feces and had been for approximately 2.5 hours. He stated he initiated his call light again about an hour ago and no one has come to clean him yet.
On 05/06/2025 at 9:32 a.m., an interview was conducted with S15CNA. She stated she was aware Resident #11 was soiled at this time. She stated I am not going to change him now. It takes two people and about an hour to get him cleaned up.
On 05/06/2025 at 9:50 a.m., an interview was conducted with S2DON. He was made aware of Resident #11 being soiled for approximately 2.5 hours. He stated the policy regarding incontinence care was to clean them as soon as possible. He stated it was not acceptable for a resident to remain soiled for this period of time.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
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 residents received therapeutic diets as ord...
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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 residents received therapeutic diets as ordered by the physician for 3 of 3 (#7, #39, and #40) residents reviewed with double/large portions with meals.
Findings:
Review of the facility's policy titled, Therapeutic Diet Orders with a revision date of 11/2024 revealed the following, in part:
Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by the physician, and/or assessed by the interdisciplinary team to support the patient's/resident's treatment/plan of care, in accordance with his/her goals and preferences.
Policy explanation and compliance guidelines:
5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.
Resident #7
Review of Resident #7's Clinical Record revealed she was admitted to the facility on [DATE].
Review of Resident #7's current Physician Orders revealed a diet order for double portions.
Review of Resident #7's lunch Meal Ticket dated 05/05/2025 revealed she should have received double portions.
An observation was made of Resident #7's lunch meal on 05/05/2025 at 12:46 p.m. Her meal ticket revealed she should have been served double portions. Her lunch plate contained one taco, one serving of rice, and one serving of corn. An interview was conducted with Resident #7 at that time. She stated she only received single portions of the lunch meal and should have received double portions.
Resident #39
Review of Resident #39's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #7's current Physician Orders revealed a diet order for large portions.
Review of Resident #39's lunch Meal Ticket dated 05/05/2025 revealed he should have received large portions.
An observation was made of Resident #39's lunch meal on 05/05/2025 at 12:48 p.m. His meal ticket revealed he should have been served large portions. His lunch plate contained one taco, one serving of rice, and one serving of corn. An interview was conducted with Resident #39 at that time. He stated he only received single portions of the lunch meal and should have received double portions.
Resident #40
Review of Resident #40's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #40's current Physician Orders revealed a diet order for double portions.
Review of Resident #40's lunch Meal Ticket dated 05/05/2025 revealed he should have received double portions.
An observation was made of Resident #40's lunch meal on 05/05/2025 at 12:49 p.m. His meal ticket revealed he should have been served double portions. His lunch plate contained one taco, one serving of rice, and one serving of corn. An interview was conducted with Resident #40 at that time. He stated he only received single portions of the lunch meal and should have received double portions.
An observation was made of Residents #7, #39, and #40 with S11CNA on 05/05/2025 at 12:50 p.m. S11CNA confirmed Residents #7, #39, and #40 received a single portion of the lunch meal. She confirmed Residents #7 and #40's meal tickets revealed they should have received double portions. S11CNA confirmed Resident #39's meal ticket revealed he should have received large portions. She stated large portions was double portions.
An interview was conducted with S10DM on 05/05/2025 at 12:55 p.m. She reviewed Residents #7, #39, and #40 meal tickets and confirmed they should have received double portions. She stated large portions meant the same thing as double portions.
An interview was conducted with S4ADON on 05/06/2025 at 8:42 a.m. She confirmed Residents #7, #39, and #40 should have received double portions as ordered by the physician and determined by the interdisciplinary team. She stated any resident with an order for double portions or double/large portions on their meal ticket should have received them.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to ensure meals were provided at regular meal times comparable to normal mealtimes in the community and consistent with facil...
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Based on observations, interviews, and record reviews, the facility failed to ensure meals were provided at regular meal times comparable to normal mealtimes in the community and consistent with facility scheduled meal times for 2 (Hall A and Hall B) of 3 (Hall A, Hall B, and Hall C) halls observed for dining. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen.
Findings:
Review of the facility's policy dated 05/2023 and titled, Frequency of Meals revealed the following, in part:
Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals.
Policy Explanation and Compliance Guidelines:
1. The facility has scheduled three regular meal times, comparable to normal meal times in the community.
Review of the posted meal times outside of the facility's dining room revealed the following:
Breakfast - 7:30 a.m.
Lunch - 11:30 a.m.
Dinner - 4:30 p.m.
An observation was made of the first Hall A breakfast meal tray cart being prepared in the facility's kitchen on 05/05/2025 at 9:10 a.m.
An observation was made of Hall B breakfast meal trays being passed out to residents on 05/05/2025 at 9:58 a.m.
An interview was conducted with Resident #52 on 05/05/2025 at 10:05 a.m. She stated meal times were inconsistent and often came an hour or two late.
An observation was made of Resident #9 eating her lunch on 05/05/2025 at 2:03 p.m. She stated she had just received her lunch tray. She stated meal trays were often passed out late and were almost never on time as scheduled. She stated she wanted more consistent meal times.
An interview was conducted with S13CNA on 05/05/2025 at 2:25 p.m. She stated lunch meal trays were scheduled to be delivered at 12:00 p.m. She stated Hall B meal trays were delivered at 1:30 p.m. today, which was late.
An interview was conducted with S23CNA on 05/06/2025 at 12:57 p.m. She confirmed she was assigned to Hall A. She stated meal trays were supposed to be delivered at 8:00 a.m. for breakfast and 11:30 p.m. for lunch. She stated breakfast was usually delivered around 9:30 a.m. She stated sometimes the residents complained because the meal trays were late.
An observation was made of the first Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 12:59 p.m.
An observation was made of the second Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 1:18 p.m.
An interview was conducted with Resident #22 on 05/07/2025 at 8:37 a.m. She stated meal trays were frequently delivered late. She stated lunch was frequently delivered around 2:00 p.m.
An interview was conducted with S24LPN on 05/07/2025 at 8:45 a.m. She stated residents complained of late meal trays.
An interview was conducted with Resident #94 on 05/07/2025 at 8:48 a.m. She stated the meal times were never consistent. She stated breakfast was delivered anywhere from 8:00 a.m. - 10:00 a.m., lunch from 12:30 p.m. - 2:00 p.m., and supper 6:00 p.m. - 8:00 p.m. She stated she wanted consistent meal times. She stated most all meals were delivered after the posted meal times.
An interview was conducted with S10DM on 05/06/2025 at 1:11 p.m. She stated scheduled meal times were 8:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for supper. She stated all residents should have been served within one hour of the scheduled meal time.
An interview was conducted with S1ADM on 05/07/2025 at 9:00 a.m. She stated scheduled meal times were breakfast at 8:00 a.m., lunch at 12:00 p.m., and supper at 5:00 p.m. She stated she would expect all meal trays should have been delivered to the residents within 30 to 35 minutes of the posted meal time. She was made aware of the breakfast and lunch meal time observations on 05/05/2025 and 05/06/2025. She confirmed the observations of late meal times were unacceptable time frames for meal service.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure:
1. The k...
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Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure:
1. The kitchen floor remained clean;
2. Food was properly sealed in the refrigerator of the facility's kitchen;
3. Food cans and containers remained uncompromised in the dry storage areas of the facility's kitchen;
4. The dishes were cleaned and sanitized in a way that minimized the spread of foodborne illness; and
5. The food service area remained in a sanitary condition during the meal serving process.
This deficient practice had the potential to affect the 140 residents who were served food from the kitchen.
Findings:
On 05/05/2025 at 8:54 a.m., an initial tour was made of the kitchen with S10DM. Observations were made of the following:
1. Food particles and residue were on the floor throughout the kitchen.
2. The refrigerator contained 1 uncovered bowl of pineapple and 1 uncovered container of pudding.
3. The dry storage pantries contained 7 dented cans of mandarin oranges, 2 dented cans of tropical fruit salad, and 11 crushed containers of quick rolled oats.
On 05/05/2025 at 9:15 a.m., an interview was conducted with S10DM. She confirmed the above observations and stated the kitchen should have remained clean, all foods in the refrigerator should have been covered, and containers in the dry storage pantries should have been uncompromised.
On 05/05/2025 at 10:10 a.m., an observation was made of S18DW performing the dishwashing process in the facility's kitchen. S18DW placed 18 meal trays upright with two stacked together with no spacing between them in one washing tray. He stacked 17 insulated food tray bases, one on top of the other, with no spacing between them through the dishwasher. A drink lid was observed between two insulated food tray bases after the washing process was completed and the food tray bases were holding water.
On 05/05/2025 at 10:15 a.m., an observation was made of the dishes after being sent through the dishwasher with S10DM. An interview was conducted with S10DM at that time. She confirmed the above observation. S10DM confirmed dishes should not have been stacked because they could not be effectively cleaned. She stated the dishes should have been placed in a tray basket, one per compartment/slot, for effective cleaning.
On 05/05/2025 at 11:38 a.m., an observation was made of the facility's meal serving process. There was a black, fuzzy substance on the wall, ceiling, and air vent above the meal service table.
On 05/07/2025 at 9:00 a.m., an interview was conducted with S1ADM. She stated staff should have effectively performed the dishwashing and sanitation process. She confirmed the facility was responsible for ensuring the kitchen was maintained sanitarily, and the functions of the kitchen were carried out effectively.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to ensure patient care equipment was maintained in safe operating con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interviews, the facility failed to ensure patient care equipment was maintained in safe operating condition for 2 (#92 and #97) of 2 (#92 and #97) sampled residents reviewed for call light safety.
Findings:
Resident #92
Review of the Clinical Record revealed Resident #92 was admitted to the facility on [DATE] with the following diagnoses, in part: Need for Assistance for Personal Care, Cognitive Communication Deficit, and Other Symptoms involving Cognitive Function and Awareness.
Review of Resident #92's Quarterly MDS, with an ARD of 12/31/2024, revealed a BIMS of 13 indicating she was cognitively intact.
On 05/05/2025 at 11:00 a.m., an observation was made in Resident #92's room of the call light pulled off the wall with the wires exposed.
On 05/05/2025 at 2:00 p.m., an interview was conducted with Resident #92, she stated the call light cover had been pulled off the wall for weeks. She stated she told staff about it several times.
On 05/06/2025 at 8:45 a.m., an interview and observation was conducted with S8MS. S8MS observed the call light cover in Resident #92's room. He stated it should have been secured to the wall, and should not have been hanging with wires exposed.
On 05/06/2025 at 8:50 a.m., an interview was conducted with S1ADM. She observed the call light in Resident #92's room pulled off the wall with wires exposed. She stated Resident #92's call light should not have wires exposed.
Resident #97
Review of the Clinical Record revealed Resident #97 was admitted to the facility on [DATE] with the following diagnoses, in part: Osteomyelitis, Dementia, and Immobility Syndrome (Paraplegia).
Review of Resident #97's Quarterly MDS, with an ARD of 03/20/2025, revealed a BIMS of 15 indicating he was cognitively intact.
On 05/07/2025 at 2:00 p.m., an observation was made in Resident #97's room of the call light pulled off the wall with the wires exposed.
On 05/05/2025 at 2:00 p.m., an interview was conducted with Resident #97. He stated the call light cover had been pulled off the wall for weeks. He stated he told staff about it several times.
On 05/07/2025 at 2:30 p.m., an interview and observation was conducted with S8MS. S8MS observed the call light cover in Resident #97's room. He stated it should have been secured to the wall, and should not have been hanging with wires exposed.
CONCERN
(F)
📢 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 F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on observations and interviews, the facility failed to ensure dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the f...
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Based on observations and interviews, the facility failed to ensure dietary support personnel had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service. The facility failed to ensure S18DW was competent to effectively and sanitarily perform the functions of the facility's dishwasher. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen.
Findings:
An observation was made of S18DW performing the dish washing process in the facility's kitchen on 05/05/2025 at 10:10 a.m. S18DW was observed to place 18 meal trays upright with two stacked together with no spacing between them in one washing tray. He was observed to stack 17 insulated food tray bases, one on top of the other, with no spacing between them and sent them through the dishwasher. A drink lid was observed between two insulated food tray bases after the washing process was complete and the food tray bases were holding water. An interview was conducted with S18DW at that time. He stated the dishwasher did not utilize a sanitizing solution and he did not know how to test the concentration.
An observation was made of the dishes after being sent through the dishwasher on 05/05/2025 at 10:15 a.m. with S10DM. An interview was conducted with S10DM at that time. She confirmed the above observation. S10DM confirmed dishes should not have been stacked because they could not be effectively cleaned. She stated the dishes should have been placed in a tray basket, one per compartment/slot, for effective cleaning. S10DM stated the dishwasher utilized a sanitizing solution for sanitizing the dishes.
An interview was conducted with S18DW on 05/05/2025 at 10:20 a.m. He stated he began working as a dishwasher at the facility 2 weeks ago. He stated he was oriented when he first started but was not trained on everything. He stated the dishwasher utilized only hot water for sanitation and did not utilize a sanitizing solution. He stated he was provided training on how to utilize the dishwasher, but was not trained on how to utilize the sanitation concentration test strips or when/how often he should test the sanitization solution concentration.
An interview was conducted with S19DDM and S10DM on 05/06/2025 at 1:20 p.m. S10DM stated she was responsible to ensure S18DW was competent in using the dishwasher and effectively washing dishes. S19DDM stated S18DW should have been trained the dishwasher utilized a sanitizing solution for dish sanitization and he should have been trained how to test the concentration of the sanitizing solution. S19DDM stated S18DW should have been trained and competent to effectively load the dishes to ensure sanitization and how to test the sanitizing concentration.
An interview was conducted with S1ADM on 05/07/2025 at 9:00 a.m. She stated S18DW should have been competent in utilizing the dishwasher. She stated S18DW should have been trained the dishwasher utilized hot water and sanitization and how to check the sanitation concentration of the dishwasher. She stated the dishwasher should have been trained on how to properly load the dishwasher to ensure the cleanliness and sanitation of the dishes. She confirmed, ultimately, the facility was responsible to ensure the functions of the kitchen and dietary services were carried out effectively.
CONCERN
(F)
📢 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 F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure sufficient dietary support personnel were e...
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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 sufficient dietary support personnel were employed to safely and effectively carry out the functions of the food and nutrition service when meals were served late on 05/05/2025 and 05/06/2025. This deficient practice had the potential to affect any of the 140 residents who received meals from the facility's kitchen.
Findings:
Review of the facility's policy dated 05/2023 and titled, Dietary Services - Staffing revealed the following, in part:
Policy: The facility employs sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.
Policy Explanation and Compliance Guidelines for Staffing:
6. The facility will provide sufficient support personnel to safely and effectively carry out the supportive functions of the Food and Nutrition Services. These functions include, but are not limited to:
a. Safe and timely meal preparation;
c. Providing meals and/or supplements in accordance with residents' needs . preferences, and care plans
Review of the facility's policy dated 05/2023 and titled, Frequency of Meals revealed the following, in part:
Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals.
Policy Explanation and Compliance Guidelines:
1. The facility has scheduled three regular meal times, comparable to normal meal times in the community.
Review of the facility's Facility assessment dated [DATE] revealed the following, in part:
Information about our staffing patterns:
Food and Nutrition Services: Staffing in the dietary department is adequate as evidenced by timely meal service, consistent staffing assignments, adherence to dietary needs and preferences, and positive resident feedback on meals and service.
Review of the posted meal times outside of the dining room revealed the following:
Breakfast - 7:30 a.m.
Lunch - 11:30 a.m.
Dinner - 4:30 p.m.
Review of the Dietary departments' time cards dated 05/05/2025 and 05/06/2025, revealed there were five dietary support personnel for breakfast and lunch.
An observation was made of the first Hall A breakfast meal tray cart being prepared in the facility's kitchen on 05/05/2025 at 9:10 a.m.
An observation was made of Hall B breakfast meal trays being passed out to residents on 05/05/2025 at 9:58 a.m.
An interview was conducted with Resident #52 on 05/05/2025 at 10:05 a.m. She stated meal times were inconsistent and often came an hour or two late.
An observation was made of Resident #9 eating her lunch on 05/05/2025 at 2:03 p.m. She stated she had just received her lunch tray. She stated meal trays were often passed out late and almost never on time as scheduled. She stated she wanted more consistent meal times.
An interview was conducted with S13CNA on 05/05/2025 at 2:25 p.m. She stated lunch meal trays were scheduled to be passed out at 12:00 p.m. She stated Hall B meal trays were served at 1:30 p.m. today, which was late.
An interview was conducted with S23CNA on 05/06/2025 at 12:57 p.m. She confirmed she was assigned to Hall A. She stated meal trays were supposed to be delivered at 8:00 a.m. for breakfast and 11:30 p.m. for lunch. She stated breakfast was usually delivered around 9:30 a.m. She stated sometimes the residents complained because the meal trays were late. She stated if the kitchen was short staffed, which was about two days per week, the trays were delivered late.
An observation was made of the first Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 12:59 p.m.
An observation was made of the second Hall A lunch meal tray cart being delivered to the hall on 05/06/2025 at 1:18 p.m.
An interview was conducted with Resident #22 on 05/07/2025 at 8:37 a.m. She stated meal trays were frequently delivered late. She stated lunch was frequently delivered around 2:00 p.m.
An interview was conducted with S24LPN on 05/07/2025 at 8:45 a.m. She stated residents complained of late meal trays.
An interview was conducted with Resident #94 on 05/07/2025 at 8:48 a.m. She stated the meal times were never consistent. She stated breakfast was delivered anywhere from 8:00 a.m. to 10:00 a.m., lunch from 12:30 p.m. to 2:00 p.m., and supper 6:00 p.m. to 8:00 p.m. She stated she wanted consistent meal times. She stated most meals were served after the posted meal times.
An interview was conducted with S20DA on 05/07/2025 at 9:52 a.m. She stated the kitchen needed more staff to assist with carrying out the functions of the dietary service timely. She stated they each have to pitch in and help cook, serve, and clean. She stated they began serving lunch at 11:30 a.m., and the last tray went out at 1:30 p.m. She stated they would be able to get the trays out sooner if there were more dietary staff.
An interview was conducted with S21DA on 05/07/2025 at 9:52 a.m. She stated the kitchen needed more staff to carry out the functions of the dietary service timely and effectively. She stated the meal trays would have been delivered sooner if there were more dietary staff.
An interview was conducted with S22C on 05/07/2025 at 9:58 a.m. She stated the kitchen was very short staffed and needed more help. She stated she never got to take a break. She stated they had to cook, serve, clean, and set up. She stated with the current amount of staff, which was a total of five, meals were late daily. She stated the whole process of getting meal trays out did not get completed timely due to not having enough dietary staff. She confirmed the hall trays had been late due to not having enough staff.
An interview was conducted with S10DM on 05/06/2025 at 1:11 p.m. She stated she had been short staffed in the kitchen. She stated she could not keep staff, they called out, or they didn't show up. She stated the dietary service was currently being carried out with one cook, one cook assistant, two dietary aides, and a dishwasher for each meal. She stated the kitchen needed one cook, one cook assistant, three dietary aides, and a dishwasher to effectively carry out the functions of the dietary service. She stated the scheduled meal times were 8:00 a.m. for breakfast, 12:00 p.m. for lunch, and 5:00 p.m. for supper. She stated all residents should have been served within one hour of the scheduled meal time. She stated when the meal trays were late to the hallway, it was because she did not have enough staff in the kitchen. She confirmed she needed more dietary staff to carry out the functions of the dietary service effectively and timely. S10DM stated she was also acting as a dietary support personnel in addition to office duties and training new staff.
An interview was conducted with S19DDM on 05/06/2025 at 1:20 p.m. She stated the facility was currently carrying out the functions of the dietary service with five staff for each meal. She stated the kitchen needed a total of at least six dietary staff for each meal to effectively carry out the functions of the dietary service.
An interview was conducted with S1ADM on 05/07/2025 at 9:00 a.m. She stated scheduled meal times were breakfast at 8:00 a.m., lunch at 12:00 p.m., and supper at 5:00 p.m. She stated she would expect all meal trays to be delivered to the residents within 30-35 minutes of the posted meal time. She was made aware of the breakfast and lunch meal times observations on 05/05/2025 and 05/06/2025. She confirmed the observations of late meal times were unacceptable time frames for meal service. She stated there should have been enough dietary support personnel to effective carry out the functions of the dietary service.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observation, record review, and interview, the facility failed to ensure the results of the most recent standard survey and complaint survey were posted in a place readily accessible to resid...
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Based on observation, record review, and interview, the facility failed to ensure the results of the most recent standard survey and complaint survey were posted in a place readily accessible to residents, family members, and legal representatives.
This deficient practice had the potential to affect the 148 residents who currently resided in the facility.
Findings:
Review of the facility's policy titled, Availability of Survey Results and dated 07/2024, revealed in part, the following:
4. The facility will maintain reports of any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect in respect to the facility. This information will be available for any individual to review upon request.
Review of the facility's Survey History revealed the most recent standard survey was completed on 06/27/2024. Further review revealed a complaint survey was completed on 11/26/2024.
An observation was made on 05/05/2025 at 11:05 a.m. of the facility's Survey Results binder located near the facility's conference room, which was not a location readily accessible to residents, family members, and legal representatives.
Review of the Survey Results binder revealed no documented evidence of the survey results from the previous standard survey dated 06/27/2024 and the complaint survey dated 11/26/2024.
An interview was conducted on 05/05/2025 at 11:08 a.m. with S1ADM. She reviewed the facility's Survey Results binder. She confirmed the survey results from the previous standard survey dated 06/27/2024 and complaint survey dated 11/26/2024 were not in the binder or in a place readily accessible to residents, family members, or legal representatives.
Mar 2025
3 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
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 accuracy of Minimum Data Set (MDS) Assessments 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 the accuracy of Minimum Data Set (MDS) Assessments for 1 (#2) of 7 (#1-#7) residents reviewed in the sample. The facility failed to ensure:
1. Resident #2 was coded for diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD); and
2. Resident #2 was coded for his most recent Gradual Dose Reduction (GDR) date and the provider's response.
This deficient practice had the potential to affect a current census of 147 residents.
Findings:
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #2's Psychiatry Progress Note, dated 01/31/2025, revealed, in part, the following:
Active Diagnoses: Schizoaffective Disorder and PTSD.
Review of Resident #2's GDR, performed on 01/09/2025, revealed, in part, the following:
Medications Reviewed:
Seroquel 400mg 1 by mouth every night.
Vistaril 25mg by mouth three times daily.
Physician Response to Review:
Currently on minimal effective doses with dose reduction inappropriate at this time. Continue current doses due to actively delusional, psychotic intermittently, recent in-patient psych stay.
Review of Resident #2's most recent MDS Assessment, with an Assessment Reference Date of 02/03/2025, revealed, in part, the following:
I600-Schizophrenia: Unchecked.
I6100-PTSD: Unchecked.
N0450-Has a GDR been attempted? 0. No.
N0450C-Date of last attempted GDR: Blank.
N0450D-Physician documented GDR as clinically contraindicated: 0. No.
N0450E-Date Physician documented GDR as clinically contraindicated: Blank.
An interview was conducted on 03/12/2025 at 3:30 p.m. with S3MDS. S3MDS reviewed Resident #2's MDS Assessment, dated 02/03/2025, and confirmed he was not coded to have Schizoaffective Disorder or PTSD and should have been. S3MDS reviewed Resident #2's MDS Assessment, dated 02/03/2025, and confirmed Resident #2's aforementioned GDR and provider response was not coded on his MDS Assessment and should have been.
An interview was conducted on 03/12/2025 at 3:40 p.m. with S2DON. S2DON confirmed all MDS Assessments should accurately reflect the resident's status and Resident #2's did not.
An interview was conducted on 03/12/2025 at 3:45 p.m. with S1ADM. S1ADM confirmed all MDS Assessments should accurately reflect the resident's status and Resident #2's did not.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop a trauma-informed, comprehensive person-centered care pla...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop a trauma-informed, comprehensive person-centered care plan, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 (#2) of 7 (#1-#7) residents reviewed in the sample. The facility failed to develop a care plan for Resident #1's diagnoses of Schizoaffective Disorder and Post Traumatic Stress Disorder (PTSD).
This deficient practice had the potential to affect a current census of 147 residents.
Findings:
Review of the facility's Care Plan Revisions Upon Status Change policy, effective 05/2023, revealed, in part, the following:
Policy Explanation and Compliance Guidelines:
1. The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change.
2. Procedure for reviewing and revising the care plan when a resident experiences a status change:
f. Care Plans will be modified as need by the MDS Coordinator or other designated staff member.
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE].
Review of Resident #2's Psychiatry Progress Note, dated 01/31/2025, revealed, in part, diagnoses including Schizoaffective Disorder and PTSD.
Review of Resident #2's Care Plan, as of 03/10/2025, revealed, in part, no documented evidence of a Care Plan for diagnoses of Schizoaffective Disorder and PTSD.
An interview was conducted on 03/12/2025 at 3:30 p.m. with S3MDS. S3MDS reviewed Resident #2's Care Plan and confirmed he was not care planned for Schizoaffective Disorder or PTSD and should have been.
An interview was conducted on 03/12/2025 at 3:40 p.m. with S2DON. S2DON confirmed all Care Plans should accurately reflect the resident's status and Resident #2's did not.
An interview was conducted on 03/12/2025 at 3:45 p.m. with S1ADM. S1ADM confirmed all Care Plans should accurately reflect the resident's status and Resident #2's did not.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0741
(Tag F0741)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to:
1. Develop a facility assessment which addressed staff training for skills and non-pharmacological interventions and the process to eval...
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Based on interviews and record reviews, the facility failed to:
1. Develop a facility assessment which addressed staff training for skills and non-pharmacological interventions and the process to evaluate competency of skill sets necessary to provide the level and type of care necessary to meet the mental and psychosocial health needs of their resident population diagnosed with Schizophrenia Disorder, Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD); and
2. Provide staff training for non-pharmacological interventions and ensure competency in the skill sets necessary to meet the mental and psychosocial health needs of their resident population diagnosed with Schizophrenia, PTSD and SUD for 4 of 4 (S4LPN, S5LPN, S6RN, and S7MSW) Personnel Files reviewed.
This deficient practice had the potential to affect a current census of 147 residents.
Findings:
Review of the Facility Assessment, dated 03/15/2024, revealed, in part, the following:
Part 1: Our Resident Profile
1.3 Diseases/Conditions, Physical and Cognitive Disabilities Accepted by Facility
Psychiatric/Mood Disorders; such as, Schizophrenia and PTSD that Needs Interventions.
Acuity
1.5 Describe your resident's acuity levels.
Major RUG-IC Categories:
Behavioral Symptoms and Cognitive Performance - 15
Special Treatments and Conditions:
Mental Health - Behavioral Health Needs - 10
Mental Health - Active or Current Substance Use Disorder - 10
Part 2: Services we offer based on our residents' needs
2.1 Resident Support/Care Needs
Specific Care and Practices for Mental Health and Behavior
Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, are of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.
Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population
3.4 Staff Training/Education and Competencies
No documented evidence of the training process for non-pharmacological interventions related to mental and psychosocial health diagnoses or the process for ensuring staff competency in the skill sets required to provide appropriate care for residents with mental and psychosocial health diagnoses.
Review of the facility's Employee Training Materials for the Use of Non-Pharmacological Interventions to Meet the Mental and Psychosocial Health Needs for Residents with Schizophrenia and SUD was attempted on 03/12/2025 with no documented evidence produced for review.
Review of the facility's Competency Evaluation Materials for the Use of Non-Pharmacological Interventions to Meet the Mental and Psychosocial Health Needs for Residents with Schizophrenia, PTSD and SUD was attempted on 03/12/2025 with no documented evidence produced for review.
Review of S4LPN, S5LPN, S6RN, and S7MSW's Personnel File, as of 03/12/2025, revealed, in part, no documented evidence of training for the use of non-pharmacological interventions for Schizophrenia and SUD or competency evaluations to ensure the skill sets necessary to meet the mental and psychosocial health needs of the resident population; including, Schizophrenia, PTSD and SUD.
An interview was conducted on 03/12/2025 at 3:45 p.m. with S1ADM. S1ADM reviewed the Facility Assessment and confirmed it did not outline the process for staff training and ensuring the competency of staff's skill sets in the use of non-pharmacological interventions for residents diagnosed with Schizophrenia, PTSD and SUD and it should. S1ADM the facility's training materials for Schizophrenia and SUD and confirmed it did not address the use of non-pharmacological interventions for residents diagnosed with Schizophrenia and SUD and it should. S1ADM confirmed the facility did not currently have a process to ensure competency of staff's skill sets in the use of non-pharmacological interventions for residents diagnosed with Schizophrenia, PTSD and SUD and it should. S1ADM reviewed Personnel Files for S4LPN, S5LPN, S6RN, and S7MSW and confirmed they did not contain documented evidence of training for the use of non-pharmacological interventions for Schizophrenia and SUD or competency evaluations to ensure the skill sets necessary to meet the mental and psychosocial health needs of the resident population; including, Schizophrenia, PTSD and SUD and they should.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for therapeutic diets. The facility failed to ensure Resident #2's diet order was updated in the electronic medical record.
The deficient practice had the potential to affect the 134 residents residing in the facility receiving physician ordered nutrition.
Findings:
Review of the facility's policy titled, Therapeutic Diet Orders with a revision date of 11/2024, revealed the following, in part:
Policy Explanation and Compliance Guidelines:
4. The therapeutic diet order shall be documented in the medical record .
Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Unspecified Cerebral Infarction and Pneumonitis Due To Inhalation of Food and Vomit.
Review of Resident #2's current electronic Physician Orders revealed the following, in part:
Diet: Controlled Carbohydrate, Mechanical Soft, Honey/Moderately Thick Liquids with Double Portions all meals.
Review of Resident #2's handwritten Physician Order dated 10/25/2024 revealed the following, in part:
Diet upgrade to Regular texture/Thin liquids as per Pharyngogram results.
Review of Resident #2's undated Diet Requisition Form revealed the following, in part:
Diet Change
Texture - Regular
Liquids - Thin
Review of Resident #2's Meal Tickets dated 11/25/2024 for breakfast, lunch, and supper revealed a Controlled Carbohydrate Diet, Regular Texture, Thin Liquids, and Double Portions diet.
On 11/25/2024 at 2:10 p.m., an interview was conducted with S3RD. She stated Resident #2 admitted to the facility after a stroke and was prescribed a mechanical soft diet with honey thickened liquids. She stated, on 10/25/2024, Resident #2's diet was upgraded to a regular texture with thin liquids. She reviewed and confirmed the handwritten physician order was Resident #2's current diet order. She reviewed and confirmed the speech therapist filled out the diet requisition order. She stated the nurse received and signed the diet requisition order. She confirmed Resident #2's electronic record should have reflected the updated, accurate, diet order and did not.
On 11/25/2024 at 2:30 p.m., an interview was conducted with S2ADON. She reviewed Resident #2's current physician orders, handwritten diet order dated 10/25/2024, undated diet requisition form, and meal tickets dated 11/25/2024. She confirmed Resident #2's electronic record should have been updated by the nurse who signed the diet requisition form.
On 11/25/2024 at 3:15 p.m., an interview was conducted with S1DON. She reviewed Resident #2's current physician orders, handwritten diet order dated 10/25/2024, undated diet requisition form, and meal tickets dated 11/25/2024. She stated the nurse who signed the diet requisition form for Resident #2's diet change should have updated the diet order in the electronic record. She confirmed Resident #2's electronic physician orders did not reflect the accurate diet order and should have.
Jun 2024
18 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
Deficiency F0558
(Tag F0558)
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 accommodate a resident's needs for tube feeding man...
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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 accommodate a resident's needs for tube feeding management for 1 (#19) of 3 (#1, #19, and #72) residents reviewed for tube feeding.
Findings:
Review of Resident #19's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Muscle Wasting and Atrophy, Dysphagia, and Gastrostomy Status.
Review of Resident #19's Annual MDS with an ARD of 04/12/2024 revealed, in part, a BIMS of 11, which indicated moderate cognitive impairment.
Review of Resident #19's current Care Plan revealed the following, in part:
Problem: I am at risk for adequate nutrition; I have a PEG tube; I have a diagnosis of Dysphagia; and I am NPO.
Interventions: Provide feedings per MD order.
Problem: I am NPO; I require tube feeding; I am at risk for aspiration related to my diagnosis of Dysphagia.; and I am disconnected from my tube feeding as ordered due to I like to propel myself around facility at times.
Interventions: Provide resident with feeding and fluids as ordered
Further review of Resident #19's care plan revealed no documentation Resident #19 refused enteral feedings.
Review of Resident #19's current Physician Orders revealed the following, in part:
Diet: Nothing by mouth;
Two Cal HN 0.08 gram - 2 KCAL/mL run at 40 mL/hr for 20 hours from 6:00 p.m. - 2:00 p.m. via PEG tube; and
Stop tube feeding 4 hours a day from 2:00 p.m. to 6:00 p.m.
An observation was made of Resident #19 on 06/24/2024 at 8:43 a.m. Her PEG tube feeding was not connected or infusing.
An interview was conducted with Resident #19 on 06/24/2024 8:45 a.m. She stated sometimes the staff did not connect her tube feeding as scheduled.
An observation was made of Resident #19 on 06/24/2024 at 12:33 p.m. She was in the hallway in her wheelchair with no PEG tube feeding infusing.
An interview was conducted with Resident #19 on 06/26/2024 at 2:11 p.m. She stated she liked to propel herself around the facility. She stated she wanted something on her chair so she could have her PEG tube feedings while she propelled around the facility.
An interview was conducted with S32LPN on 06/26/2024 at 1:38 p.m. She stated Resident #19's PEG tube feedings were scheduled to connect at 6:00 p.m. and disconnect the following day at 2:00 p.m. She confirmed there were some days, including 06/24/2024, Resident #19 did not receive her PEG tube feedings for the physician ordered time frame. She stated once Resident #19 got out of bed, she did not want to have the tube feeding connected. She confirmed sometimes Resident #19 requested to have her tube feeding disconnected so she can propel around the facility. She confirmed Resident #19's wheelchair did not accommodate her tube feeding and should have.
An interview was conducted with S31CNA on 06/26/2024 at 2:21 p.m. She stated she was frequently assigned to Resident #19. She confirmed Resident #19 had a PEG tube she gets feeding through, and she did not consume any calories by mouth. She stated the nurse was responsible to connect and disconnect the tube feeding. She stated when she would get Resident #19 up in the morning, Resident #19 would ask the nurse to disconnect the tube feeding so she could propel through the facility. She stated Resident #19 usually got back in bed around 11:30 a.m. and the nurse would reconnect her PEG tube feeding. She stated during the time frame of her being up, she was not connected to her tube feeding. She stated Resident #19 was cognitively intact and never refused feedings or care. She stated Resident #19 wanted her PEG tube feedings disconnected because her wheelchair did not accommodate her tube feeding.
An interview was conducted with S30CNA on 06/27/2024 at 8:43 a.m. She stated Resident #19 received PEG tube feedings. She stated Resident #19 liked to get out of bed around 10:00 a.m. and would ask the nurse to disconnect her tube feeding. She stated Resident #19 usually stayed out of her room and propelled herself around the facility. She stated on Monday, she got Resident #19 out of bed around 10:00 a.m., and she did not go back to her room on her shift, which meant she did not have her tube feeding. She stated she left her shift at 2:00 p.m., and Resident #19 was still up in her wheelchair and not in her room. She stated Resident #19 was compliant with her care. She stated Resident #19 was not the type of resident to refuse things. She stated the reason Resident #19 requests to have her tube feeding disconnected is because she wants to roam the facility, and her wheelchair did not accommodate her PEG tube feedings.
An interview was conducted with S26LPN on 06/27/2024 at 8:52 a.m. She confirmed Resident #19 had continuous PEG tube feeding ordered from 6:00 p.m. to 2:00 p.m. the following day, which meant it was held from 2:00 p.m. to 6:00 p.m. daily. She stated Resident #19 often asked the nurse to disconnect the tube feeding because she wanted to propel through the facility. She stated Resident #19 was compliant with her care and was not the type of resident to refuse care. She confirmed Resident #19's wheelchair did not accommodate her PEG tube feeding. She confirmed Resident #19 should be able to propel through the facility as she wished and still have her tube feeding administered as ordered.
A telephone interview was conducted with S33RD on 06/27/2024 at 10:46 a.m. She stated she was very familiar with Resident #19 and monitored her weights and nutrition status closely. She stated Resident #19 was on continuous tube feeding for 20 hours per day. She stated Resident #19 often asked the staff to disconnect her PEG tube feedings so she could roam throughout the facility. She stated Resident #19 liked her freedom and the staff would disconnect it for her to allow her to have her freedom. She stated Resident #19's wheelchair did not accommodate her PEG tube feedings.
An interview was conducted with S3ADON on 06/27/2024 at 9:04 a.m. She stated Resident #19 had tube feeding scheduled 6:00 p.m. to 2:00 p.m. She confirmed Resident #19's tube feeding should have been administered as ordered. She stated Resident #19 had the right to propel through the facility with her scheduled tube feeding. She stated the tube feeding should not keep her locked up or hinder her from leaving her room.
An interview was conducted with S2DON on 06/27/2024 at 9:17 a.m. He stated residents on tube feeding should be able to leave their room and propel through the facility with the tube feeding.
A telephone interview was conducted with S12NP on 06/27/2024 at 9:52 a.m. She confirmed she was the medical provider for Resident #19. She stated Resident #19 had continuous tube feedings with an order to hold for four hours a day. She confirmed Resident #19 enjoyed propelling herself throughout the facility and sitting outside of her room. She confirmed Resident #19's wheelchair should accommodate her PEG tube feedings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Discharge MDS assessment was completed and transmitted tim...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Discharge MDS assessment was completed and transmitted timely for 1 (#105) of 2 (#100 and #105) residents reviewed for Resident Assessment.
Findings:
Review of the facility's policy dated May 2023 and titled MDS 3.0 Completion revealed, in part the following:
Policy:
Policy Explanation and Compliance Guidelines:
2. Types of OBRA Assessments.
f. Discharge Assessment - completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD.
7. Transmission Requirements:
a. All assessments must shall be transmitted to the designated CMS system (QIES ASAP) within 14 days of completion.
Review of Resident #105's clinical record revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 02/23/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment.
An interview was conducted on 06/27/2024 at 12:20 p.m. with S21MDS. She stated she was responsible for completing and transmitting MDS assessments. She reviewed Resident #105's record and confirmed a Discharge MDS Assessment was not completed and should have been.
An interview was conducted on 06/27/2024 at 12:23 p.m. with S2DON. He confirmed a Discharge MDS Assessment was not completed for Resident #105 and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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:
1. A record of the Level 1 Pre-admission Screening and Res...
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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:
1. A record of the Level 1 Pre-admission Screening and Resident Review (PASRR) form was maintained in the resident's record for 1 (#37) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR; and
2. A resident with a mental disorder had an accurate Pre-admission Screening for 1 (#46) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR.
Findings:
1.
Review of Resident #37's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Other Sequelae of Cerebral Infarction, Unspecified Mood Affective Disorder, and Recurrent Severe Major Depressive Disorder with Psychotic Symptoms.
Review of Resident #37's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2024, revealed the provider assessed the resident as having a Brief Interview of Mental Status (BIMS) of 11, indicating the resident was moderately cognitively impaired. Review of Section I - Active Diagnoses revealed Resident #37 had a triggered diagnosis of Depression listed.
Review of Resident #37's Pre-admission PASRR Level 1 Screening and Determination Review Form was attempted with no documentation available from the facility.
On 06/27/2024 at 12:30 p.m., an interview was conducted with S11SSD. She confirmed Resident #37 did not have a Level 1 Pre-admission Screening and Resident Review form on file.
On 06/27/2024 at 12:50 p.m., an interview was conducted with S10AA. She confirmed Resident #37 did not have a Level 1 Pre-admission Screening and Resident Review form on file.
2.
Review of Resident #46's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Anxiety Disorder, Depression, and Bipolar Disorder.
Review of the annual MDS with ARD of 05/23/2024, revealed the provider assessed the resident as having a BIMS of 14, which indicated the resident was cognitively intact. Review of Section A - Identification Information revealed Resident #46 was not considered for a Level II PASRR for having a serious mental illness. Review of Section I - Active Diagnoses revealed Resident #46 had a triggered diagnosis of Bipolar Disease listed.
Review of Resident #46's Notice of Medical Certification dated 05/21/2024 revealed Resident #46 was approved for Medicaid medical eligibility services for a temporary period effective 05/21/2024 through 08/29/2024 for skilled therapies. No documentation regarding the Level II PASRR evaluation was completed despite Resident #46 having had active diagnoses of Depression and Bipolar Disorder.
Review of Resident #46's Level 1 Pre-admission Screening and Resident Review completed by a social worker at a local hospital dated 05/21/2024, indicated Resident #46 did not have presently or at any point a mental disorder which could have led to chronic disability.
Review of Resident #46's Care Plan revealed the following:
Onset: 05/23/2024
Problem: At risk for inattention, depressed mood, sleep changes, anxiety, suspiciousness, withdrawal, unusual thoughts and beliefs, delusions, hallucinations, disorganized speech, and difficulty functioning secondary to diagnosis of Bipolar.
Intervention: Administer medications as ordered; Observe for effectiveness; Notify MD as needed.
Review of the facility Provider admission Progress Note dated 05/24/2024 for Resident #46 revealed the following:
admitted to facility from local hospital for skilled care due to generalized weakness on 05/23/2024. Continue Buspar, Effexor, Trazodone for Bipolar 1 Disorder, monitor mood and consult psych NP if needed. Signed by: S12NP.
On 06/25/2024 at 1:35 p.m., an interview was conducted with S11SSD. She stated she was in charge of Level II PASRR's for the facility's residents. She stated all residents who are newly admitted to the facility are required to have a Level I Pre-admission Screening and Resident Review and Notice of Medical Certification prior to physical entry into the facility. She stated when she received the Notice of Medical Certification, she looked to see if a determination was needed for Level II PASRR to be completed. If the determination had been made for the Level II to be completed, she ensured the proper paperwork had been submitted to the proper offices for their evaluation and decision. She stated she did not enter diagnoses for residents upon admission to the facility, so she assumed the person who had filled out the Level I Pre-admission Screening form prior to the resident's arrival to the facility filled the form out correctly for the Level II determination to be made correctly. S11SSD stated she would assume the person who was completing the Level I Pre-admission Screening would fill the screening form out correctly to ensure the resident was properly screened prior to admission and arrival to the nursing facility.
On 06/25/2024 at 1:40 p.m., an interview was conducted with S21MDS and S22MDS. S21MDS stated she was the coordinator responsible for completing the MDS for Resident #46. She stated she was aware Resident #46 had a diagnosis of Bipolar Disorder and also did not have a Level II PASARR completed. S21MDS stated she did not question not having a Level II PASRR for Resident #46 despite her having a diagnosis of Bipolar because a Level II was not always required. S22MDS stated her and S21MDS do not do anything with regards to ensuring accuracy or completion of the Level I and/or Level II PASRRs, they just document in the MDS if one was required based on the list provided by S11SSD. If a PASRR Level II was required, S22MDS stated either her or S21MDS would ensure the resident was care planned accordingly. S22MDS and S21MDS agreed they would assume the person who was completing the Level I Pre-admission Screening would fill the screening form out correctly to ensure the resident was properly screened.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to m...
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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 services were provided by the facility to meet quality professional standards. The facility failed to ensure documentation of weekly nurses' notes were filed as documented on the TAR for 1 (#46) of 32 residents investigated in the final sample.
Findings:
Review of Resident #30's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus, Essential Primary Hypertension, Rheumatoid Arthritis, Supraventricular Tachycardia, Vascular Dementia, Metabolic Encephalopathy, Cognitive Communication Deficit, and Bilateral Hearing Loss.
Review of Resident #30's Physician's Orders revealed the following:
04/27/2023 Weekly Nurses note should be performed every Friday on 2:00-10:00 p.m. shift
Review of Resident #30's TAR for May and June 2024 revealed the following:
Task: Weekly Nursing Note
Further review revealed the task had a checkmark, which indicated the task was completed on the following dates: 05/03/2024, 05/10/2024, 05/24/2024, 05/31/2024, 06/07/2024, 06/14/2024 and 06/21/2024.
Review of Resident #30's Nurses' Notes for May and June 2024 revealed there was no evidence nurses notes had been documented on the following dates: 05/03/2024, 05/10/2024, 05/24/2024, 05/31/2024, 06/07/2024, 06/14/2024 and 06/21/2024.
An interview was conducted with S17LPN on 06/26/2024 at 2:35 p.m. He stated a checkmark on the TAR meant a nursing task had been acknowledged. He stated the checkmark on the nursing task for weekly nurses' note dated on 06/07/2024 by him indicated he was aware and acknowledged the task to document a weekly nurses' note. He reviewed Resident #30's nursing notes and stated he did not document a nurses' note on 06/07/2024 and should have.
An interview was conducted with S27LPN on 06/27/2024 at 9:55 a.m. She stated a checkmark on the TAR meant a nursing task had been acknowledged. She stated the checkmark on the nursing task for weekly nurses' notes dated on 05/03/2024, 05/10/2024, 05/24/2024, 05/31/2024, 06/14/2024 and 06/21/2024 by her indicated she was aware and acknowledged the task to document a weekly nurses' note. She reviewed Resident #30's nursing notes and stated she did not document a nurses' notes on 05/03/2024, 05/10/2024, 05/24/2024, 05/31/2024, 06/14/2024 and 06/21/2024 and should have.
An interview was conducted with S4ADON on 06/26/2024 at 2:40 p.m. He stated a check mark on the TAR meant the staff was acknowledging and were aware of the order. He confirmed there were no nurses' notes documented on 05/03/2024, 05/10/2024, 05/24/2024, 05/31/2024, 06/07/2024, 06/14/2024 and 06/21/2024.
An interview was conducted with S2DON on 06/26/2024 at 2:55 p.m. He stated if a Physician's Order for weekly nurses' notes was placed for a resident, he would expect nursing staff to document a note despite if the resident had any changes or not. He stated a checkmark on the TAR for weekly nurses' note indicated the staff member had acknowledged and was aware of the task to complete the nurses' note during the shift. He confirmed Resident #30 had a Physician's Order for weekly nurses' noted on Fridays during the 2:00 p.m.-10:00 p.m. shift. He confirmed the TAR revealed a check mark documentation from nursing staff for every Friday during May and June 2024 indicating nursing staff were aware and acknowledged the task for a weekly nurses' note to be completed. He confirmed there were no nurses' notes documented on 05/03/2024, 05/10/2024, 05/24/2024, 05/31/2024, 06/07/2024, 06/14/2024 and 06/21/2024. He confirmed the expectation was for nursing staff to document at least weekly on a resident and they had not for Resident #30.
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
Tube Feeding
(Tag F0693)
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 a resident received enteral feedings as orde...
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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 a resident received enteral feedings as ordered by the physician for 1 (#19) of 3 (#1, #19, and #72) residents reviewed for tube feeding.
Findings:
Review of Resident #19's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Muscle Wasting and Atrophy, Dysphagia, and Gastrostomy Status.
Review of Resident #19's Annual MDS with an ARD of 04/12/2024 revealed, in part, a BIMS of 11, which indicated moderate cognitive impairment. Further review revealed Resident #19 did not exhibit rejection of care.
Review of Resident #19's current Care Plan revealed the following, in part:
Problem: I am at risk for adequate nutrition; I have a PEG tube; I have a diagnosis of Dysphagia; and I am NPO.
Interventions: Provide feedings per MD order.
Problem: I am NPO; I require tube feeding; I am at risk for aspiration related to my diagnosis of Dysphagia; and I am disconnected from my tube feeding as ordered due to I like to propel myself around facility at times.
Interventions: Provide resident with feeding and fluids as ordered
Further review of Resident #19's care plan revealed no documentation Resident #19 refused enteral feedings.
Review of Resident #19's current Physician Orders revealed the following, in part:
Diet: Nothing by mouth;
Two Cal HN 0.08 gram - 2 KCAL/mL run at 40 mL/hr for 20 hours from 6:00 p.m. - 2:00 p.m. via PEG tube; and
Stop tube feeding 4 hours a day from 2:00 p.m. to 6:00 p.m.
Review of Resident #19's MAR dated June 2024 revealed no documentation tube feeding was held or refused during the scheduled administration times of 6:00 p.m. to 2:00 p.m.
Review of Resident #19's Nurses' Notes dated February 2024 through 06/27/2024 revealed no documented refusals of PEG feedings. Further review revealed no documentation PEG feedings were held.
An observation was made of Resident #19 on 06/24/2024 at 8:43 a.m. Her PEG tube feeding was not connected or infusing.
An interview was conducted with Resident #19 on 06/24/24 8:45 a.m. She stated sometimes the staff did not connect her tube feeding as scheduled.
An observation was made of Resident #19 on 06/24/2024 at 12:33 p.m. She was in the hallway in her wheelchair with no PEG tube feeding infusing.
An interview was conducted with S32LPN on 06/26/2024 at 1:38 p.m. She stated Resident #19's PEG tube feedings were scheduled to connect at 6:00 p.m. and disconnect the following day at 2:00 p.m. She confirmed there were some days, including 06/24/2024, Resident #19 did not receive her PEG tube feedings for the physician ordered time frame
An interview was conducted with Resident #19 on 06/26/2024 at 2:11 p.m. She confirmed her PEG tube feedings were to start at 6:00 p.m. and disconnect at 2:00 p.m. the following day. She stated she never refused her PEG tube feedings. She stated sometimes the staff did not reconnect her PEG tube feedings when they were due.
An interview was conducted with S31CNA on 06/26/2024 at 2:21 p.m. She stated she was frequently assigned to Resident #19. She confirmed Resident #19 had a PEG tube she gets feeding through, and she did not consume any calories by mouth. She stated the nurse was responsible to connect and disconnect the tube feeding. She stated when she would get Resident #19 up in the morning, Resident #19 would ask the nurse to disconnect the tube feeding so she could propel through the facility. She stated Resident #19 usually got back in bed around 11:30 a.m. and the nurse would reconnect her PEG tube feeding. She stated during the time frame of her being up, she is not connected to her tube feeding. She stated Resident #19 was cognitively intact and never refused feedings or care.
An interview was conducted with S30CNA on 06/27/2024 at 8:43 a.m. She stated Resident #19 received PEG tube feedings. She stated Resident #19 likes to get out of bed around 10:00 a.m. and will ask the nurse to come disconnect her tube feeding. She stated Resident #19 usually stays out of her room and propels herself around the facility. She stated on Monday, she got Resident #19 out of bed around 10:00 a.m., and she did not go back to her room on her shift, which meant she did not have her tube feeding. She stated she left her shift at 2:00 p.m., and Resident #19 was still up in her wheelchair and not in her room. She stated Resident #19 was compliant with her care. She stated Resident #19 was not the type of resident to refuse things. She stated the reason Resident #19 requests to have her tube feeding disconnected is because she wants to roam the facility.
An interview was conducted with S26LPN on 06/27/2024 at 8:52 a.m. She confirmed Resident #19 had continuous PEG tube feeding ordered from 6:00 p.m. to 2:00 p.m. the following day, which meant it was held from 2:00 p.m. to 6:00 p.m. daily. She stated Resident #19 often asked the nurse to disconnect the tube feeding because she wanted to propel through the facility. She stated Resident #19 was compliant with her care and was not the type of resident to refuse care.
An interview was conducted with S3ADON on 06/27/2024 at 9:04 a.m. She stated Resident #19 had tube feeding scheduled 6:00 p.m. to 2:00 p.m. She confirmed Resident #19's tube feeding should have been administered as ordered. She stated there should have been documentation if tube feedings were not administered as ordered and there was not.
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
Medication Errors
(Tag F0758)
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 drug regimen was free from unnecessary psychot...
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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 drug regimen was free from unnecessary psychotropic medications by failing to ensure there was an acceptable diagnosis for antidepressant and anti-anxiety medications for 1 (#72) of 5 (#10, #46, #72, #117 and #132) residents reviewed for unnecessary medications.
Findings:
Review of the facility's policy titled Use of Psychotropic Drugs with a revision date of 10/2020 revealed the following, in part:
Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record .
1. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics.
Review of Resident #72's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction and Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
Review of Resident #72's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/2024, revealed the following, in part:
Section N- Medications
Antianxiety (is taking) - Checked
Antianxiety (indication noted) - Checked
Antidepressant (is taking) - Checked
Antidepressant (indication noted) - Checked
Review of Resident #72's current Physician Orders revealed the following, in part:
Start date 05/31/2024 Escitalopram Oxalate 20 mg give one tablet via peg tube one time a day for Dementia.
Start date 05/31/2024 Lorazepam 1 mg give one tablet via peg tube one time a day for Unspecified Dementia.
Review of Resident #72's MAR dated May 2024 - June 2024 revealed he received Escitalopram Oxalate daily at 8:00 p.m. with a diagnosed condition of Dementia for the use of the psychotropic medication. Further review revealed he received Lorazepam daily at 5:00 a.m. with a diagnosed condition of Unspecified Dementia for the use of the psychotropic medication.
On 06/25/2024 at 1:17 p.m., an interview was conducted with S12NP. She said she reviewed all resident physician orders, including medications, once monthly. She reviewed Resident #72's list of diagnoses and current physician orders. She verified Resident #72's Escitalopram Oxalate and Lorazepam were ordered with a documented diagnosis of Dementia. She confirmed Dementia was not an acceptable diagnosis for these psychotropic medications.
On 06/25/2024 at 2:10 p.m., an interview was conducted with S15LPN. She reviewed Resident #72's current physician orders and verified he was prescribed Escitalopram Oxalate and Lorazepam daily with a documented diagnosis of Dementia. She confirmed Dementia was not an acceptable diagnosis for these psychotropic medications.
On 06/25/2024 at 3:15 p.m., an interview was conducted with S2DON. He reviewed Resident #72's current physician orders and verified he was prescribed Escitalopram Oxalate and Lorazepam daily with a documented diagnosis of Dementia. He confirmed Escitlopram and Lorazepam were psychotropic medications and Dementia was not an acceptable diagnosis for these medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**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. The facility failed to ensure medications were in locked compartments permitting only authorized personnel to have access for 1 (#28) of 34 residents observed during initial screening of residents upon facility entrance.
Findings:
Review of the facility's policy titled Medication Administration Storage dated 04/2022 revealed the following:
Policy Explanation and Compliance Guidelines:
1.General Guidelines:
a.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .
b.During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage areas/cart.
Review of Resident #28's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Age-Related Cognitive Decline, Shortness of Breath, Essential (Primary) Hypertension, Unspecified Atrial Fibrillation, and Heart Failure.
Review of Resident #28's quarterly MDS with an ARD of 03/18/2024 revealed a BIMS of 14, which indicated resident was cognitively intact.
Review of Resident #28's active Physicians Orders revealed the following in part:
Diltiazem HCl Tab 60mg - Give 60 mg orally on time a day.
Acetaminophen Tab 325mg - Give 2 tablets orally two times a day for Pain
Oyster Shell 250 mg-D3 3.12mcg - Give 1 capsule orally two times a day
On 06/24/2024 at 9:04 a.m., an observation was made of Resident #28 sitting in her room in a wheelchair with granddaughter at her side. 3 loose pills were noted on top of Resident #28's bedroom refrigerator. No nursing staff were observed in the room at this time. Resident #28 verified the medications on top of the refrigerator were her medications.
On 06/24/2024 at 9:06 a.m., an observation was made of Resident #28's room with S18LPN. 3 loose pills were noted on top of Resident #28's bedroom refrigerator. S18LPN identified the 3 pills on the refrigerator as Oscal Vit D, Diltiazem, and Tylenol. S18LPN confirmed pills should not have been stored on the refrigerator.
On 06/25/24 at 4:07 p.m., an interview was conducted with S3ADON. She confirmed the nurse should never leave the medication at the bedside.
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 F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received a therapeutic diet as orde...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received a therapeutic diet as ordered by the physician for 1 (#132) of 3 (#102, #131, #132) residents reviewed for food.
Findings:
Review of the facility's policy last approved May 2023 and titled, Therapeutic Diet Orders revealed the following, in part:
Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.
5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.
Review of Resident #132's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Muscle Wasting and Atrophy, Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, and Type 2 Diabetes Mellitus.
Review of Resident #132's Current Physician Orders revealed, in part, a diet order for double portions of protein and vegetables with all meals.
Review of Resident #132's Quarterly MDS with an ARD of 05/06/2024 revealed he had a BIMS Summary Score of 15, which indicated he was cognitively intact.
An interview was conducted with Resident #132 on 06/24/2024 at 10:11 a.m. He stated he was supposed to receive double portions of proteins and vegetables. He stated he frequently did not receive his ordered double portions.
An observation was made of Resident #132's lunch tray and meal ticket on 06/24/2024 at 2:05 p.m. Resident #132's lunch tray had one serving of red beans and rice, sausage, and greens. Resident #132 did not have double portions of protein and vegetables.
Resident #132's lunch meal ticket dated 06/24/2024 revealed he should have received double portions of protein and vegetables with all meals.
An observation was made of Resident #132's lunch tray on 06/24/2024 at 2:16 p.m. with S6DM present. An interview was conducted with S6DM at that time. S6DM confirmed Resident #132 was served single portions of all lunch meal items and should have been served double portions of sausage and greens.
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 ensure all medical records regarding the resident's code status co...
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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 all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#30) of 36 residents reviewed in the initial screening for advanced directives.
Findings:
Review of the facility's policy with a last approved date of 05/2023 titled Residents' Rights Regarding Treatment and Advance Directives revealed the following:
Policy:
It is the policy of this facility to support and facilitate a resident's right to . formulate an advance directive.
Policy Explanation and Compliance Guidelines:
3. Should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.
Review of Resident #30's clinical record revealed she was admitted to the facility on [DATE].
Review of the quarterly MDS with an ARD of [DATE] revealed Resident #30 had a BIMS of 1, which indicated she had severe cognitive impairment.
Review of Resident #30's Advanced Directive in her physical chart dated [DATE] revealed the following:
A. Cardiopulmonary Resuscitation (CPR): Box checked - DNR/Do Not Attempt Resuscitation (Allow Natural Death)
D. Summary: Discussed with Personal Health Care Representative (PHCR); the basis for these orders is: Box Checked - Patient's Personal Health Care Representative (Qualified Patient without Capacity)
Signed by: Resident #30's PHCR and Hospice physician on [DATE]
Review of Resident #30's Care Plan revealed the following:
Onset: [DATE]
Problem: Resident is a DNR
Intervention: Alert staff of DNR status; Keep copy of advanced directives on chart; Honor resident/family wishes in regards to DNR code status
Review of Resident #30's [DATE] and [DATE] Physician's Orders revealed the following:
[DATE] Code Status: Full Code
On [DATE] at 1:20 p.m., an interview was conducted with S17LPN. He stated Resident #30 was a DNR. He confirmed Resident #30's Physician's Orders in her electronic medical record stated full code. He stated he would go by what was in the Resident's hard copy chart.
On [DATE] at 3:28 p.m., an interview was conducted with S15LPN. She stated for a resident's code status she would look in the computer orders and then double check the hard chart to confirm. She stated if the code status in the hard chart and computer did not match, she would go by the signed forms in the hard chart.
On [DATE] at 12:35 p.m., an interview was conducted with hospice nurse from Resident #30's local hospice company. She stated Resident #30 was a DNR as of [DATE] when her sister/RP signed a new advanced directive document. She stated a copy of the new advanced directive was provided to the facility, and was also kept in her hospice binder at the facility. She stated she would expect the facility's EHR orders for code status to match what the paper copy in the hard chart was.
On [DATE] at 9:55 a.m., an interview was conducted with S27LPN. She stated Resident #30's Physician's Orders in her electronic medical record stated full code. She stated she would go by what was in the Resident's hard copy chart.
On [DATE] at 11:25 a.m., an interview was conducted with S2DON. He stated the expectation was for staff to check the paper chart for a resident's code status in the case of an emergency. He reviewed Resident #30's advanced directive dated [DATE] in her hospice binder, facility hard chart, and also the Physician's Orders from the EHR for May and June of 2024. He confirmed the advanced directive dated on [DATE] was signed by the hospice MD provider and Resident #30's responsible party designating Resident #30 as a DNR. He confirmed the Physician's Orders from the EHR for both May and [DATE] stated Resident #30 was a full code. He confirmed both the EHR and hard chart code statuses should match and they did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
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 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 binder with current orders, certification period and care plans for 1 (#30) of 4 (#28, #72, #30 and #78) residents reviewed for hospice care.
Findings:
Review of the Hospices Services Agreement with an effective date of 10/01/2020 between the facility and local hospice company revealed the following:
Article III Facility Services
Section 3.5 Facility shall:
d) The Facility's designated interdisciplinary team member is responsible for the following:
4) Obtaining the following information from the hospice: (A) The most recent hospice plan of care specific to each patient; (C) Physician certification and recertification of the terminal illness specific to each patient; (F) Hospice medication information specific to each patient; and (G) Hospice physician and attending physician (if any) orders specific to each patient.
Review of the facility's policy last approved 05/2023 titled Hospice Services Facility Agreement revealed the following:
Policy:
Policy Explanation and Compliance Guidelines:
6. The designated member of the facility working with hospice representative is responsible for:
d. Obtaining the following information from the hospice:
i. The most recent hospice plan of care specific to each resident
iii. Physician certification and recertification of the terminal illness specific to each resident
vi. Hospice medication information specific to each resident
vii. Hospice physician and attending physician (if any) orders specific to each resident
Review of Resident #30's clinical record revealed she was admitted to the facility on [DATE] and was admitted into hospice services on 01/10/2024.
Review of Resident #30's current Physician's Orders revealed the following:
01/10/2024 Consult and admit to local hospice agency for Vascular Dementia, RA and DM2
Review of Resident #30's current Care Plan revealed the following:
Onset: 03/11/2024
Problem: Resident #30 has chosen to receive hospice care from St. [NAME] hospice as of 02/02/2024.
Review of Resident #30's Nurses' Notes revealed the following:
02/02/2024 7:44 p.m. Hospice nurse from local hospice agency arrived at facility to admit resident to hospice. Signed by: S28LPN
Review of Resident #30's Hospice Medical Records maintained by the facility revealed no plan of care, hospice staff assessments, physicians' orders (current or standing), or physician certification/recertification for terminal illness.
On 06/26/2024 at 11:30 a.m., an interview was conducted with S2DON. He stated he was responsible for ensuring each hospice resident's binder was up to date in partner with the hospice care team. S2DON reviewed Resident #30's hospice binder and confirmed there was no plan of care, physician certification/recertification for terminal illness, current/standing orders or hospice care team assessments in her hospice medical binder and there should have been.
On 06/26/2024 at 12:35 p.m., an interview was conducted with Resident #30's hospice nurse who stated Resident #30 was currently admitted to the local hospice agency. The hospice nurse reviewed Resident #30's hospice medical record and confirmed it did not contain a plan of care, physician certification/recertification for terminal illness, current/standing orders or hospice care team assessments plan of care and it should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control progr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S13TN and S16CNA wore proper Personal Protective Equipment while providing care for 1 (#72) of 3 (#1, #19, and #72) sampled residents reviewed for peg tube care.
Findings:
Review of the facility's policy titled Enhanced Barrier Precautions with a revision date of 03/2024 revealed the following, in part:
Policy: It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug-resistant organisms.
Definitions: Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities.
3. Implementation of Enhanced Barrier Precautions:
b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .
High-contact resident care activities include:
Device care or use: (feeding tubes)
Review of Resident #72's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Malignant Neoplasm of Larynx and Gastrostomy Status.
On 06/26/2024 at 8:39 a.m., an observation was made of a sign on Resident #72's door, which stated Enhanced Barrier Precautions Required.
On 06/26/2024 at 8:40 a.m., an observation was made of peg tube care for Resident #72 with S13TN and S16CNA. S13TN did not don a gown and performed peg tube care and repositioning of Resident #72 in bed. S16CNA assisted S13TN with peg tube care and repositioning Resident #72 in bed and did not don a gown or gloves.
On 06/26/2024 at 8:50 a.m., an interview was conducted with S13TN. She said Resident #72 had a peg tube and was on Enhanced Barrier Precautions to prevent infections. She confirmed she should have worn a gown and S16CNA should have worn a gown and gloves when providing care to Resident #72.
On 06/26/2024 at 8:56 a.m., an interview was conducted with S16CNA. She said Resident #72 had a peg tube and was on Enhanced Barrier Precautions. She confirmed she did not don a gown or gloves when providing care for Resident #72 and should have.
On 06/26/2024 at 9:30 a.m., an interview was conducted with S2DON. S2DON stated Enhanced Barrier Precautions were used for any resident with an indwelling device or wounds to prevent infections. He verified Resident #72 had a peg tube and was on Enhanced Barrier Precautions. He confirmed S13TN and S16CNA should have donned a gown and gloves when providing care to Resident #72.
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 record review and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screenin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASARR) Level II by failing to:
1. Refer all Level II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II resident review after expiration of 6 month temporary effective period for 1 (#5) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASARR; and
2. Incorporate a PASARR Level II determination and recommendations into a resident's care plan for 1 (#37) of 5 (#5, #12, #37, #46 and #131) residents reviewed for PASRR.
Findings:
1.
Review of Resident #5's Clinical Record revealed she was admitted to facility on [DATE] with diagnoses, which included in part Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Other Bipolar Disorders, and Depression.
Review of Resident #5's quarterly MDS with ARD of [DATE] revealed a BIMS of 12, which indicated the resident was moderately impaired.
Louisiana Department of Health and Hospitals Medicaid Program Notice Of Medical Certification was reviewed and revealed Resident #5 was approved for admission by Level II Authority for a temporary period effective [DATE] through [DATE]. There was no documentation found that a Level II screening had been resubmitted after expiration. Further review revealed there was no documentation of recommendations from PASARR II determination.
On [DATE] at 10:05 a.m., an interview was conducted with S11SSD. She confirmed the PASARR for Level II for Resident #5 was expired and had not been resubmitted.
On [DATE] at 10:09 a.m., an interview was conducted with S10AA. She stated Resident #5's Level II PASARR was not resubmitted after expiration. She stated PASARR would only be resubmitted if/when private pay ended or if there was a significant change with a resident. She stated no recommendations were given at the time of Resident #5's temporary approval due to COVID 19. She confirmed the PASARR was expired and had not been resubmitted. She also confirmed the PASARR was never resubmitted after COVID, therefore recommendations were never received.
2.
Review of Resident #37's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Other Sequelae of Cerebral Infarction, Unspecified Mood Affective Disorder and Recurrent Severe Major Depressive Disorder with Psychotic Symptoms. Further review revealed she was approved for admission by Level II Authority for a temporary period effective [DATE] through [DATE].
Review of Resident #37's current Care Plan revealed no documentation of Level II PASARR recommendations.
On [DATE] at 12:30 p.m., an interview was conducted with S11SSD. She stated she was responsible for PASARRs at the facility. She stated Resident #37 was approved for Level II services in [DATE]. She stated MDS was responsible for updating resident care plans. She stated she notified the MDS nurses when a resident was approved for Level II services. She stated Resident #37's care plan had not been updated with the Level II recommendations because she had not notified S14LPN and should have.
On [DATE] at 1:28 p.m., an interview was conducted with S14LPN. She stated she was responsible for resident care plans. She stated S11SSD notified her when a resident was approved for a Level II PASARR and she updated the resident care plan. She stated she was not aware Resident #37 was approved for Level II services. She confirmed Resident #37 was not care planned for a Level II PASARR and should have been.
On [DATE] at 2:45 p.m., an interview was conducted with S2DON. He stated S11SSD was responsible for resident PASARR's. He stated the MDS nurses were responsible for updating resident care plans. He confirmed S14LPN should have notified when S11SSD received Resident #37's Level II determination and the care plan should have been updated.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 maintain acceptable parameters of nutritional statu...
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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 maintain acceptable parameters of nutritional status by failing to implement interventions after weight loss for 1 (#45) of 5 (#17, #19, #45, #52, and #132) residents reviewed for nutrition.
Findings:
Review of Resident #45's clinical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses, which included Osteomyelitis, Stage 3 Pressure Ulcer Of Sacral Region, Stage 4 Pressure Ulcer Of Right Ankle, Stage 3 Pressure Ulcer Of Other Site, Stage 4 Pressure Ulcer Of Other Site, Stage 3 Pressure Ulcer Of Right Ankle, Stage 2 Pressure Ulcer Of Sacral Region, Type 2 Diabetes Mellitus Without Complications, and Dysphagia.
Review of Resident #45's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/2024, revealed the provider assessed the resident as having a BIMS of 12, which indicated the resident was moderately cognitively impaired.
Review of Resident #45's current care plan revealed the following, in part:
I am at risk for weight loss related to my diet
Interventions:
Supplements as ordered
Review of Resident #45's weights from May 2024 to June 2024 revealed the following:
04/2024- 204 pounds
5/28/2024- 177 pounds
6/14/2024- 170 pounds
Review of Resident #45's current Physician Orders revealed the following, in part:
Start date 06/02/2024 Boost with meals for Maintenance
Review of Resident #45's MAR dated June 2024 revealed no documentation a Boost supplement or equivalent was administered to Resident #45.
On 06/25/2024 at 8:30 a.m., an observation was made of Resident #45 in bed eating breakfast. Review of Resident #45's meal card revealed no documentation he received a Boost. He did not have a Boost on his meal tray.
On 06/25/2024 at 1:30 p.m., an interview was conducted with S35CNA. He said he was assigned to Resident #45 and set up his meal trays. He said he never saw a Boost supplement on Resident #45's meal trays. He verified the Boost supplement was not printed on Resident #45's meal tickets.
On 06/26/2024 at 8:39 a.m., an observation was made of Resident #45 in bed eating breakfast. Review of Resident #45's meal card revealed no documentation he received a Boost. He did not have a Boost supplement on his meal tray.
On 06/26/2024 at 9:00 a.m., an interview was conducted with Resident #45. He said he never received a Boost on his meal trays. He said he would like a Boost with his meals and would drink it if it was provided. He said he needed all the protein he could get to help his wounds heal.
On 06/26/2024 at 9:02 a.m., an observation was made of Resident #45 with S36CNA present. S36CNA said she was assigned to Resident #45. S36CNA observed Resident #45's meal tray and confirmed there was no supplement or Boost on the meal tray. S36CNA reviewed Resident #45's meal ticket and confirmed there was no documentation a Boost or supplement was required on the meal tray.
On 06/26/2024 at 9:18 a.m., an interview was conducted with S15LPN. She said she was assigned to Resident #45, who had pressure ulcers. She said the dietician made recommendations for supplements. She said the facility did not carry Boost supplements. She reviewed Resident #45's current physician orders and verified, on 06/02/2024, he was ordered Boost with all meals. She said the order for Boost was entered under dietary, not under the MAR, so the nurses were not triggered to ensure Resident #45 received the Boost. She said the supplement should have been provided by nursing staff. She confirmed Resident #45 was ordered a Boost supplement for weight loss and he should have received it.
On 06/26/2024 at 11:30 a.m., an interview was conducted with S37RD. She said Resident #45 had a 16% weight loss in 60 days, with an additional 4% weight loss over the last 30 days. She said she followed Resident #45's weights monthly because he had wounds and weight loss. She said she made recommendations for Resident #45 to receive Boost with all meals due to his weight loss. She said she was not aware Resident #45 was not receiving the Boost supplement, and the resident reported he wanted them. She said she saw Resident #45 on 06/24/2024 and sent recommendations on 06/25/2024 to continue the Boost supplement or house equivalent with all meals due to his weight loss.
On 06/26/2024 at 12:30 p.m., an interview was conducted with S12NP. She said Resident #45 had wounds and weight loss, and the dietician was following him. She said she was aware Resident #45 was ordered Boost supplements for his wounds and weight loss, but was not aware he was not receiving them. She said Resident #45 should have been receiving the Boost supplement as ordered.
On 06/27/2024 at 1:45 p.m., an interview was conducted with S5ADON. She said the dietician assessed the residents and provided recommendations. She said the dietician's recommendations were sent to S12NP to approve, and the floor nurses or administrative nurses entered the orders. She reviewed Resident #45's physician order dated 06/02/2024 for Boost with meals and confirmed the order did not trigger for nursing or dietary staff. She said ordered supplements should have been offered and provided. She reviewed and confirmed Resident #45 had a 7 pound weight loss documented from 05/28/2024 to 06/14/2024.
On 06/26/2024 at 9:35 a.m., an interview was conducted with S2DON. He said S37RD made recommendations for supplements and S12NP reviewed and approved them. He said supplements were either provided from dietary or nursing. He said ordered supplements should have been provided. He reviewed Resident #45's weights dated May 2024 to June 2024 and confirmed Resident #45 had significant weight loss. He confirmed Resident #45 not receiving the Boost supplement or an equivalent as ordered could have contributed to his continued weight loss.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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:
1. Physician ordered narcotic pain medication was availabl...
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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:
1. Physician ordered narcotic pain medication was available for administration for 1 (#132) of 5 (#5, #12, #45, #78, and #132) residents reviewed for pain management; and
2. As needed narcotic pain medication was documented as administered on the MAR for 1 (#132) of 5 (#5, #12, #45, #78, and #132) residents reviewed for pain management.
Findings:
1.
Review of the facility's Medication Reordering policy with an approval date of May 2023 revealed the following, in part:
Policy: it is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident.
Policy Explanation and Compliance Guidelines:
1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident.
3. Each time a nurse is administering medications and observes 6 or less doses left of one kind, that nurse will reorder the medication, time permitting.
Review of Resident #132's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, and Other Chronic Pain.
Review of Resident #132's Current Care Plan revealed the following, in part:
Problem:
I am at risk for pain. Resident complains of phantom pain to bilateral leg amputations
Interventions:
Administer medication as ordered
Review of Resident #132's Quarterly MDS with an ARD of 05/06/2024 revealed he had a BIMS Summary Score of 15, which indicated he was cognitively intact.
Review of Resident #132's Physician Orders revealed the following, in part:
Start: 05/01/2024, Discontinued: 06/14/2024 Endocet (Oxycodone HCl-Acetaminophen) Tablet 10-325 mg 1 tablet by mouth every 6 hours as needed for pain; and
Start: 06/14/2024 Percocet (Oxycodone-Acetaminophen) 10-325 mg every 8 hours as needed for pain.
Review of Resident #132's Individual Narcotic Record for Oxycodone-Acetaminophen revealed the following, in part:
06/13/2024 at 2:30 a.m. - amount on hand - 1; amount given - 1; amount remaining - 0; name of person giving - S23LPN
Further review revealed Resident #132's Oxycodone-Acetaminophen 10-325 mg was refilled on 06/14/2024 and administered on 06/14/2024 at 1:49 p.m. by S26LPN
Review of Resident #132's Nurses' Notes January 2024 through 06/25/2024 revealed the following, in part:
06/13/2024 at 7:00 a.m. by S26LPN: Resident expressed his pain was a level 6. Resident was given Tylenol 325mg x 2 upon request
An interview was conducted with Resident #132 on 06/24/2024 at 9:43 a.m. He stated the facility ran out of his narcotic pain medication last week. He stated he requested his pain medication every eight hours related to phantom pain from his bilateral below knee amputations.
A telephone interview was conducted with S23LPN on 06/26/2024 at 9:05 a.m. She confirmed she was assigned to Resident #132 on 06/12/2024 from 10:00 p.m. to 6:00 a.m. and 06/13/2024 from 10:00 p.m. to 6:00 a.m. She confirmed she administered Resident #132's last dose of Oxycodone-Acetaminophen on 06/13/2024 at 2:30 a.m. She stated when she worked with Resident #132 on 06/13/2024 from 10:00 p.m. to 6:00 a.m., he requested his Oxycodone-Acetaminophen. She stated there was not any available to administer.
An interview was conducted with S26LPN on 06/26/2024 at 3:11 p.m. She confirmed she was assigned to Resident #132 on 06/13/2024 and 06/14/2024 from 6:00 a.m. to 10:00 p.m. She stated Resident #132 ran out of his Oxycodone-Acetaminophen during this time. She stated Resident #132 was out of his pain medication for a whole day. She stated Resident #132 requested his pain medication, she went to administer the medication, and there was none available. She stated the facility should not have run out of Resident #132's pain medication.
An interview was conducted with S12NP on 06/26/2024 at 12:44 p.m. She stated the facility was responsible to notify her when they were running low on any resident's narcotic pain medication. She explained narcotic pain medications required a hard script be sent to the pharmacy. She stated her process was to write the medication order and have S25MD sign off on the hard script, and then she sent it to the pharmacy. She stated she was not notified Resident #132 was running low on his Oxycodone-Acetaminophen until he only had two pills left. She stated the facility did not notify her in enough time to have the medication to the facility prior to Resident #132 running out. She confirmed since the medication was ordered as needed, it should have been available as needed.
A telephone interview was conducted with S24P on 06/26/2024 at 12:36 p.m. He stated the pharmacy received the hard script for Resident #132's Oxycodone-Acetaminophen on 06/14/2024 at 7:00 a.m. and the medication was filled and delivered to the facility on [DATE].
An interview was conducted with S3ADON on 06/26/2024 at 3:47 p.m. She stated she was aware Resident #132 ran out of his pain medication in June 2024. She confirmed the facility should not have run out of Resident #132's narcotic pain medication and it should have been available for administration.
2.
Review of the facility's Controlled Substance Administration & Accountability policy with an approval date of May 2024 revealed the following, in part:
Policy Explanation and Compliance Guidelines:
1. General Protocols:
f. All controlled substances are accounted for in one of the following ways:
ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form.
g. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record.
Review of Resident #132's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee, and Other Chronic Pain.
Review of Resident #132's Physician Orders revealed the following, in part:
Start: 05/01/2024, Discontinued: 06/14/2024 Endocet (Oxycodone HCl-Acetaminophen) Tablet 10-325 mg 1 tablet by mouth every 6 hours as needed for pain; and
Start: 06/14/2024 Percocet (Oxycodone-Acetaminophen) 10-325 mg every 8 hours as needed for pain.
Review of Resident #132's Individual Narcotic Record for Oxycodone revealed the following, in part:
06/10/2024 at 4:00 a.m. - amount on hand - 8; amount given - 1; amount remaining - 7; name of person giving - S23LPN
06/11/2024 at 10:00 a.m. - amount on hand - 7; amount given - 1; amount remaining - 6; name of person giving - S23LPN
06/12/2024 at 2:00 a.m. - amount on hand - 5; amount given - 1; amount remaining - 4; name of person giving - S23LPN
06/12/2024 at 8:00 a.m. - amount on hand - 4; amount given - 1; amount remaining - 3; name of person giving - S23LPN
06/12/2024 at 2:00 p.m. - amount on hand - 3; amount given - 1; amount remaining - 2; name of person giving - S23LPN
06/13/2024 at 2:30 a.m. - amount on hand - 1; amount given - 1; amount remaining - 0; name of person giving - S23LPN
Review of Resident #132's MAR dated June 2024 revealed no documentation Resident #132 received his Oxycodone/Acetaminophen 10-325 mg on the following dates and times:
06/10/2024 at 4:00 a.m.,
06/11/2024 at 10:00 a.m.,
06/12/2024 at 2:00 a.m.,
06/12/2024 at 8:00 a.m.,
06/12/2024 at 2:00 p.m., and
06/13/2024 at 2:30 a.m.
A telephone interview was conducted with S23LPN on 06/26/2024 at 9:05 a.m. She confirmed if she signed Resident #132's Oxycodone-Acetaminophen out on the narcotic record, she administered it to Resident #132. She stated she sometimes forgets to document administration of pain medication on the MAR. She stated if she documented administration of Resident #132's Oxycodone-Acetaminophen, it would have been on the MAR. She confirmed she should have documented it on the MAR.
An interview was conducted with S3ADON on 06/26/2024 at 3:47 p.m. She reviewed Resident #132's June 2024 MAR and Narcotic Record from 06/09/2024 through 06/13/2024. She confirmed Resident #132's Oxycodone-Acetaminophen was removed from the medication cart on the above listed dates and times and was not documented administered on Resident #132's MAR and should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to ensure meals were served at regular times comparable to normal times in the community for 1 (Hall B) of 3 (Hall A, Hall B, ...
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Based on observations, interviews, and record review, the facility failed to ensure meals were served at regular times comparable to normal times in the community for 1 (Hall B) of 3 (Hall A, Hall B, and Hall C) halls observed for dining.
Findings:
Review of the facility's policy last approved May 2023 and titled, Frequency of Meals revealed the following, in part:
Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals.
Policy explanation and compliance guidelines:
1. The facility has scheduled three regular meal times, comparable to normal meal times in the community, per day .
Review of the facility's listed meal times revealed 200 Hall should be served lunch at 12:30 p.m.
An interview was conducted with Resident #132 on 06/24/2024 at 10:11 a.m. He resided toward the end of Hall B. He stated meals are often served late. He stated sometimes he received lunch at 2:00 p.m.
An observation was made of Resident #132 on 06/24/2024 at 12:35 p.m. He did not have his lunch tray yet.
An observation was made of Resident #132 on 06/24/2024 at 1:32 p.m. He did not have his lunch tray yet.
An observation was made of the kitchen serving Hall B trays on 06/24/2024 at 1:42 p.m.
An observation was made of a CNA delivering Resident #132's lunch tray on 06/24/2024 at 2:05 p.m.
During the resident council meeting on 06/24/2024 beginning at 2:06 p.m., Resident #103 stated her lunch tray did not come until 2:00 p.m. today and she resided on Hall B.
An interview was conducted with S6DM on 06/24/2024 at 2:16 p.m. She confirmed Hall B should receive their lunch trays at 12:30 p.m. She confirmed lunch was late today and should not have been. She stated 2:00 p.m. lunch was too late.
An interview was conducted with S1ADM on 06/25/2024 at 3:23 p.m. He stated there had been issues in the past with residents complaining of not being served their meals on time. He stated there had not been any complaints recently. He was made aware the end of Hall B received their lunch trays around 2:00 p.m. yesterday and Resident #132 was served lunch at 2:05 p.m. He stated that was not acceptable.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, record review, and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions. This had the potential to effect 141 residents who were ser...
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Based on observations, record review, and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions. This had the potential to effect 141 residents who were served from the kitchen.
Findings:
Review of the policy titled Staff Attire with a revision date of 09/2017 revealed the following, in part:
Procedures:
1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.
Review of the policy titled Food Storage: Cold Foods with a revision date of 04/2018 revealed the following, in part:
Policy Statement
All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.
Procedures
5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
Review of the policy titled Food Storage: Dry Goods with a revision date of 09/2017 revealed the following, in part:
Policy Statement
All dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code.
Procedure:
5. All packaged and canned food items will be kept clean, dry, and properly sealed
6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate.
Review of the policy titled Date Marking for Food Safety with a revision date of 10/2021 revealed the following, in part:
Policy:
The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food.
Policy Explanation and Compliance Guidelines for Staffing:
1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41F or less than a maximum of 7 days.
On 06/24/2024 at 8:10 a.m., an observation was made of S7C in the kitchen. S7C had facial hair on his chin. S7C was not wearing a facial hair restraint.
On 06/24/2024 at 1:43 p.m., an observation was made of S6DM in the dishwashing area of the kitchen. S6DM confirmed she was not wearing a hairnet.
On 06/25/2024 at 12:38 p.m., an interview was conducted with S6DM. S6DM was made aware of the observation of S7C not wearing a facial hair restraint. S6DM confirmed hair nets and facial hair restraints should be worn at all times in the kitchen.
On 06/24/2024 at 8:12 a.m., an initial tour of the kitchen was conducted with S6DM. S6DM observed and confirmed the following findings:
Refrigerator:
A milk crate containing two dented / damaged single serve cartons of milk and an empty 20oz bottle of purple soda
1 unlabeled sandwich in a sandwich bag
1 bag of unsealed grapes
2 opened unsealed bags of lettuce
1 salad covered with cellophane with no date
1 container of peaches with a date of 06/13/2024
1 container of chocolate pudding with a date of 06/04/2024
2 dried spots of a white liquid were on the floor near the door to the refrigerator
Dry Goods Storage:
1 bulk storage container of rice with the scoop laying in the rice
The following items were scattered on the floor:
5 loose single serve packets of sugar
5 loose single serve packets of yellow sweetener
1 opened single serve butter packet
Several loose red colored beans
The bottom shelves of the food preparation tables stored the following items:
1 empty bulk tub of peanut butter
1 opened unsealed packet of brown gravy mix
1 uniform shirt in a plastic retail bag
Drink Dispensing Table:
Juice machine dispensing spouts were hanging down loose and uncovered x2
On the bottom shelf of the drink machine table the following was observed:
A dried reddish colored substance on the air compressor for the drink machine
A large lidded pot was sitting in a puddle of light brownish liquid
The covering over the bottom shelf of the table was peeled up and exposed a reddish colored surface beneath
Food Preparation Area:
A round large trash barrel without a lid and large areas of all sides discolored by a reddish brown substance
Near the Bread Rack
An approximately 1 reddish brown insect crawling down the wall and across the floor to another wall
Food Serving Area:
Top shelf of a 3 tiered metal wire cart had a blackish substance on the top shelf
A scoop was laying in the ice of the ice machine
Several loose packets of salt and pepper and pieces of cardboard were scattered on the floor
The serving line steam table:
Splotches of a brown substance were noted on the back wall of the table's storage compartment and on the controls for the table
Crumbs were on the bottom shelf of the steam table
On 06/24/2024 at 8:12 a.m., an interview was conducted with S6DM. S6DM confirmed food in the refrigerator could only be held for 7 days. S6DM stated the dried white spots on the floor of the refrigerator were probably milk. S6DM confirmed the scoop should not be laying in the rice. S6DM confirmed the packet of gravy mix should be sealed and not under the food preparation table. S6DM confirmed the juice machine drink spouts should not dangle and should be covered. S6DM confirmed the trash barrel should have a lid. S6DM confirmed the insect was a roach. S6DM confirmed the ice scoop should not be lying in the ice.
On 06/24/2024 at 9:00 a.m., an observation was made of the food preparation tables in the kitchen. Two large silver metal tables with bottom shelves. The longest table had a grate on the preparation surface. The grate contained the following:
1 plastic coated paper clip
1 bread twist tie
A large amount of crumbs
On 06/24/2024 at 9:06 a.m., an interview was conducted with S7C. S7C confirmed the tables in the kitchen were for food preparation. S7C observed and confirmed the contents inside the grate. S7C stated the grate should be cleaned every day. S7C confirmed the grate did not get that dirty overnight and had been that way for a while.
On 06/25/2024 at 3:26 p.m., an interview was conducted with S1ADM. S1ADM was made aware of the aforementioned findings. S1ADM stated he would expect food items to be sealed labeled and dated. S1ADM confirmed kitchen staff should wear hair nets and facial restraints.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the...
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Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the potential to affect 142 residents who currently reside in the facility.
Findings:
On 06/24/2024 at 8:31 a.m., an observation was made of a live roach the size of an almond outside of the bathroom in Room K.
On 06/24/2024 at 8:31 a.m., an observation was made of a live roach the size of an almond outside Resident #78's bathroom. An interview was conducted with Resident #78 at that time. He stated he sees roaches often.
On 06/24/2024 at 8:42 a.m., an observation was made of a small live roach noted on the wall just outside of Room F.
On 06/24/2024 at 8:43 a.m., an observation was made of Resident #3's bathroom. There was one large brown, live roach approximately 3 inches in length. An interview was conducted with Resident #3 at that time. Resident #3 stated he saw live roaches often in his room and bathroom. He stated he sprayed and the pest control company sprayed, but he had not done it in a while.
On 06/24/2024 at 8:43 a.m., an interview was conducted with Resident #28. She stated she saw a roach in her room on 06/23/2024.
On 06/24/2024 at 9:15 a.m., an observation was made of small live roach in Room G.
On 06/24/2024 at 9:17 a.m., an interview was conducted with Resident #7. She stated she saw a roach on 06/23/2024. She stated staff were aware of bugs in the facility.
On 06/24/2024 at 9:20 a.m., an interview was conducted with Resident #47. He stated he had seen a bug in his room on 06/23/2024.
On 06/24/2024 at 10:05 a.m., an observation was made of Resident #20 asleep in bed with black flies swarming the room, and one fly on her right arm.
On 06/24/24 at 10:22 a.m., an interview was conducted with Resident #46. She stated roaches were crawling the walls of the facility and staff were spraying in residents' rooms if they were not allergic.
On 06/24/2024 at 10:24 a.m., an interview was conducted with Resident #453. She stated there were flies, house roaches, and cockroaches in the facility. She stated staff were aware of bugs in the facility.
On 06/24/2024 at 12:37 p.m., an observation was made of an almond size, dead roach, outside of Hall B whirlpool room. There was also a gnat flying around.
On 06/25/2024 at 8:00 a.m., an observation was made of a fly flying in Hall A.
On 06/25/2024 at 8:10 a.m., an observation was made of a small brown roach crawling across the floor in Room D.
On 06/25/2024 at 8:25 a.m., an observation was made in Room F of small roach on a styrofoam cup on top of the refrigerator.
On 06/25/2024 at 8:40 a.m., an observation was made of a gnat flying in hallway outside Room H.
On 06/25/2024 at 8:42 a.m., an observation was made of a fly flying in Hall A.
On 06/25/2024 at 8:47 a.m., an observation was made of one fly and two gnats flying around Resident #12 while he was lying in bed. An interview was conducted with Resident #12 at that time. He stated he had been having gnats and flies flying around in his room.
On 06/25/2024 at 9:09 a.m., an observation was made of a gnat flying around Resident #132. An interview was conducted with Resident #132 at that time. He stated there were gnats in his room all the time, and they were really aggravating.
On 06/25/2024 at 9:12 a.m., an observation was made of a gnat was flying around outside Room I.
On 06/25/2024 at 10:43 a.m., an observation was made of a dead insect on the floor of Hall A.
On 06/25/2024 at 12:00 p.m., an observation was made of a fly flying around a medication cart on Hall C.
On 06/26/2024 at 8:36 a.m., an observation was made of an almond sized live roach in Room D.
On 06/26/2024 at 8:50 a.m., an observation was made of ants crawling on the floor of Room E.
On 06/26/2024 at 9:15 a.m., an observation was made of a small brown roach crawling on the floor underneath a resident's wheelchair on Hall A.
On 06/27/2024 at 8:30 a.m., an observation was made of small live roach on the wall in Room E.
On 06/27/2024 at 8:30 a.m., an observation was made of a small live roach in Nursing Station J.
On 06/27/2024 at 10:00 a.m., an observation was made of a small black roach flying around Room D.
On 06/27/2024 at 10:04 a.m., an observation was made of a small roach flying around in Room D.
On 06/27/2024 at 12:51 p.m., an observation was made of two live roaches inside Room E. One roach was the size of a grain of rice and one was the size of a black bean.
On 06/27/2024 at 11:34 a.m., a telephone interview was conducted with a representative from a local pest control company. He stated the entire facility was treated for pests annually. He stated annual treatment was scheduled for 06/17/2024, but was not completed due to the facility not being prepared.
On 06/27/2024 at 12:51 p.m., an interview was conducted with S1ADM. He stated, It's that time of year for pests. He stated the pest control company came out last Monday to treat the entire facility, but the facility did not have enough staff to remove all residents from rooms so the entire building could be treated.
CONCERN
(F)
📢 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
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observations, interviews and record review, the facility failed to post nurse staffing data on a daily basis which included the total resident census number, and total number and actual hours...
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Based on observations, interviews and record review, the facility failed to post nurse staffing data on a daily basis which included the total resident census number, and total number and actual hours worked for licensed and unlicensed nursing staff. This deficient practice had the potential to affect any of the 142 residents currently residing in the facility.
Findings:
Review of the facility's policy dated June 2024 and titled Nurse Staffing Posting Information revealed in part, the following:
Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time.
Policy Explanation and Compliance Guidelines:
1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:
c. Facility's current resident census
d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
i. Registered Nurses
ii. Licensed Practical Nurses/Licensed Vocational Nurses
iii. Certified Nurse Aides
4. b. Staffing shall include all nursing staff who are paid by the facility.
An observation was made on 06/24/2024 at 1:27 p.m. of the nurse staffing data sheets for licensed and unlicensed nursing staff dated 06/24/2024 posted at Nursing Station K revealed it did not include the resident census, the total number of hours worked for Certified Nurse Aides and Licensed Practical Nurses, and the total number and the actual hours worked for Registered Nurses.
An observation was made on 06/24/2024 at 1:36 p.m. of the nurse staffing data sheets for licensed and unlicensed nursing staff dated 06/24/2024 posted at Nursing Station L revealed it did not include the resident census, the total number of hours worked for Certified Nurse Aides and Licensed Practical Nurses and the total number and the actual hours worked for Registered Nurses.
An observation was made on 06/24/2024 at 1:45 p.m. of the nurse staffing data sheets for licensed and unlicensed nursing staff dated 06/24/2024 posted at Nursing Station J revealed it did not include the resident census, the total number of hours worked for Certified Nurse Aides and Licensed Practical Nurses and the total number and the actual hours worked for Registered Nurses.
An interview was conducted on 06/24/2024 at 1:38 p.m. with S4ADON. S4ADON stated he was responsible for posting the nurse staffing data sheet for licensed nursing staff at Nursing Station L. S4ADON confirmed the resident census number and the total number and actual hours worked for Registered Nurses were not included on the nurse staffing data sheet for licensed nursing staff and he was not aware it should have been included. S4ADON stated the format of posting the hours worked by Licensed Practical Nurses met the requirements of posting both the total number and actual hours worked for Licensed Practical Nurses.
An interview was conducted on 06/24/2024 at 2:16 p.m. with S3ADON. She stated she was responsible for posting the nurse staffing data sheet for licensed nursing staff at Nursing Station K. S3ADON confirmed the nurse staffing data sheet should include the resident census number, the total number of hours worked for Licensed Practical Nurses, and the total number and actual hours worked for Registered Nurses and it did not.
An interview was conducted on 06/24/2024 at 2:22 p.m. with S5ADON. She stated she was responsible for posting the nurse staffing data sheet for licensed nursing staff at Nursing Station J. S5ADON confirmed the resident census number and the total number and actual hours worked for Registered Nurses was not included on the nurse staffing data sheet for licensed nursing staff and she was not aware that it should have been included.
An interview was conducted on 06/24/2024 at 2:28 p.m. with S29CNAS. She stated she was responsible for posting nurse staffing data sheets for unlicensed nursing staff at Nursing Stations J, K, and L. She confirmed the resident census number and the total number of hours worked for Certified Nurse Aides were not included on the nurse staffing data sheets for unlicensed nursing staff. S29CNA stated she was not aware this data should have been included.
An interview was conducted on 06/24/2024 at 2:35 p.m. with S2DON. S2DON confirmed the resident census number, the total number of hours worked for Licensed Practical Nurses and Certified Nurse Aides and the total number of hours worked and actual hours worked for Registered Nurses were not included on the nurse staffing data sheets and he was not aware it should have been.
Jul 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 all medical records regarding the resident's code status c...
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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 all medical records regarding the resident's code status consistently reflected the resident's wishes for 2 (#1 and #104) of 32 residents reviewed for advanced directives in the initial pool process.
Findings:
Resident #1
Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Dementia.
Review of Resident #1's current Physician's Orders revealed the following:
[DATE] - Code Status: DNR
Review of Resident #1's Physical Hard Chart revealed a Resident/Family Consent for Cardiopulmonary Resuscitation Form, which indicated he did not want CPR if found with no pulse or respirations.
Review of Resident #1's dashboard/bed board revealed a Full Code status.
On [DATE] at 11:55 a.m., an interview was conducted with S11LPN. She stated in the event of an emergency, she would refer to the Physical Hard Chart, Physician Orders, or dashboard/bed board to determine a residents' code status. She confirmed Resident #1's dashboard/bed board revealed a full code status, and the physician order and advanced directive document revealed a DNR code status. She stated the Advanced Directive Form, Physician Orders, and dashboard/bed board did not match and should have. She explained she was unsure which one was accurate.
On [DATE] at 12:47 p.m., an interview was conducted with S12LPN. She stated in the event of an emergency she would refer to the Advanced Directive Form in the Physical Hard Chart, Physician Orders, or the dashboard/bed board view to determine the code status for a resident.
On [DATE] at 12:24 p.m., an interview was conducted with S6ADON. She stated in the event of an emergency, each residents' code status was located in the resident's Physical Hard Chart on the Advanced Directive Form, physician orders or dashboard/bed board view. She confirmed the Advanced Directive Form, dashboard/bed board, and physician orders, should all match.
Resident #104
Review of Resident #104's Clinical Record revealed he was admitted to facility on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia, and Acute Kidney Failure.
Review of Resident #104's current Physician's orders revealed the following:
[DATE] Do Not Resuscitate.
Review of Resident #104's Resident/Family Consent for Cardiopulmonary Resuscitation Form in the Physical Hard Chart revealed he signed consent to receive Cardiopulmonary Resuscitation on [DATE].
Review of Resident #104's Louisiana Physicians Orders for Scope of Treatment (LaPOST) dated [DATE] revealed Do Not Resuscitate code status. A copy of the LaPOST was not in his physical chart.
Review of Resident #104's dashboard/bed board revealed a Full Code status.
On [DATE] at 1:00 p.m., an interview was conducted with S14LPN. She reviewed Resident #104's Physical Hard Chart. She confirmed the only advanced directive form on the chart revealed a full code status. She was presented with Resident #104's LaPOST and confirmed it revealed a code status of Do Not Resuscitate, and further confirmed the LaPOST did not match the Advance Directive Form.
On [DATE] at 12:25 p.m., an interview was conducted with S2DON. He stated each residents' code status could be found on the Advanced Directive Form in the Physical Hard Chart, in Physician Orders, and on the dashboard/bed board. He stated all three locations should match. He confirmed Resident #1's bed board view revealed a full code status and his Advanced Directive Form and physician orders reflected a DNR status. He stated Resident #1 was a DNR, and the dashboard/bed board should have reflected a code status of DNR. He confirmed Resident #104's bed board view revealed a full code status and should have been a DNR. He further confirmed the LaPost Form, which indicated a DNR status was not found on the Physical Hard Chart and should have been. He stated Resident #104 was a DNR, and the dashboard/bed board should have reflected a code status of DNR.
On [DATE] at 2:07 p.m., an interview was conducted with S1ADM. He confirmed each residents' most recent advanced directive should be on the front page of the Physical Hard Chart and the code status should be the same for the dashboard/bed board, physician's orders and Physical Hard Chart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment for 5 residents (#44, #61, #114, #112, and #285) of 32 r...
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Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment for 5 residents (#44, #61, #114, #112, and #285) of 32 resident rooms observed in the initial screening. The facility failed to ensure:
1.
Baseboard was secured to the wall in Resident #44's room;
2.
Walls were clean in Resident #61's room;
3.
Equipment and floor were free of tube feeding formula in Resident #114's room;
4.
Sheetrock was intact in Resident #285's room; and
5.
Faucet was in working condition in Resident #112's room.
Findings:
Resident #44
On 07/10/2023 at 11:50 a.m., an interview was conducted with Resident #44. She stated the baseboard under her sink had been ripped off for months. She stated maintenance was aware of the baseboard. She stated maintenance had been in her room in the past month, however no changes had been made.
On 07/10/2023 at 11:52 a.m., an observation was made under the sink in Resident #44's room. The baseboard was observed to be detached from the wall.
On 07/11/2023 at 10:57 a.m., an interview was conducted with S11M. He stated he should be notified by staff immediately of any issues related to maintenance by filling out a maintenance card or immediately calling him. He stated he was aware of the detached baseboard in Resident #44's room and should have addressed the issues it immediately.
Resident #61
On 07/10/2023 at 8:30 a.m., an observation was made of Resident #61's room. A large area of a smeared dark dried red substance was observed on the wall on the left side of the bed.
On 07/10/2023 at 8:35 a.m., an interview was conducted with S14RT in Resident #61's room. S14RT confirmed the dark, dried red substance the wall was is blood and should have been cleaned off the wall.
On 07/10/2023 at 3:10 p.m., an observation was made of Resident #61's room. The dark smeared dried red substance on the wall was still present and has not been cleaned.
On 07/11/2023 at 8:15 a.m., an observation was made in Resident #61's room with C12CNA. She confirmed the dark smeared dried red substance on the wall was blood and still present.
On 07/11/2023 at 10:53 a.m., an interview was conducted with S10EVM. She stated if a nurse or staff member identified bodily fluids in a resident area or resident's room, they should immediately notify housekeeping. She stated housekeeping was responsible for ensuring it is promptly cleaned.
Resident #114
On 07/11/2023 at 9:40 a.m., an observation was made of Resident #114's room. A very large amount of brown substance was observed on the resident's floor near the head of the bed, under the tube feeding pole, on the right side wall, the tube feeding pole, and on the feeding pump.
On 07/11/2023 at 9:41 a.m., an interview was conducted with S9LPN in Resident #114's room. She stated the brown substance located on the resident's floor near the head of the bed, under the tube feeding pole, on the right side wall, the tube feeding pole, and on the feeding pump was tube feeding solution. She confirmed the tube feeding solution should have been cleaned after it was spilled.
On 07/11/2023 at 10:53 a.m., an interview was conducted with S10EVM. She stated if a nurse or staff member identified spilled tube feeding solution in a resident area or resident's room, they should immediately notify housekeeping. She stated housekeeping was responsible for ensuring it was promptly cleaned.
Resident #285
On 07/10/2023 1:13 p.m., an observation was made in Resident #285's room. A 6 inch x 6 inch hole was observed in the wall on the left side of the AC unit.
On 07/10/2023 at 1:14 p.m., an interview was conducted with Resident #285. Resident #285 stated he told maintenance about the hole months ago.
On 07/11/2023 at 10:57 a.m., an interview was conducted with S11M. He stated he should be notified by staff immediately of any issues related to maintenance by filling out a maintenance card or immediately calling him. He stated he was aware of the hole in Resident #285's room and should have addressed it immediately.
Resident #112
On 07/10/2023 at 10:39 a.m., an observation was made of the bathroom sink in Resident #112's room. The hot water faucet was turned on and the water was observed to be leaking onto the floor under the sink.
On 07/10/2023 at 10:40 a.m., an interview was conducted with Resident #112. She stated she notified maintenance and filled out a maintenance form multiple times in the last 2 months related to the hot water leaking under her sink. She stated the maintenance tech came in 2 weeks ago and said he was going to fix the leak. She stated the leak had not been fixed.
On 07/11/2023 at 12:44 p.m., an environmental tour of the facility was conducted with the following: S1ADM, S3AADM, S10EVM, and S11M. The following observations were made and confirmed with the administrative staff.
Resident #44's bathroom room had a detached baseboard under the sink.
Resident #61's wall, which was previously soiled with smeared dark clotted blood, had been cleaned after housekeeping was notified by C12CNA on 07/11/2023 at 8:15 a.m.
Resident #114's room had a dried brown substance on the floor near the head of the bed, under the feeding pole, on the wall, on the tube feeding pole, and on the tube feeding pump.
Resident #285's room had a 6 inch by 6 inch hole in the wall located on the left side of the ac unit.
Resident #112's bathroom sink leaked hot water when the faucet was turned on.
On 07/11/2023 at 12:52 p.m., an interview was conducted with S1ADM and S11M. Both confirmed the above issues should have been addressed immediately. Both confirmed the above issues were not acceptable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to complete and transmit MDS assessments in the required timeframe fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to complete and transmit MDS assessments in the required timeframe for 14 (#16, #17, #29, #38, #39, #56, #58, #65, #72, #82, #90, #113, #117, and 119) of 14 (#16, #17, #29, #38, #39, #56, #58, #65, #72, #82, #90, #113, #117, and 119) residents reviewed for resident assessment.
Findings:
Review of the facility's policy titled Assessment Frequency/Timeliness revealed the following, in part;
Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI manual.
Review of the MDS assessments revealed the following resident assessments were open and not transmitted for greater than 120 days:
-Resident #16's Quarterly MDS dated [DATE].
-Resident #17's Annual MDS dated [DATE].
-Resident #29's Quarterly MDS dated [DATE].
-Resident #38's Discharge MDS dated [DATE].
-Resident #39's Annual MDS dated [DATE].
-Resident #56's Quarterly MDS dated [DATE].
-Resident #58's Quarterly MDS dated [DATE].
-Resident #65's Annual MDS dated [DATE].
-Resident #72's Quarterly MDS dated [DATE].
-Resident #82's Discharge MDS dated [DATE].
-Resident #90's Quarterly MDS dated [DATE].
-Resident #113's Quarterly MDS dated [DATE].
-Resident #117's Quarterly MDS dated [DATE].
-Resident #119's Quarterly MDS dated [DATE]
On 07/11/2023 at 10:30 a.m., an interview was conducted with S8MDS. She confirmed the MDS assessments had not been submitted to CMS within the required timeframe for Residents #16, #17, #29, #38, #39, #56, #58, #65, #72, #82, #90, #113, #117, and 119. S8MDS said these residents MDS assessments were greater than 120 day past due for transmission.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interviews, and record review, the facility failed to ensure services were provided to meet quality pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interviews, and record review, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure staff observed 1 of 1 (#62) resident consume his medication.
Findings:
Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part:
3. Development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with compassion, including increased and ongoing development of self-awareness, sound judgement, [NAME], ethical thing and behaviors, problem solving and critical thinking abilities.
7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team.
Review of the facility's Policy titled Medication Administration, revealed the following: Policy explanation and compliance guidelines:
15. Observe resident consumption of medication.
A review of Resident #62's MDS with an ARD of 04/05/2023, revealed, in part, Resident #62 was assessed by the facility to have a BIMS of 12, which indicated he was cognitively intact.
On 07/11/2023 at 9:30 a.m. an observation was made of 3 white pills, 1 pink, 1 green, 1 yellow and 1 yellow green capsule in the AC vent in Resident #62 room.
On 07/11/2023 at 3:30 p.m., an interview was conducted with Resident #62. He confirmed the pills observed in the AC vent were his. He stated 3 weeks ago, before taking his medication, which was left by the nurse in a pill cup, fell out of his hand and into the AC vent. He stated he did not report this to the nursing staff. He confirmed nursing staff did not always watch him consume his medications prior to exiting the room.
On 07/11/2023 at 3:36 p.m., an interview was conducted with S9LPN. She identified 7 pills being displaced in Resident #62 AC vent. She stated she had no prior knowledge or observed medications being in the AC Vent. She stated during medication administration all medications should be observed to be consumed prior to exiting the residents' room.
On 07/11/2023 at 3:39 p.m., an observation was conducted with S2DON. He identified 7 pills being displaced in Resident #62 AC vent. He stated he would expect his nursing staff to remain in the room and watch the resident consume medications prior to the nurse exiting the room. He confirmed facility policy was for nursing staff to observe resident consumption of medication.
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 and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure:
1. Food was properly sealed and dated after o...
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Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure:
1. Food was properly sealed and dated after opening; and
2. Dietary staff wore a beard restraint while preparing food.
There were a total of 112 out of 116 facility residents who were provided meals and beverages from the facility's kitchen.
Findings:
Review of the facility policy titled, Food Safety Requirements revealed the following, in part;
Policy: Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.
3c. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date and keeping foods covered or in tight containers.
Review of the facility policy titled, Date Marking for Food Safety revealed the following, in part;
3. The individual opening or preparing of food shall be responsible for date marking the food at the time the food is opened or prepared.
6. The Directory Manager or designee shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly.
Review of the facility policy titled, Dietary Employee Personal Hygiene revealed the following, in part;
Policy: It is the policy of this facility to utilize the following as guidelines for employee personal hygiene to prevent contamination of food by foodservice employees.
4. Hair Restraints
a. All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food.
During the initial tour of the facility's kitchen on 07/10/2023 at 8:15 a.m., the following observations were made:
Walk in Freezer:
-1 bag of white cheese opened, undated, and unsealed.
-2 boxes of bacon opened, undated, and unsealed.
Walk in Refrigerator:
-2 bags of chopped pork opened, undated, and unsealed.
-1 box of cookie dough opened, undated, and unsealed.
-1 box of green peas opened, undated, and unsealed.
-1 bag of hash browns opened, undated, and unsealed.
-1 bag of pork chops opened, undated, and unsealed.
During the initial tour of the facility's kitchen on 07/10/2023 at 8:15 a.m., an observation was made of S1DS and S2DS assisting with food preparation. Both staff members had facial hair not covered. S3DM verified the staff mentioned above had facial hair which should have been covered with a beard restraint while assisting with food preparation.
An interview was conducted on 07/10/2023 at 8:15 a.m. with S3DM during the initial tour of the kitchen. She verified the above observations and acknowledged the facility failed to store foods properly. She confirmed all opened food products should have been labeled with the date opened. She further confirmed she was responsible for ensuring all food was labeled and sealed after opening. S3DM confirmed all dietary staff must wear hair restraints and/or beard restraints to prevent hair from contacting food.
Jan 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 residents received adequate supervision to p...
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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 residents received adequate supervision to prevent elopement for 1 (#5) of 7 (#1, #2, #3, #4, #5, #6, RR1) sampled residents.
Findings:
Review of the facility's Employee/Agency Onboarding Packet revealed, in part, the following:
Resident Therapeutic Leave
o
All residents are required to sign out at the front desk with the [NAME] Clerk on duty when leaving the facility property on a therapeutic leave.
o
If a resident leaves the facility and fails to sign out and/or let the nurse on duty know please make sure the resident is educated upon returning to the facility.
o
If a resident is seen leaving the facility, please verify with the [NAME] Clerk/Front Desk that the correct procedure was followed and that the resident signed out of the facility.
o
If a resident fails to return from a therapeutic leave for an extended period of time, please notify DON or Administrator and initiate Code Purple (Dr. Walker) protocol.
Resident #5
Review of the clinical record for Resident #5 revealed he was admitted to the facility on [DATE] with diagnoses, which included Human Immunodeficiency Virus, Cognitive Communication Deficit, Other Symptoms, Signs involving Cognitive Functions and Awareness, Alcohol Abuse, and Human Immunodeficiency Virus Dementia.
Review of the Quarterly MDS with an ARD of 01/05/2023 revealed Resident #5 had a BIMS of 10, which indicated he was moderately cognitively impaired. Review of the resident's Functional Status indicated Resident #5 was mobile, able to ambulate and required supervision with activities of daily living.
Review of the facility's incident investigation revealed the following:
Incident Occurred: 01/05/2023 at 2:30 p.m.
Incident Discovered: 01/05/2023 at 6:00 p.m.
Description: Facility discovered Resident #5 called a taxi to the facility on [DATE] and left around 2:50 p.m. S7LPN saw him leave in the taxi. Resident did not sign out per policy. Resident #5 was not at the facility at 8:00 p.m. medication pass and administration and local law enforcement were notified.
An interview was conducted with S8WC on 01/09/2023 at 1:34 p.m. She stated she was responsible for monitoring the locked front entry door. She stated if a resident left the premises, they should stop by the desk, sign out and she would let them out the front locked door. She stated it is not a good system because residents go out to the smoking patio and leave without signing out. She confirmed if a resident left the unsecure smoking patio she would not be aware.
An interview was conducted with Resident #5 on 01/10/2023 at 9:18 a.m. He stated he had resided in the facility for one year. He stated the first time he left the facility was on 01/05/2023 when he called a taxi. He stated the bank would not give him money and he did not have any transportation back to the facility. He stated he was gone for twenty hours and was on the side of the road during the night. He stated he did not know he needed to sign out or let the staff know when he left the facility. He stated the facility staff instructed him to sign out after the local law enforcement returned him to the facility on [DATE].
An interview was conducted with S9CNA on 01/10/2023 at 11:11 a.m. She stated on 01/05/2023 she worked from 2:00 p.m.-10:00 p.m. She stated when her shift started on 01/05/2023, she gave Resident #5 coffee and saw him walk toward the elevator. She stated at supper time, estimated 5:00 p.m.-6:00 p.m., she looked for Resident #5 and he was not there. She stated she reported it to S6LPN at that time.
An interview was conducted with S6LPN on 01/10/2023 at 12:30 p.m. She stated on 01/05/2023 she worked from 2:00 p.m.-10:00 p.m. She stated, at the start of her shift, she was told Resident #5 was downstairs smoking. She stated Resident #5 was not in his room for the 4:00 p.m. medication pass. She stated when supper started, between 5:00 p.m. and 6:00 p.m., she noticed Resident #5 was not in the dining room, his room, or on the unlocked smoking patio. At this time she notified S4ADON. She stated staff were unable to find Resident #5, and the local law enforcement was contacted. She confirmed on 01/05/2023 at approximately 7:00 p.m., S7LPN informed her that she saw Resident #5 leave the facility in a taxi at 2:50 p.m. She stated when she completed her shift on 01/05/2023, Resident #5 had not been located.
An interview was conducted with S7LPN on 01/10/2023 at 1:13 p.m. She stated the residents know the code to go outside onto the smoking patio. She explained once on the patio there is a gate that is unlocked and opens to the parking lot. She confirmed on 01/05/2023 at 2:50 p.m. she saw Resident #5 leave in a yellow cab but did not check the sign out book.
An interview was conducted with S4ADON on 01/11/2023 at 9:01 a.m. He stated on 01/05/2023 he was notified Resident #5 could not be located. He stated on 01/06/2023 at 12:58 p.m. Resident #5 was returned to the facility by the local law enforcement. He stated staff should be notified by the resident if they left the facility premises and Resident #5 did not notify anyone. He confirmed the residents could leave the facility from the smoking patio. He confirmed if a resident left the smoking patio without informing staff they would not know the resident left.
An interview was conducted with S3DON on 01/11/2023 at 10:20 a.m. He stated he was notified by staff on 01/05/2023 between 5:00 p.m. -6:00 p.m. that Resident #5 was missing. He stated the local law enforcement was notified between 7:00 p.m. -8:00 p.m. He stated on 01/06/2023 at 12:45 p.m. Resident #5 was returned to the facility by the local law enforcement office. He stated if a resident left the facility premises, the resident was expected to sign out with the ward clerk and the ward clerk would then let the resident out of the secure front door. He stated they do not have staff assigned to the unlocked smoking patio. He confirmed residents can exit the unlocked smoking patio gate and facility staff would not be aware the resident left.
On 01/11/2023 at 11:00 a.m., an observation was made of the smoker's patio with S2MD. He confirmed the patio gate did not have a lock and residents could leave the facility without staff knowing.
An interview was conducted with S1ADM on 01/11/2023 at 3:09 p.m. He stated Resident #5 was out on pass but did not sign out in the book. He confirmed Resident #5 left the facility and he was notified on 01/05/2023 at about 7-8 p.m. that he had not returned. He said on 01/06/2023 at 12:58 p.m. Resident #5 was returned to the facility by the local law enforcement. He stated the normal process for a resident to leave the facility premises was for the resident to sign out with the ward clerk. The ward clerk would then let the resident out of the secure front door. He stated education was conducted with Resident #5 regarding the signing out process after he returned to the facility on [DATE]. He stated residents are informed of this during admission, but when Resident #5 was admitted his cognitive function was impaired and he was not allowed to sign himself out. He confirmed when Resident #5's cognitive function improved he was not informed he needed to sign out when leaving. He confirmed residents could leave from the unlocked smoking patio and staff would not be aware.
Dec 2022
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure 2 (#5, #R1) of 6 (#1, #2, #3, #4, #5, and #R1) sampled residents received maintenance services necessary to maintain...
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Based on observations, interviews, and record review, the facility failed to ensure 2 (#5, #R1) of 6 (#1, #2, #3, #4, #5, and #R1) sampled residents received maintenance services necessary to maintain a sanitary, orderly, and comfortable environment.
The facility failed to ensure:
1. Resident #5 and Resident #R1's air conditioning unit was properly secured to the wall;
2. Resident #5 and Resident #R1's air conditioning unit had no standing water inside the unit;
3. Resident #5 and Resident #R1's room was comfortable and without exposure to cold drafts due to an opening in the air conditioning unit; and
4. The baseboard on the wall next to Resident #5 and Resident #R1's air conditioner unit was properly secured to the wall.
Findings:
Review of the Maintenance Log dated October 2022 to December 2022 revealed no entries for Resident #5 and Resident #R1's air conditioning unit.
Resident #5
Review of Resident's quarterly MDS with ARD of 11/18/2022 revealed Resident #5 had a BIMS of 15, which indicated he was cognitively intact.
Resident #R1
Review of Resident's quarterly MDS with ARD of 10/19/2022 revealed Resident #R1 had a BIMS of 3, which indicated he was severely cognitively impaired.
On 12/20/2022 at 9:25 a.m., an observation was made of Resident #R1 in bed wrapped head to toe in a thick comforter. A cold draft was observed in the resident's room from an opening in the air conditioner unit. The air conditioner unit was unsecured from the wall, and contained a small puddle of water inside the unit. The ground outside was visible through the opening. The baseboard on the wall next to the air conditioner unit was unattached from the wall.
On 12/20/2022 at 9:30 a.m., an interview was conducted with Resident #5. He was in the hallway outside his room door wearing a thick jacket with a hood on his head. He said there was a cold draft in the room which made it cold in there. He said he was not sure of the last time the facility's staff checked the air conditioning unit.
On 12/21/2022 at 8:35 a.m., an interview was conducted with Resident #5. He said he told S2MS this morning to check the air conditioner unit. He said S2MS pressed on some buttons and turned the air conditioner unit on. He said there was a still a cold draft coming from that side of the room.
On 12/21/2022 at 8:50 a.m., an observation was conducted of Resident #5 and Resident #R1's air conditioner unit. A cold draft was observed in the resident's room from an opening in the air conditioner unit. The air conditioner unit was unsecured from the wall, with a puddle of water visible inside the unit, and the ground outside was visible through the opening. The baseboard on the wall next to the air conditioner unit was unattached from the wall. Resident #R1 was observed in bed wrapped head to toe in a thick comforter.
On 12/21/2022 at 8:55 a.m., an interview was conducted with S2MS. He said he was responsible for maintenance services at the facility. He confirmed Resident #5 requested he look at his room air conditioner unit this morning. He confirmed Resident #5 and Resident #R1's air conditioner unit was not properly secured to the wall, it contained a small puddle of water visible inside the unit, and the ground outside the facility was visible through the opening in the air conditioner unit. He also confirmed a cold draft was coming into their room, and the baseboard on the wall next to the air conditioner unit was unattached from the wall. He confirmed he did not check the air conditioner unit.
On 12/21/2022 at 9:42 a.m., an interview was conducted S1ADM. He verified Resident #5 and Resident #R1 were roommates. He confirmed S2MS was responsible for making sure the air conditioner units and baseboards were securely attached to the wall.
On 12/21/2022 at 10:30 a.m., an interview was conducted with S4LPN. She verified Resident #5 and Resident #R1 were roommates. She said Resident #5 reported feeling a cold breeze in his room on 12/19/2022. She said she observed the air conditioner unit unhooked from the wall and felt a cold draft. She said Resident #R1 was nonverbal and could not mouth words. She said she notified S3ADON on 12/19/2022 of the need for S2MS to fix the air conditioner unit in Resident #5 and Resident #R1's room.
On 12/21/2022 at 3:50 p.m., an interview was conducted with S3ADON. She said she was not aware that Resident #5 and Resident #R1's air conditioner unit needed to be checked by S2MS. She said she did not recall S4LPN notifying her of any issues with their air conditioner unit. She said if she would have been made aware she would have written it in the maintenance log book. She reviewed the maintenance book with logs dated October through December 2022. She confirmed there was no entry for Resident #5 and Resident #R1's room air conditioner unit.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Center Point Health Care And Rehab's CMS Rating?
CMS assigns Center Point Health Care and Rehab an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Center Point Health Care And Rehab Staffed?
CMS rates Center Point Health Care and Rehab's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 50%, compared to the Louisiana average of 46%. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Center Point Health Care And Rehab?
State health inspectors documented 48 deficiencies at Center Point Health Care and Rehab during 2022 to 2025. These included: 47 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Center Point Health Care And Rehab?
Center Point Health Care and Rehab is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 172 certified beds and approximately 139 residents (about 81% occupancy), it is a mid-sized facility located in BATON ROUGE, Louisiana.
How Does Center Point Health Care And Rehab Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Center Point Health Care and Rehab's overall rating (1 stars) is below the state average of 2.4, staff turnover (50%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Center Point Health Care And Rehab?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "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 below-average staffing rating.
Is Center Point Health Care And Rehab Safe?
Based on CMS inspection data, Center Point Health Care and Rehab has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Center Point Health Care And Rehab Stick Around?
Center Point Health Care and Rehab has a staff turnover rate of 50%, 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 Center Point Health Care And Rehab Ever Fined?
Center Point Health Care and Rehab has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Center Point Health Care And Rehab on Any Federal Watch List?
Center Point Health Care and Rehab 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.