FLANNERY OAKS GUEST HOUSE
For profit - Limited Liability company
130 Beds
PLANTATION MANAGEMENT COMPANY
Data: November 2025
Trust Grade
33/100
#199 of 264 in LA
Photo by Flannery Oaks Guest House
Photo by Flannery Oaks Guest House
Photo by Flannery Oaks Guest House
1 / 5 photos
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Flannery Oaks Guest House has received a Trust Grade of F, which indicates significant concerns about the facility's overall care and management. It ranks #199 out of 264 nursing homes in Louisiana, placing it in the bottom half of facilities in the state, and #18 out of 25 in East Baton Rouge County, suggesting that only a few local options are better. The facility is showing signs of improvement, with issues decreasing from 15 in 2024 to 2 in 2025. However, staffing is a notable weakness, receiving a rating of 1 out of 5 stars and a high turnover rate of 58%, which is above the state average. The facility has also faced fines totaling $9,750, which is concerning but average compared to other facilities in Louisiana. Specific incidents noted by inspectors include failures to complete required quarterly assessments for residents, resulting in potential gaps in necessary care, and inaccuracies in resident evaluations regarding their mental health status. Overall, while there are positive trends in reducing issues, families should weigh these strengths against the significant weaknesses in staffing and care management.
- Trust Score
- F
- In Louisiana
- #199/264
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $9,750 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 7 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Bottom 25%
No red flags
15 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 15 issues
2025: 2 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: 58%
12pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $9,750
Below median ($33,413)
Minor penalties assessed
Chain: PLANTATION MANAGEMENT COMPANY
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (58%)
10 points above Louisiana average of 48%
The Ugly 29 deficiencies on record
Jan 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by S5CNA.
The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
A review of the facility's policy dated 03/05/2023 and titled, Abuse-Prevention and Prohibition Policy and Procedure revealed the following, in part:
Purpose: Each resident has the right to be free from abuse .No one shall abuse a resident .This policy applies to facility staff
Policy:
3. Physical Abuse includes hitting, slapping .
A review of Resident #2's clinical record revealed he was admitted to the facility on [DATE]. The resident had diagnoses, which included Vascular Dementia, Depression, and Anxiety Disorder.
A review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/2024 revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact.
A review of the facility's Self-Reported Incident Report, dated 12/22/2024, revealed the following, in part:
Victim: Resident #2
Accused: S5CNA
Allegations: Physical abuse
Incident Occurred: 12/22/2024
A review of Resident #2's Nurse's Note dated 12/22/2024 at 8:10 a.m. revealed the following, in part:
Resident #2 was upset because he didn't receive coffee on his breakfast tray. Resident #2 threatened to hit S5CNA in the face. Resident #2 hit S5CNA, and S5CNA hit Resident #2. Resident #2 and S5CNA were separated. Resident #2 denies injury. Police, NP, RP, and S1ADM notified.
A review of S5CNA's written statement dated 12/22/2024 revealed the following: Resident #2 said he would hit me. Resident #2 hit me, and I responded with my hand, popping Resident #2.
A review of S7HK's written statement dated 12/22/2024 revealed the following: Resident #2 slapped S5CNA in the face, and S5CNA hit Resident #2.
On 12/30/2024 at 10:50 a.m., an interview was conducted with S7HK. She stated she was working on 12/22/2024, and she witnessed the physical altercation between Resident #2 and S5CNA. She stated Resident #2 hit S5CNA in her face. She stated S5CNA hit Resident #2 on his forehead with the palm of her hand. She stated she separated Resident #2 and S5CNA. She stated S5CNA hitting Resident #2 was abuse. She stated she received in-services on abuse prevention and prohibition on 12/22/2024.
On 12/30/2024 at 11:05 a.m., an interview was conducted with S2DON. She stated on 12/22/2024, S1ADM called her and notified her S5CNA hit Resident #2, after Resident #2 hit S5CNA. She stated if a staff member hit a resident, it was abuse. She stated S5CNA left the facility immediately after the altercation and was terminated. She stated she assessed Resident #2, and no injuries were noted. She stated police, Resident #2's RP, and S1ADM were notified. She stated following this incident all staff received in-services on abuse prevention and prohibition with a posttest given by herself and S1ADM starting on 12/22/2024 with 100% completion by 12/25/2024. She stated she received the in-service on 12/22/2024 by S1ADM. She stated Resident #2 was assessed daily by herself for 3 days and interviewed by the social worker 3 times a week for 2 weeks to monitor for changes. She stated random residents were interviewed daily by herself for 2 weeks to monitor for further abuse allegations, with none identified.
On 01/02/2025 at 8:30 a.m., an interview was conducted with S1ADM. He stated on 12/22/2024, he was notified of the altercation between Resident #2 and S5CNA. He stated he reviewed camera footage, which revealed Resident #2 hit S5CNA in her face, and then S5CNA hit Resident #2 on his forehead. He stated he saw S7HK separate Resident #2 and S5CNA. He stated S5CNA was sent home as soon as the incident occurred and was terminated. He stated it was never appropriate for a staff member to hit a resident. He stated S2DON assessed Resident #2, and no injuries were noted. He stated police, Resident #2's RP, and state office were notified on 12/22/2024. He stated following the incident all staff received in-services on abuse prevention and prohibition with a posttest given by himself and S2DON starting on 12/22/2024 with 100% completion by 12/25/2024. He stated he received the in-service on 12/22/2024 by corporate. He stated all staff had a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition. He stated Resident #2 was assessed daily for 3 days by S2DON and interviewed by the social worker 3 times a week for 2 weeks to monitor for changes. He stated random residents were interviewed daily for 2 weeks to monitor for further abuse allegations by S2DON, with none identified. He stated in morning meetings, he followed up for 2 weeks to ensure a resident had not voiced concerns of potential abuse, with none identified.
On 01/02/2025 at 8:33 a.m., an interview was conducted with Resident #2. He stated on 12/22/2024, he hit S5CNA in the face and S5CNA hit him in the forehead with her hand. He stated S5CNA was taken out of the facility and terminated. He stated S2DON assessed him for injuries and checked on him daily since 12/22/2024. He stated the social worker interviewed him multiple times following the incident.
On 01/02/2025 at 9:02 a.m., an interview was conducted with S8SSD. She stated on 12/22/2024, S2DON notified her S5CNA hit Resident #2, after Resident #2 hit S5CNA. She stated if a staff member hit a resident, it was abuse. She stated S5CNA left the facility immediately after the altercation and was terminated. She stated S2DON assessed Resident #2, and no injuries were noted. She stated police, Resident #2's RP, and S1ADM were notified. She stated following this incident all staff received in-services on abuse prevention and prohibition with a posttest given by S2DON and S1ADM starting on 12/22/2024 with 100% completion by 12/25/2024. She stated Resident #2 was assessed daily by S2DON for 3 days and interviewed by herself 3 times a week for 2 weeks to monitor for changes, with none identified. She stated random residents were interviewed daily by herself for 2 weeks to monitor for further abuse allegations, with none identified.
On 01/02/2025 at 9:19 a.m., an interview was conducted with S3RN. She stated she received in-services on 12/23/2024 on abuse prevention and prohibition by S2DON. She stated she completed a posttest and answered questions related to abuse by S2DON.
On 01/02/2025 at 9:22 a.m., an interview was conducted with S6RN. She stated she received in-services on 12/22/2024 on abuse prevention and prohibition by S2DON. She stated she completed a posttest and answered questions related to abuse by S2DON.
Throughout the survey from 12/30/2024 to 01/02/2025, observations, record reviews, and staff interviews revealed staff received training on the facility's abuse policies and procedures, de-escalating aggressive behaviors, and the effect of staff approach in relation to resident's behaviors. Interviews revealed staff were knowledgeable of the types of abuse and were aware abuse should be reported to administration immediately.
The facility had implemented the following actions to correct the deficient practice:
1. Corrective actions were accomplished for residents found to be affected by the alleged deficient practice include:
a. Resident #2 and S5CNA separated. Resident #2 brought to a safe place. S5CNA was escorted outside of the facility.
b. Administrator notified.
c. Police notified.
d. Head to toe assessment completed on Resident #2.
e. Resident #2 and S5CNA interviewed and statements received.
f. In-service all staff regarding policy and procedure for abuse prevention and prohibition.
2. All residents have the potential to be affected by this alleged deficient practice.
3. The measures put into place to prevent this alleged deficient practice from re-occurring:
a. In-service all staff regarding policy and procedure for abuse prevention and prohibition.
b. Residents with a BIMS of 9-15 interviewed by staff to ensure that the resident has not felt abused and that each resident feels safe.
c. Resident #2 interviewed by social services 3 times a week for 2 weeks to ensure Resident #2 does not have any psychological concerns following the incident.
d. Head to toe assessment completed by nurse daily for 3 days to ensure Resident #2 does not have any physical concerns following the incident.
4. Facility will monitor its performance to ensure sustained compliance by the following:
a. Administrator and or designee will have a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition.
b. Administrator and or designee will follow-up in morning meeting and with weekend supervisor for 2 weeks and as needed to ensure a resident has not voiced concerns of potential abuse.
c. Additional in-servicing and/or progressive disciplinary action will occur if further noncompliance is noted.
5. Corrective action will be completed by 01/07/2025.
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 F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to complete quarterly assessments for 2 (#1, #3) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment.
Findings:
Review of the f...
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Based on record review and interviews, the facility failed to complete quarterly assessments for 2 (#1, #3) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment.
Findings:
Review of the facility's policy titled, MDS Policy and Procedure with an effective date of 06/25/2015 revealed the following, in part:
Policy Statement:
All Minimal Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual.
Resident #1
On 01/02/2025, a review of Resident #1's MDS assessment revealed a Quarterly MDS with an ARD (Assessment Reference Date) of 12/18/2024. Further review revealed the MDS assessment was not completed by 01/01/2025.
Resident #3
On 01/02/2025, a review of Resident #3's MDS assessment revealed a Quarterly MDS with an ARD of 12/11/2024. Further review revealed the MDS assessment was not completed by 12/25/2024.
An interview was conducted on 01/02/2025 at 11:50 a.m. with S4MDS. He confirmed all Quarterly Assessments should be completed within 14 days of the ARD. He confirmed Resident #1's MDS should have been completed by 01/01/2025, but was not completed timely. He further confirmed Resident #3's MDS should have been completed by 12/25/2024, but was not completed timely.
An interview was conducted on 01/02/2025 with S2DON. She confirmed Quarterly MDS Assessments should be completed within 14 days of the ARD. She further confirmed Resident #1 and Resident #3's Quarterly MDS Assessments were not completed timely, but should have been.
May 2024
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure an alleged violation of physical abuse was reported within ...
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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 an alleged violation of physical abuse was reported within 2 hours to the State Survey Agency after an allegation was made for 1 (#295) of 3 (#5, #294, and #295) residents reviewed for abuse.
Findings:
Review of the facility's policy titled Abuse - Prevention and Prohibition Policy and Procedure revealed the following:
Purpose:
Each resident has the right to be free from abuse . This policy applies to covered individuals (the owner, operator, employees, managers, vendors, agency staff, agents, or contractors) . present in our facility.
Policy:
To provide a safe, abuse-free environment for all residents. If you suspect physical abuse of a resident contact the Administrator immediately.
I. Types of Abuse:
3. Physical Abuse may including hitting, slapping, pinching, biting, shoving, and kicking.
II. Procedures
7. Reporting/Response
The facility employee or covered individual who becomes aware of abuse shall immediately report the matter to the facility administrator.
The Administrator shall immediately initiate a report to the State Agency and the facility's local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical abuse .) .
All covered individuals are required by law to report any suspected abuse or neglect.
Review of Resident #295's Clinical Record revealed she was admitted to the facility on [DATE] with Diagnoses which included Dementia and Traumatic Subdural Hemorrhage.
Review of the admission MDS with ARD of 05/10/2024 revealed the provider assessed Resident #295 as having a BIMS of 4, which indicated the resident had severe cognitive impairment.
Review of the Nurses/Care team notes revealed the following:
05/12/2024 9:01 p.m. LATE ENTRY FROM 05/11/2024 2:00 p.m.: While resident was sitting in the lobby near the television area next to Resident #80, Resident #295 began hitting Resident #80 in the face and was witnessed by S15CNA who removed resident along with S16RNS. Resident #295 was placed in her room and monitored for the remainder of the shift. Signed by: S17LPN
Review of the facility's Incident Log, dated November 2023 through current, revealed no documented incident between Residents #295 and #80.
Review of the facility's state agency reported incidents for the past six months revealed no reports of the above incident.
On 05/14/2024 at 12:08 p.m., an interview was conducted with S15CNA. She stated she witnessed the incident between Resident #295 and Resident #80 on 05/11/2024. She stated Resident #295 and #80 were seated in the day room area near NSB. She stated she saw Resident #295 slapping Resident #80 in the face. S15CNA stated she immediately separated Resident #295 from Resident #80 and brought her to her room. She stated what she witnessed was physical abuse. She stated once she separated the residents, she immediately reported the incident to her supervisor.
On 05/14/2024 at 12:57 p.m., an interview was conducted with S1ADM. He stated he was made aware of the incident between Residents #295 and #80 sometime around 12:30 p.m. on 05/11/2024 by a staff member. He stated it was reported to him Resident #295 was hitting Resident #80. He stated he did not consider the incident to be physical abuse and did not report it to the state agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure services were provided by the facility to meet quality of professional standards. The facility failed to obtain physician's orders ...
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Based on interviews and record review, the facility failed to ensure services were provided by the facility to meet quality of professional standards. The facility failed to obtain physician's orders when the facility received medications from the pharmacy for 1 (#23) of 5 (#23, #51, #26, #294, and #47) residents reviewed for medication administration.
Findings:
Review of Resident #23's Clinical Record revealed a facility admit date of 10/01/2023 with diagnoses which included Stage 3 Chronic Kidney Disease, Urinary Tract Infection, Unspecified Injury of Unspecified Kidney, Acute Kidney Failure, Disorder of Urinary System, Overactive Bladder, and Personal History of Urinary Tract Infections.
Review of the yearly MDS with ARD of 04/17/2024 revealed Resident #23 had a BIMS of 15, which indicated she was cognitively intact.
Review of the most recent Care Plan revealed the following:
Onset: 04/01/2024
Problem: I am at risk for infection returning
Intervention: Administer my medications as ordered
Onset: 11/28/2023
Problem: I have overactive bladder
Intervention: Administer my medications as ordered
On 05/13/2024 at 8:46 a.m., an interview was conducted with Resident #23. She stated she had an appointment with her urologist on Wednesday, 05/08/2024 and received a prescription for an antibiotic, but had not received the antibiotic as of this morning, Monday, 05/13/2024. She stated she had asked about the medication and was told there was something wrong with how the prescription was written, which was delaying her getting the medication.
On 05/14/2024 at 9:57 a.m., an interview was conducted with S3IP. She stated Resident #23 had an appointment with her urologist last week. She stated the facility's pharmacy delivered Levaquin, Pyridium and Macrobid for Resident #23 on Friday, 05/10/2024, but there were no physician orders for the medications. She stated on Monday, 05/13/2024, the facility contacted the urologist and obtained orders for the medications received.
On 05/14/2024 at 2:30 p.m., an interview was conducted with S4NP. She stated she was unaware the facility had received medications ordered by Resident #23's urologist on 05/10/2024 for Levaquin, Pyridium and Macrobid. She stated on 05/13/2024, orders were obtained from Resident #23's urologist, and medications were started on the evening of 05/13/2024. She stated she was not informed medications were delivered on 05/10/2024 without physician orders, and should have been.
On 05/15/2024 at 9:00 a.m., a telephone interview was conducted with the medical assistant at Resident #23's urologist's office. She confirmed Resident #23 was seen in the clinic on 05/08/2024. She stated on 05/10/2024, Resident #23's urologist electronically prescribed Levaquin, Macrobid and Pyridium to the facility's pharmacy. She stated she did not have any missed calls or voicemails from staff from the facility on 05/10/2024. She stated she received a call on 05/13/2024 from the facility requesting orders for Levaquin, Macrobid and Pyridium.
On 05/15/2024 at 9:15 a.m., a telephone interview was conducted with the pharmacist at the facility's pharmacy. She stated an electronic prescription was received for Resident #23's Levaquin, Macrobid and Pyridium on 05/10/2024 at 9:49 a.m. and was sent out for facility delivery on the first truck which left the pharmacy on 05/10/2024 at 12:00 p.m. She stated the facility should have received the medication by 2:00 p.m. on 05/10/2024. She stated the Levaquin and Pyridium prescriptions were to be started upon receipt of the medications and the Macrobid was to be started once the Levaquin prescription was completed.
On 05/15/2024 at 1:27 p.m., an interview was conducted with S2DON. She stated if medications were delivered to the facility for a resident with no physician's orders, she would expect the nurse to obtain orders from the ordering physician. She stated nursing staff should have obtained orders for the antibiotics as quickly as possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 provide care and services in accordance with order...
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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 provide care and services in accordance with orders written for dining for 1 (#78) of 2 (#9 and #78) residents reviewed for requiring feeding assistance.
Findings:
Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed he was admitted to a local hospice agency on 02/08/2024 with a diagnosis of Muscle Wasting and Atrophy.
Review of Resident #78's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, indicating resident was severely cognitively impaired. Further review revealed he required supervision or touching assist with eating.
Review of Resident #78's Hospice Plan of Care, dated 02/08/2024, revealed, in part, the following:
Physician's Orders:
Patient must be fed all meals.
Problem:
Nutrition/Hydration diminished due to disease progression.
Goal:
For facility staff, family/friends, patient, adjust to changing nutritional needs, ongoing.
Review of Resident #78's Weight Log, dated 02/14/2024 through 04/16/2024, revealed, in part, the following:
02/14/2024: 128.6 pounds;
03/19/2024: 123.6 pounds; and
04/16/2024: 123.2 pounds.
An observation was conducted on 05/13/2024 at 10:45 a.m. of a sign hanging on the wall in Resident #78's room indicating he should be fed all meals.
An observation was conducted on 05/13/2024 at 12:05 p.m. of Resident #78 seated in bed attempting to feed himself with no staff present in the room. Throughout the course of lunch service, no staff arrived to feed Resident #78.
An observation and interview was conducted on 05/14/2024 at 11:25 a.m. of S10CNA delivering Resident #78's meal tray to his bedside table then exiting his room. She stated Resident #78 did not require feeding assistance with meals and never had.
An interview was conducted on 05/15/2024 at 10:50 a.m. with S9LPN. She confirmed Resident #78 had a current order to be fed all meals by staff.
An interview was conducted on 05/15/2024 at 9:50 a.m. with Resident #78's hospice nurse. She confirmed Resident #78 had an order to be fed all meals because frequently he would not eat if staff were not there to assist and provide encouragement. She confirmed if the hospice agency wrote an order, the hospice agency expected the facility staff to follow them as written.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. She confirmed Resident #78 had an active order to be fed all meals. She confirmed she would expect staff to implement orders as written.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles...
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Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (MR1) of 2 (MR1 and MR2) medication storage rooms observed. The facility failed to ensure a urine specimen was labeled with resident's first and last name, include a second identifier, and include the date and time of specimen collection.
Findings:
Review of the lab provider's policy, titled Urine Specimens, reviewed 05/14/2024, dated 01/2024, revealed, in part:
Urinalysis and Culture and Susceptibility-Submit a urinalysis preservative tube and culture and susceptibility preservative tube. Label both tubes with the patient's first and last name and a second identifier. Include the date and time of specimen collection on each specimen container.
On 05/14/2024 at 8:27 a.m., an observation was made of MR1 with S3IP. In the refrigerator labeled Specimens, a clear bag with two tubes filled with yellow fluid was discovered. Both tubes did not have a resident's name, date and time collected, or a second identifier.
On 05/14/2024 at 8:28 a.m., an interview was conducted with S3IP. She confirmed both specimen tubes did not have a resident's name, date and time collected, or a second identifier. She stated specimens collected should have a date, time, and resident's name on it when collected.
On 05/14/2024 at 9:30 a.m., an interview was conducted with S2DON. She verbalized she would expect all staff would label specimens with the resident's name, date and time collected, and a second identifier. She verbalized labeling specimens was common professional standard.
On 05/14/2024 at 9:32 a.m., an interview was conducted with S1ADM. He confirmed he would expect all specimens collected would be labeled with the resident's name, date and time collected, and a second identifier.
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 observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to ...
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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 maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #86) residents observed with an indwelling catheter.
Findings:
A review of Resident #86's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses included the following: Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, and Cystitis.
A review of Resident #86's MDS, with an ARD of 04/22/2024, indicated the resident had a BIMS of 7, which indicated he had severe cognitive impairment. Further review revealed he had an indwelling urinary catheter.
On 05/13/2024 at 8:40 a.m., an observation was made of Resident #86 ambulating in his room, the indwelling catheter bag was hooked to the trash can.
On 05/13/2024 at 11:20 a.m., an observation was made of Resident #86 ambulating in his room. The resident was dragging the indwelling catheter bag on the floor.
On 05/15/2024 at 9:35 a.m., an observation was made of Resident #86 sitting on his bed. The indwelling catheter bag was set in the bed. Indwelling catheter bag was not below the level of the bladder and half full of urine which was flowing back.
On 05/15/2024 at 9:36 a.m., an interview was conducted with S13LPN. Upon entering Resident #86's room, S13LPN observed Resident #86's indwelling catheter bag in resident's bed. She stated Resident #86 puts his catheter bag in the trash can. S13LPN confirmed the indwelling catheter bag should be kept below the level of the bladder, out of the trash can, and off the floor.
On 05/15/2024 at 2:22 p.m., an interview was conducted with S2DON. S2DON confirmed the indwelling catheter bag should be kept below the bladder, out of trash can, and off the floor due to increased risk of infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident...
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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 resident assessments accurately reflected the resident's status. The facility failed to ensure:
1.Staff accurately marked a resident was evaluated for PASRR on 2 (#62, #66) of 4 (#8, #36, #62, #66) resident's reviewed for PASRR; and
2.Staff accurately reflected the discharge status for 1 (#91) of 5 (#38, #84, #88, #91, #92) residents reviewed for discharge; and
3.Staff accurately reflected a resident had pressure ulcers for 1 of 1 (#43) resident reviewed for pressure ulcers.
1.
Resident #62
Review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder and Borderline Personality Disorder.
Review of Resident #62's clinical record revealed a Level II PASRR with approval dates of 04/03/2024 through 04/02/2024.
Review of Resident #62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no.
Resident #66
Review of Resident #66's clinical record revealed the resident was admitted to the facility on [DATE] with Diagnoses which included Paranoid Schizophrenia.
Review of Resident #66's clinical revealed a Level II PASRR with approval dates of 05/09/2023 through 05/07/2024.
Review of Resident #66's yearly MDS with ARD of 02/07/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no.
An interview was conducted with S7MDS on 05/14/2024 at 3:20 p.m. She reviewed Resident #62's and Resident #66's clinical records and confirmed both had been evaluated for a Level II PASRR. She reviewed Resident #62's and Resident #66's MDS both dated 02/07/2024. She confirmed both Resident #62's and Resident #66's MDS revealed question A1500, Resident evaluated for PASRR, was answered as no. She confirmed both Resident #62 and Resident #66 MDS was inaccurate.
An interview was conducted with S2DON on 05/15/2024 at 2:10 p.m. She confirmed MDS staff were expected to accurately capture resident's information on the assessments. She confirmed the MDS should accurately reflect if a resident was evaluated for PASRR.
2.
Resident #91
Review of Resident #91's clinical record revealed the resident was admitted to the facility on [DATE] and discharged to home on [DATE].
Review of Resident #91's Discharge MDS with an ARD of 03/19/2024 indicated the following:
A2000: discharge date - 03/19/2024; and
A2105: Discharge Status - 4. Short Term General Hospital.
Review of Resident #91's Nurse Notes revealed a note written on 03/19/2024 at 9:52 p.m. indicated at 10:00 a.m. resident was discharged to home.
An interview was conducted on 05/15/2024 at 1:45 p.m. with S13LPN. S13LPN confirmed she was Resident #91's nurse at the time of her discharge. S13LPN confirmed Resident #91 discharged to home from the facility.
An interview was conducted on 05/15/2024 at 1:40 p.m. with S6MDS. S6MDS confirmed Resident #91's MDS Discharge Assessment revealed Resident #91 was discharged to the hospital which was incorrect. S6MDS confirmed Resident #91's MDS Discharge Assessment should have been coded correctly.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. She confirmed she would expect MDS Assessments to be coded accurately and Resident #91's was not.
3.
Resident #43
Review of Resident #43's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Cutaneous Abscess of Buttock.
Review of the current Physician Orders revealed in part:
04/23/2024-Right Medial buttock Stage 3 clean with wound cleanser, pat dry, apply sodium chloride dressing, and cover with dry dressing until resolved.
05/13/2024 Stage 3 to right heel, clean with wound cleanser, pat dry, paint with gentian violet and leave open to air.
Review of current wound log dated revealed Resident #43 had a right buttock Stage 3 with identified date of 02/27/2024, and Unstageable to right heel identified date of 04/27/2024.
Review of Resident #'s 43 admission MDS with an ARD of 03/04/2024 indicated the following:
M0100A: Risk determination: has PU/injury, scar, dressing - Unchecked
Further review of Section I-Active Diagnoses revealed no diagnosis for Pressure Ulcers.
An interview was conducted on 05/15/2024 at 10:26 a.m. with S19WCN. She confirmed Resident #43 had a Right Medial buttock Stage 3 and Stage 3 to right heel.
An interview was conducted on 05/15/2024 at 10:38 a.m. with S6MDS. S6MDS confirmed if a resident was receiving wound care and had a current pressure ulcer there should be an active diagnosis for wounds. After reviewing Resident #43's admission MDS with ARD of 03/04/2024 Section M, S6MDS confirmed Resident #43 did not have an active diagnosis and was not checked for having a pressure ulcer and should have.
An interview was conducted on 05/15/2024 at 11:00 a.m. with S2DON. She stated MDS was made aware of new wound care orders and new wounds in the morning meetings and 24 hour communication report sheet. She stated she expected resident's MDS to be accurate.
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 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 1 (#36) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR.
Findings:
Review of Resident #36's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Psychosis not due to a substance or known physiological condition (Onset Date: 08/25/2017).
Review of Resident #36's most recent Level I PASRR Screening and Determination form revealed her previous assessment was performed on 08/18/2017.
Review was attempted of Resident #36's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 08/25/2017 with no documentation available for review.
Review of Resident #36's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 0, indicating the resident was significantly cognitively impaired. Further review revealed, in part, the following:
Section I: Diagnoses
I5950: Psychotic Disorder (other than Schizophrenia) - Checked.
I8000: Additional ICD Diagnosis - F29 Unspecified Psychosis not due to a substance or known physiological condition.
An interview was conducted on 05/15/2024 at 2:00 p.m. with S1ADM. He confirmed Resident #36's Pre-admission Level I PASRR Screen and Determination was most recently submitted on 08/18/2017. He confirmed on 08/25/2017, Resident #36 received a new diagnosis of a relevant mental illness; Unspecified Psychosis not due to a substance or known physiological condition. He confirmed the facility did not resubmit a new Level I PASRR Screen and Determination with the onset of the new diagnosis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 record of the Level 1 Preadmission Screening Resident Rev...
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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 record of the Level 1 Preadmission Screening Resident Review (PASRR) form was maintained in the resident's record for 1 (#8) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR.
Findings:
Review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, the following; Schizophrenia (Onset Date: 07/27/2006).
Review of Resident #8's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2024, 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:
I6000: Schizophrenia - Checked.
Review was attempted of Resident #8's Pre-admission PASRR Level 1 Screening and Determination Review Form with no documentation available for review.
An interview was conducted on 05/15/2024 at 2:00 p.m. with S1ADM. He confirmed Resident #8 had an active diagnosis of Schizophrenia. He confirmed Schizophrenia was one of the relevant mental illnesses listed on the Level I PASRR Screen and Determination. He confirmed the facility did not have a copy of Resident #8's most recent Level 1 PASRR Screen and Determination. He confirmed the facility had not submitted a Level 1 PASRR Screen and Determination for Resident #8 when she was admitted to the facility on [DATE].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centere...
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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 develop and implement a comprehensive person-centered care plan to meet the needs of 2 (#23, #86) residents out of a 25 total sampled residents. The facility failed to:
1. Report Resident #23's urinalysis results to the consulting provider as ordered; and
2. Ensure care plan was comprehensive and individualized for Resident #86 whom exhibited frequent refusals and behaviors.
Findings:
1.
Review of the facility's policy titled, Notifying Clinicians - Laboratory/Diagnostic Testing Policy & Procedure revealed the following:
Procedure:
I. Laboratory Services (483.50)
d. The facility must promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results . per the ordering physician's orders.
Process:
III. Once the laboratory . test is completed the results will be reported to the order physician, physician assistant, or nurse practitioner in a timely manner.
Review of Resident #23's Clinical Record revealed she was admitted on [DATE] with diagnoses which included Stage 3 Chronic Kidney Disease, Urinary Tract Infection, Unspecified Injury of Unspecified Kidney, Acute Kidney Failure, Disorder of Urinary System, Overactive Bladder, and Personal History of Urinary Tract Infections.
Review of the most recent Care Plan the following:
Onset: 04/01/2024
Problem: I am at risk for infection returning
Intervention: My labs need to be done as ordered by my MD; notify my MD of significant changes
Review of the most recent Physician Orders, dated November 2023 through current, revealed the following:
05/09/2024 U/A with C&S - Fax results to urologist fax number
Review of the Nurses/Care Team Notes, dated November 2023 through current, revealed the following:
On 05/08/2024 at 8:47 p.m. Resident returned from urology appointment with new order for urine culture and to fax results to urologist fax number. Signed by: S3IP
Review of Laboratory Results ordered on 05/09/2024 by Resident's urologist for urinalysis revealed the specimen was collected on 05/09/2024, sent to the facility's outside lab company and reported to the facility on [DATE].
On 05/14/2024 at 9:40 a.m., an interview was conducted with S14LPN. After reviewing Resident #23's chart, she stated the results of the UA collected on 05/09/2024 were not in Resident #23's chart at this time.
On 05/15/2024 at 9:00 a.m., a telephone interview was conducted with the medical assistance for Resident #23's urologist. She confirmed Resident #23 was seen in the clinic by her urologist on 05/08/2024 and was sent back to the facility with an order for a urinalysis with culture and sensitivity and request of the results to be faxed to the clinic office once received. She stated the clinic still had not received the results of the urinalysis.
On 05/15/2024 at 1:27 p.m., an interview was conducted with S2DON. She stated she was responsible for checking for resulted lab tests and ensuring the results are sent to providers once resulted. She stated there is a lab notification log kept at the front nurses' station with the ward clerk. She stated when a nurse gets an order for a lab, they are to notify the ward clerk of the order so they can notify the facility's outside lab company. If the specimen to be collected is urine, the nurse will write on the notification log the date and time the specimen was collected. She stated she checks the log daily to check to see if the lab company has resulted the pending specimen sample(s). She confirmed she did not send the results of Resident #23's urinalysis as ordered by the urologist.
2.
Review of Resident #86's Clinical Record revealed he was readmitted on [DATE] with diagnoses which included Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, Cystitis, and Gastrostomy Status.
Review of the 5 day MDS with ARD of 04/22/2024 revealed Resident #86 had a BIMS of 7, which indicated the resident was severely cognitively impaired. Review of Section GG - Functional Abilities and Goals revealed Resident #86 required partial/moderate assistance with toileting. Review of Section H - Bladder and Bowel revealed Resident #86 had an indwelling urinary catheter. Review of Section K-Swallowing/Nutritional Status revealed Resident #86 had a feeding tube.
Review of the most recent Care Plan the following revealed that Resident #86 was not care planned for refusal of care related to his PEG and catheter or behaviors.
Review of the Nurses/Care Team Notes, dated March 2024 through current, revealed the following:
On 03/27/2024 at 12:49 p.m. Resident #86 refused tube feeding.
On 04/01/2024 at 4:45 p.m. Resident #86 was redirected and educated not to pull on his PEG tube or catheter.
On 04/09/2024 at 8:28 a.m. Resident #86 noted pulling at catheter.
On 04/09/2024 at 8:28 p.m. Resident #86 pulled catheter.
On 04/19/2024 at 5:38 a.m. Resident #86 refused bolus feeding.
On 04/22/2024 at 8:42 a.m. Resident #86 refused morning feeding.
Review of the 24 hour Communication Report log dated 05/01/2024 to current revealed on 05/10/2024 resident #86 refused care and slammed door on CNA hand.
On 05/14/2024 at 11:04 a.m., an interview was conducted with S13LPN. She stated Resident #86 constantly puts his indwelling catheter bag in the trash can and she has to constantly educate him to remove the catheter bag from the trash can. S13LPN stated Resident #86 had orders to apply a leg beg every morning, but he often refused to have it applied.S13LPN stated Resident #86 also frequently refused this PEG tube feedings and flushes. She stated she documented refusals of care and behaviors in nurse's notes and sometimes on the 24 hour Communication Report log.
On 05/15/2024 at 9:50 a.m., an interview was conducted with S6MDS. She stated she was responsible for care plans. S6MDS stated the process for care plan updating or revisions was for her to get updates in the morning meeting and reviewing the 24 hour Communication Report logs daily. She stated then she would update the care plan by adding interventions. S6MDS confirmed she was not aware of Resident #86's frequent refusals and behaviors.
On 05/15/2024 at 2:22 p.m., an interview was conducted with S2DON. She confirmed staff should be documenting refusals of care on the MAR, Nurses' notes, and 24 hour Communication Report log. S2DON confirmed if a resident was frequently refusing care and exhibiting behaviors MDS should be made aware in the morning meeting using the 24 hour Communication Report logs and refusals and behaviors should be properly care planned. After reviewing Resident #86's current care plan, S2DON confirmed Resident #86 was not care planned for frequent refusals and behaviors.
CONCERN
(E)
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 reviews, the facility failed to ensure a resident was offered a therapeutic diet wh...
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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 a resident was offered a therapeutic diet when the health care provider ordered a therapeutic diet for 2 (#9 and #78) of 3 (#9, #70 and #78) residents reviewed for nutritional status.
Findings:
Resident #9
Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Dementia; Alzheimer's; Delusional Disorders; Aphasia; and Dysphagia.
Review of Resident #9's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, which indicated resident had severe cognitive impairment. Further review revealed, in part, Resident #9 received a therapeutic diet.
Review of Resident #9's current Physician Orders revealed, in part, the following:
02/01/2024: Pudding with Lunch and Dinner;
02/26/2024: Protein Juice with all Meals; and
10/03/2023: Ice Cream with Lunch and Supper.
Review of Resident #9's Nutrition Assessment, dated 01/29/2024, revealed, in part, the following:
Nutrition Diagnosis: Inadequate energy intake due to condition .
Nutrition Interventions: . Receiving ice cream with lunch and supper. Significant weight loss of 5% in 49 days. Continue to encourage intake.
Review of Resident #9's Care Plan, revealed, in part, the following:
I am at risk for weight loss related to poor intake. (Created 11/15/2023.)
I need my meals served as ordered by my physician; and
Provide my supplements to me as ordered.
Review of Resident #9's meal ticket revealed no documentation of the need for protein juice drink with all meals, pudding with lunch and dinner or ice cream with lunch and supper.
An observation was conducted on 05/13/2024 at 12:10 p.m. with S10CNA. Resident #9 was observed in bed with S10CNA seated at bedside feeding her. Resident #9's meal tray was observed with no protein juice, pudding or ice cream on the tray.
An observation was conducted on 05/14/2024 at 11:35 a.m. with S12CNAS. Resident #9 was observed seated in her wheelchair in the main dining room. Resident #9's meal tray was observed with no protein juice, pudding or ice cream on the tray. S12CNAS confirmed there was not a protein juice, pudding or ice cream present on Resident #9's meal tray. S12CNAS confirmed she was not aware of any orders for Resident #9 to receive extra items with meals.
An interview was conducted on 05/15/2024 at 8:50 a.m. with S4NP. She confirmed Resident #9 had some weight loss since the beginning of the year and should be receiving ice cream with lunch and supper, pudding with lunch and dinner and a protein juice with all meals. She confirmed if she was not receiving the extra food/beverage items as ordered, this could be a contributing factor to her weight loss. S4NP confirmed she would expect staff to follow orders as written.
Resident #78
Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed he was admitted to a local hospice agency on 02/08/2024 with a diagnosis of Muscle Wasting and Atrophy.
Review of Resident #78's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, indicating resident was severely cognitively impaired. Further review revealed, in part, Resident #78 received a therapeutic diet.
Review of Resident #78's current Physician Orders revealed, in part, the following:
03/19/2024: Protein Juice Drink with all Meals;
02/09/2024: Pureed Soup with Lunch and Dinner; and
10/03/2023: Ice Cream with Lunch and Supper.
Review of Resident #78's Hospice Plan of Care, dated 02/08/2024, revealed, in part, the following:
Problem: Nutrition/Hydration diminished due to disease progression.
Goal: For facility staff to adjust to changing nutritional needs, ongoing.
Review of Resident #78's meal ticket revealed no documentation of the need for protein juice drink with all meals, pureed soup with lunch and dinner or ice cream with lunch and supper.
An observation was conducted on 05/13/2024 at 12:05 p.m. of Resident #78's bedside table sitting next to the bed with his lunch tray sitting on top. No protein juice, ice cream or soup was noted on his meal tray.
An observation was conducted on 05/14/2024 at 11:25 a.m. with S10CNA. Resident #78's meal tray was observed arriving to his room without protein juice, ice cream or soup on his meal tray. S10CNA confirmed Resident #78's meal tray did not contain a protein juice, ice cream or soup. S10CNA confirmed Resident #78 did not typically receive those items and she was not aware he should.
An interview was conducted on 05/15/2024 at 9:50 a.m. with Resident #78's hospice nurse. She confirmed Resident #78 was one of her patients. She confirmed the hospice agency expected the facility staff to follow all of Resident #78's orders as written.
An interview was conducted on 05/14/2024 at 11:40 a.m. with S12CNAS. S12CNAS confirmed the dietary staff were in charge of placing the appropriate food and beverage items on each resident's tray to match their orders.
An interview was conducted on 05/15/2024 at 12:40 p.m. with S11DS. S11DS confirmed she was aware of a history of weight loss for Resident #9 and Resident #78 but was not aware of any current dietary addition orders for either of them. S11DS provided a copy of Resident #9 and Resident #78's meal tickets, which did not accurately reflect the resident's current dietary orders. S11DS stated she and S2DON met weekly to discuss residents at high risk for weight loss. S11DS stated during this weekly meeting, S2DON provided her with a list of each resident's orders for additional food and beverage items so she could add it to each resident's meal ticket. S11DS stated the meal tickets were then printed for each resident for the week and were used by her staff to accurately prepare every meal tray leaving the kitchen. S11DS confirmed the dietary staff would not know to add the necessary additions if she were not told of the orders by S2DON.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. S2DON confirmed Resident #9 had the following active orders; pudding with lunch and dinner, ice cream with lunch and supper and protein juice with all meals. S2DON confirmed Resident #78 had the following active orders; protein juice drink with all meals, pureed soup with lunch and dinner, and ice cream with lunch and supper. She confirmed she and S11DS met weekly to discuss residents at high risk for weight loss. S2DON confirmed she was responsible for providing S11DS with any additions or changes in dietary orders during their weekly meeting and she must have missed Resident #9 and Resident #78's. S2DON confirmed she would expect staff to implement all dietary orders as written, especially when a resident had a recent history of weight loss.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to identify a resident's past history of trauma, and/or triggers whic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization for 1of 1(#86) resident reviewed for Post-Traumatic Stress Disorder (PTSD).
Findings:
Review of Resident #86's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included the following: Bacteremia, Benign Prostate Hyperplasia, Lack of Coordination, and PTSD.
Review of Resident #86's most recent Care Plan revealed, Resident #86 was not care planned for PTSD.
Review of Resident #86's Social assessment dated [DATE] revealed the Trauma Informed Care screening questions were answered no.
Review of Resident #86's physician progress notes dated 03/19/2024 to current revealed Resident #86's history of present illness included a PTSD diagnosis.
Review of Resident #86's Psychiatric Notes dated 03/15/2024 revealed, in part, other comorbidities PTSD.
On 05/14/2024 at 10:56 a.m., an interview was conducted with S20CNA. She stated she was Resident #86's aide. S20CNA stated she was not aware of Resident #86's diagnosis of PTSD.
On 05/14/2024 at 11:04 a.m., an interview was conducted with S13LPN. She stated she was aware of Resident #86's PTSD diagnosis. S13LPN confirmed there were no interventions in place to address Resident #86's history of PTSD.
On 05/14/2024 at 2:01 p.m., an interview was conducted with S2DON. She stated when a resident had a diagnosis of PTSD, a routine social assessment should be completed and the facility's provider should review the assessment. She stated when a new resident was admitted the Social Services department was responsible for completing the assessment.
On 05/15/2024 at 11:56 a.m., an interview was conducted with Resident #86's Responsible Party (RP). She stated Resident #86's was diagnosed with PTSD. She stated no one at the facility had spoken to her about Resident #86's PTSD diagnosis.
On 05/15/2024 at 1:35 p.m., a telephone interview was conducted with S21SW. She stated when a resident was admitted to the facility with a diagnosis of PTSD, she would speak to the resident about the nature of events, triggers, etc. and then refer the resident to be seen by the psychiatric nurse practitioner. S21SW confirmed she completed Resident #86's Social assessment on 03/21/2024. S21SW confirmed she completed the assessment, but was not aware the resident had a history or diagnosis of PTSD.
On 05/16/2024 at 9:28 a.m., a telephone interview was conducted with the Psychiatric Nurse Practitioner. She stated she was aware of Resident #86's diagnosis of PTSD. She stated the facility staff should have been aware of the PTSD diagnosis. She confirmed when she evaluated Resident #86 on 03/16/2024, she did not evaluate the resident for PTSD due to him only being oriented to self. She stated when a resident had an active diagnosis or history of PTSD, a PTSD evaluation should be completed. She confirmed a PTSD evaluation should have be completed for Resident #86 and it was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 PRN orders for psychotropic medications were limited to 14 ...
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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 PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#63, #78) of 3 (#63, #80, and #78) residents reviewed receiving hospice services.
Findings:
Resident #63
Review of Resident #63's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder, Delusional Disorders, Major Depressive Disorder, and Restlessness and Agitation.
Review of Resident #63's May 2024 Physician's Orders revealed an order written on 03/13/2024 for Ativan 1 mg tablet, one tablet by mouth every 4 hours as needed (PRN) for anxiety/agitation. Further review revealed the PRN medication had no stop date.
Review of Resident #62's May 2024 Medication Administration Record (MAR) revealed an Ativan 1 mg tablet by mouth every for hours as needed for anxiety/agitation was started on 03/13/2024. Further review revealed the PRN medication had no stop date.
Resident #78
Review of Resident #78's clinical record revealed the resident was admitted to the facility on [DATE] and admitted to a local hospice agency on 02/08/2024.
Review of Resident #78's May 2024 Physician's Orders revealed an order written on 05/08/2024 for Ativan 1mg tablet, administer 1 tablet by mouth every 4 hours PRN for anxiousness. Further review revealed the PRN medication had no stop date.
An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. She confirmed Ativan was a psychotropic medication. She confirmed Resident #63 had an order on 03/13/2024 for PRN Ativan 1mg tablet with no stop date. She confirmed Resident #78 had an order on 05/08/2024 for PRN Ativan 1mg tablet with no stop date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure medical records were accurately documented for 1 (#24) of ...
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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 medical records were accurately documented for 1 (#24) of 5 (#23, #24, #47, #62, #80) resident's reviewed for unnecessary medications.
Findings:
Review of Resident #24's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Delusional Disorders (onset 04/14/2023), and Major Depressive Disorder.
Review of Resident #24's May 2024 Physician's orders revealed an order started on 10/01/2023 for Risperdal 0.5 mg tablet, one tablet by mouth every evening. Diagnosis Major Depressive Disorder.
Review of Resident #24's May 2024 MAR revealed an order started on 10/01/2023 for Risperdal 0.5 mg tablet, one tablet by mouth every evening. Diagnoses Major Depressive Disorder
Review of Resident #24's Pharmaceutical Consultant Report, Antipsychotic Diagnosis Request, dated 05/02/2023 revealed the physician documented the diagnosis of Delusional Disorder as the reason the resident was receiving Risperdal.
An interview was conducted with S2DON on 05/15/2024 at 10:00 a.m. She stated each prescribed psychotropic medication should have an appropriate diagnoses linked to it to indicate what the medication was being used to treat. She stated medical records was responsible for reviewing resident's pharmaceutical consultant reports and adjusting the diagnosis in the system.
An interview was conducted with S5MR on 05/15/2024 at 10:20 a.m. She stated she was not responsible for reviewing the pharmaceutical consultant reports and updating or changing diagnoses attached with psychotropic medications.
An interview was conducted with S2DON on 5/15/2024 at 10:25 a.m. She reviewed Resident #24's pharmaceutical consultant report and confirmed, on 05/02/2023, the physician documented the Risperdal was to be administered to treat the diagnosis of Delusional Disorder. She reviewed Resident #24's Physician's orders and MARs and confirmed Risperdal was documented as being administered to treat the diagnosis of Major Depressive Disorder. She confirmed the records were inaccurate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to develop procedures to ensure 2 (#51 and #62) of 5 (#9, #51, #62, #70 and #90) resident's records had documentation indicating resident ei...
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Based on record reviews and interviews, the facility failed to develop procedures to ensure 2 (#51 and #62) of 5 (#9, #51, #62, #70 and #90) resident's records had documentation indicating resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Findings:
Review of the facility's policy, titled Pneumococcal Vaccination of Resident Policy and Procedure, reviewed 05/14/2024, dated 08/01/2022, revealed, in part:
Purpose: It is the policy of this facility that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccinations and their age at the time of vaccination. The records that accompany the resident also will be used to determine immunization status.
Procedure:
2. Facility will document pneumonia vaccine administration on Form Immunization Record and Form Vaccination [NAME] Roster.
Review of Resident #51's clinical record from 10/01/2023 to 05/13/2024 revealed no documentation of pneumococcal immunization status.
Review of Resident #62's clinical record from 10/01/2023 to 05/13/2024 revealed no documentation of pneumococcal immunization status.
On 05/14/2024 at 12:58 p.m., an interview was conducted with S3IP. She confirmed she was responsible for obtaining consents, documentation, and administration of pneumococcal vaccines for all residents. She reported the pneumococcal vaccine was available in the pharmacy for administration between 10/01/2023 to 05/14/2024. She confirmed all pneumococcal immunization administration and documentation was not complete for all residents at this time.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to electronically transmit a subset of items upon a resident's disch...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to electronically transmit a subset of items upon a resident's discharge for 2 (#38, #84) of 5 (#38, #84, #88, #91, and #92) residents reviewed for discharge.
Resident #38
Review of Resident #38's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on 01/31/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment.
Resident #84
Review of Resident #84's clinical record revealed the resident was admitted to the facility on [DATE] and discharged on 01/23/2024. Further review revealed the resident did not have an electronically transmitted discharge MDS assessment.
An interview was conducted with S6MDS on 05/15/2024 at 12:38 p.m. She reviewed Resident #38's clinical record. She stated the resident was discharged on 01/31/2024 and a discharge assessment was not electronically transmitted. She confirmed a discharge assessment should have been completed on 01/31/2024. She reviewed Resident #84's clinical record. She stated the resident was discharged from the facility on 01/23/2024 and a discharge assessment was not electronically transmitted. She confirmed a discharge assessment should have been completed for Resident #84 on 01/23/2024.
An interview was conducted with S2DON on 05/15/2024 at 2:10 p.m. She confirmed MDS staff should have completed and transmitted a discharge assessments after a resident was discharged from the facility.
Apr 2023
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
Deficiency F0658
(Tag F0658)
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 services were provided to meet quality professional standa...
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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 services were provided to meet quality professional standards. The facility failed to ensure:
1. 1 (#21) of 3 (#21, #59, and #91) residents reviewed for falls were assessed with neurological checks following an unwitnessed fall; and
2. 1 (#103) of 2 (#103 and #363) residents reviewed for catheters were monitored for urinary retention after a urinary catheter was discontinued.
Findings:
Review of the facility's policy titled Falls revealed the following, in part:
Purpose
To evaluate extent of injury.
To prevent complications.
Procedure
9. If the fall was un-witnessed or involved a potential head injury, initiate neurological assessment checks.
13. Document all appropriate information in medical record.
1.
Review of Resident #21's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included; Metabolic Encephalopathy, Muscle Wasting and Atrophy, Other Lack of Coordination, and Unspecified Abnormalities of Gait and Mobility.
Review of Resident #21's Nurses Note written by S11LPN, dated 03/26/2023 at 1:24 a.m., indicated resident was found sitting on the floor by S12CNA on 03/25/2023 at approximately 4:30 a.m.
Review of the facility's Fall Log revealed Resident #21 had an unwitnessed fall on 03/25/2023 at 4:31 a.m.
Review of the facility's Incident Report for Resident #21 revealed the following, in part:
Date/Time: 03/25/2023 at 4:31 a.m.
Incident Location: Resident's room
Incident Level: Non-Witnessed
Incident Reported by S12CNA
Report prepared by S11LPN
Narrative of Incident and Description of Injuries: S12CNA informed me that resident was sitting on floor.
Review of Resident #21's Neurological Observations Head Injury Form revealed neurological checks were initiated at 10:45 a.m. on 03/25/2023.
On 04/26/2023 at 8:05 p.m., a telephone interview was conducted with S12CNA. She said on 03/25/2023 around 4:30 a.m. she found Resident #21 on the floor in her room, sitting on her buttocks. She said the resident told her she had fallen after getting out of bed without calling staff for assistance.
On 04/27/2023 at 10:35 a.m., a telephone interview was conducted with S11LPN. She said when a resident had a fall, neurological checks were to be initiated and documented every 15 minutes x 4, every 30 minutes x 4, every 1 hour x 4, and then once a shift for the next 72 hours. She verified she worked on 03/25/2023 when S12CNA found Resident #21 sitting on the floor. She confirmed she did not initiate and document neurological checks for Resident #21 following her unobserved fall.
On 04/27/2023 at 10:47 a.m., an interview was conducted with S7LPN. She confirmed S11LPN had not immediately initiated neurological checks following Resident #21's unwitnessed fall at 4:30 a.m. on 03/25/2023. She stated neurological checks were not initiated for Resident #21 until 10:45 a.m. on 03/25/2023. She confirmed following any unobserved fall, neurological checks should be immediately initiated and documented for 72 hours.
On 04/27/2023 at 11:15 a.m., an interview was conducted with S3DON. She said after a resident had an unobserved fall the nurse should initiate neurological checks and document them on the Neurological Observations Head Injury Form. She verified Resident #21 had an unobserved fall on 03/25/2023 at 4:31 a.m. She reviewed the Neurological Observations Head Injury Form dated 03/25/2023 for Resident #21 and verified neurological checks were not initiated immediately following an unwitnessed fall but should have been.
2.
Review of Resident #103's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included; Unspecified Retention of Urine.
Review of Resident #103's Physician's Orders dated March 2023 revealed the following:
03/22/2023: Catheter: 16 French, 10 CC Indwelling Foley. DX: Urinary Retention. Discontinued 03/28/2023.
03/30/2023: Check Resident for urine output. If no urine output perform in and out catheter, replace Foley catheter if residual is greater than 400 ml, offer bedpan prior to performing in and out cath.
Review of Resident #103's Nurse's Notes dated 03/28/2023-03/30/2023 revealed the following, in part:
03/28/2023 at 3:47 p.m. by S7LPN: New order received to discontinue Foley catheter.
03/30/2023 at 9:16 p.m. by S13LPN: 4:30 p.m. In and out catheter performed, 600 cc of urine collected. S6NP notified.
Further review revealed no entries between the above two entries regarding on-going monitoring for urinary retention or if the resident voided after the urinary catheter was removed.
Review of the Resident Care Details Did Resident Void Bladder dated 03/28/2023-03/29/2023 for Resident #103 revealed:
Task Date and Time 03/28/2023 10:00 p.m.;
Documentation Date and Time-03/29/2023 5:50 a.m.; Answer-No; Documented by: S12CNA
Task Date and Time 03/29/2023 6:00 a.m.;
Documentation Date and Time-03/29/2023 3:27 p.m.; Answer-No; Documented by: S14CNA
On 04/26/2023 at 11:30 a.m., an interview was conducted with S7LPN. She verified she worked on 03/28/2023 and 03/29/2023 and was assigned to Resident #103. She did not recall if she discontinued Resident #103's urinary catheter on 03/28/2023 or if the resident voided or not. She did not recall S14CNA reporting Resident #103 could not urinate on 03/28/2023 or 03/29/2023. She confirmed when a urinary catheter was removed the resident should be monitored for urinary retention.
On 04/26/2023 at 12:17 p.m., a telephone interview was conducted with S15LPN. She verified she worked on 03/28/2023 and 03/29/2023 and was assigned to Resident #103. She said Resident #103's urinary catheter was removed on 03/28/2023 but she did not recall what time. She was not aware of Resident #103's lack of urination during her shifts on 03/28/2023 and 03/29/2023. She said the hall CNA should have notified her if Resident #103 was not urinating but did not.
On 04/26/2023 at 3:14 p.m., an interview was conducted with S13LPN. She verified she worked on 03/30/2023 and was assigned to Resident #103. She said Resident #103 complained of back pain and not being able to urinate. She said Resident #103 had not urinated on her shift. She said she notified the NP, performed an in and out catheter on Resident #103, and removed 600 cc of urine. She confirmed when a urinary catheter was removed the resident should be monitored for urinary retention.
On 04/26/2023 at 7:55 p.m., a telephone interview was conducted with S12CNA. She verified she worked at the facility on 03/28/2023. She was notified of her documentation on the Resident Care Summary Did Resident Void Bladder dated 03/28/2023 for Resident #103. She said if she documented No that meant Resident #103 did not urinate on her shift. She said the only time she notified the nurse a resident did not urinate was if the nurse asked her to. She said she did not recall if she notified the nurse Resident #103 did not urinate during her shift.
On 04/27/2023 at 8:27 a.m., an interview was conducted with S14CNA. She verified she worked on 03/29/2023 and was assigned to Resident #103 from 6 a.m. to 10 p.m. She confirmed during her shifts, Resident #103 did not void. She said she notified S7LPN that Resident #103 had not urinated during her shift.
On 04/27/2023 at 9:50 a.m., an interview was conducted with S6NP. She confirmed Resident #103 had a urinary catheter in place upon admission due to urinary retention. She said on 03/28/2023 she gave an order for the nursing staff to remove Resident #103's urinary catheter. She said she did not recall what day but stated she received a call from a nurse reporting Resident #103 had not urinated in 6-8 hours. She said she gave orders for the nurse to perform an in and out catheter on Resident #103. She said she was notified over 300 cc of urine was obtained so she ordered to have the urinary catheter reinserted. She said she would expect the nursing staff to monitor a resident for urinary retention after removing a urinary catheter. She would expect the nursing staff to notify the NP on call if a resident had not urinated within 6 to 8 hours after a urinary catheter was removed.
On 04/27/2023 at 11:20 a.m., an interview was conducted with S3DON. She reviewed Resident #103's electronic clinical record and verified the urinary catheter order was discontinued on 03/28/2023 at 2:50 p.m. She reviewed the nurses notes dated 03/28/2023 to 03/30/2023 for Resident #103 and verified there was no documentation of monitoring for urinary retention or if the resident did or did not urinate after the catheter was removed. She reviewed the Resident Care Summary for Resident #103 dated 03/28/2023 to 03/30/2023 and confirmed S12CNA documented No to the resident urinating on the 10 p.m. to 6 a.m. shift on 03/28/2023. She reviewed and confirmed S14CNA documented No to the resident urinating on the 6 a.m. to 2 p.m. shift on 03/29/2023. She said she expected the nurses to monitor a resident for urinary retention after removing a urinary catheter and to document in the nurse's notes whether or not the resident urinated. She said she could not determine whether or not Resident #103 urinated after her urinary catheter was removed on 03/28/2023 to 03/29/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 ensure residents received care, consistent with professional stand...
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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 residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#80) of 4 (#2, #80, #413, and #414) residents reviewed for pressure ulcers. The facility failed to ensure Resident #80 did not acquire a pressure ulcer while using a heel offloading device.
Review of Resident #80's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Essential Hypertension, Type 2 Diabetes Mellitus, and Unspecified Protein-Calorie Malnutrition. Further review revealed she had diagnoses of Pressure Induced Deep Tissue Damage of Other Site, Unspecified Soft Tissue Disorder Related to Use/Pressure, Left Lower Leg and Unspecified Soft Tissue Disorder Related to Use/Pressure, Right Lower Leg with an onset date of 04/14/2023.
Review of Resident #80's MDS with an ARD of 03/06/2023 revealed she had a BIMS of 14, which indicated she was cognitively intact. Further review revealed Resident #80 required extensive 2-person physical assistance with bed mobility and toilet use. She was totally dependent on staff for transfers, locomotion on and off the unit, dressing, personal hygiene and bathing. Resident #80's skin condition was coded as at risk for developing pressure ulcers/injuries.
Review of Resident #80's current Care Plan revealed the following, in part:
01/11/2023 Problem: Resident is at risk for skin breakdown.
Approaches: Turn and reposition resident every 2 hours and as needed.
04/14/2023 Problem: Resident has a Deep Tissue Injury to Right Inner Shin and Left Lateral shin.
Approaches: Turn and reposition resident per schedule.
Review of Resident #80's Braden Scale Assessments dated 01/12/2023, 01/19/2023, 02/01/2023, and 02/06/2023 revealed she was at risk for development of Pressure Ulcers. Further review revealed Resident #80 was considered high risk for the development of Pressure Ulcers on 03/06/2023.
Review of Resident #80's Physician Orders dated April 2023 revealed the following, in part:
04/25/2023 Deep Tissue Injury to Right and Left Calf - Clean with wound cleanser, pat dry, paint with betadine, apply abdominal pad, wrap with rolled gauze and secure with tape daily until resolved.
Review of Resident #80's Nurses' Notes dated April 2023 revealed the following, in part:
04/14/2023 at 1:50 p.m. Resident noted with Deep Tissue Injury to Left and Right Lower Legs. Wound care notified. Heels remain floated on pressure reducing device. Signed S10LPN.
04/14/2023 at 4:16 p.m. Upon assessment it appeared resident had Deep Tissue Pressure Injuries to Bilateral Lower Extremities. Resident had been utilizing a heel monitor for heel pressure relief per standing order from S6NP. Signed S5LPN
Review of Resident #80's Wound Assessment Report revealed the following:
Date of assessment: 04/14/2023
Wound type: Pressure Ulcer to Left Lateral Shin and Right Inner Shin.
Date wound identified: 04/14/2023
Present on admission: No
Assessment occasion: New wound
Stage: Unstageable Due to Suspected Deep Tissue Injury
Measurements: Right Inner Shin: length - 4.5 cm, width - 1.7 cm, depth - 0 cm
Left Lateral Shin: length - 6.0 cm, width - 2.0 cm, depth - 0 cm
An interview was conducted on 04/24/2023 at 10:00 a.m. with S8CNA. She said she provided care to Resident #80. She said Resident #80 had Bilateral Pressure Ulcers to her Lower Extremities for two weeks. She said Resident #80 used the heel offloading device under her calves all day, every day, since March 2023. She said she was never instructed to remove the heel offloading device. She said the wounds to Resident #80's Bilateral Lower Extremities were from the heel offloading device that was placed under her calves.
An interview was conducted on 04/25/2023 at 10:05 a.m. with S9CNA. She said she provided care to Resident #80. She said Resident #80 used a heel offloading device continuously under her lower legs to elevate her heels. She reported Resident #80 had the heel offloading device to elevate her calves 24 hours a day, 7 days a week. She said she was never instructed to remove the heel offloading device. She said Resident #80 had Bilateral Pressure Ulcers to her Calves for the last 2 weeks. She said the wounds to Resident #80's Bilateral Lower Extremities were from the heel offloading device that was placed under her calves.
An interview was conducted on 04/25/2023 at 11:00 a.m. with S4LPN. He said he provided care to Resident #80. He said Resident #80 was high risk for developing Pressure Ulcers. He said prior to the identification of the Bilateral Lower Extremity Pressure Wounds, Resident #80 used a heel offloading device under her legs to lift her heels off the mattress. He said she had the heel offloading device in place 24 hours a day, 7 days a week. He said Resident #80's Pressure Ulcers to her Left and Right Calves were caused by constant pressure from the heel offloading device.
An interview was conducted on 04/25/2023 at 11:15 a.m. with S5LPN. She said on 04/14/2023, she was informed by S10LPN that Resident #80 had bruising to the back of her calves. She said upon assessment, Resident #80 had Deep Tissue Pressure Injuries to Bilateral Lower Extremities. She said Resident #80 was high risk for developing Pressure Ulcers. She said prior to identification of the Bilateral Deep Tissue Pressure Injuries, Resident #80 always used a heel offloading device under her Bilateral Calves. She said the constant pressure from the heel offloading device caused the Pressure Wounds to her Bilateral Calves.
An interview was conducted on 04/25/2023 at 11:30 a.m. with S6NP. She said she provided care to Resident #80. She said she was informed by S5LPN on 04/14/2023 that Resident #80 had Deep Tissue Wounds to her Bilateral Calves. She said she could not confirm the pressure injuries were caused by the heel offloading device but since there was no other culprit, she assumed the heel offloading device was the cause of the Bilateral Pressure Wounds. She said upon each assessment of Resident #80, the heel offloading device was in place under her calves. She said Resident #80 was high risk for developing Pressure Ulcers.
An interview was conducted on 04/25/2023 at 3:00 p.m. with S2ADM. She confirmed Resident #80 sustained Bilateral Pressure Ulcers from the heel offloading device.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations and interview, 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 can...
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Based on observations and interview, 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 can opener was properly cleaned and free of a sticky black substance;
2. The juice machine was properly cleaned and free of a brownish red substance;
3. The juice machine filter was properly cleaned and free of a brown and black substance; and
4. The juice machine connecters and tubing were properly cleaned and free of a black substance.
Findings:
An initial tour of the kitchen was conducted on 04/24/2023 at 8:40 a.m., with S16DS. The following observations were made:
On 04/24/2023 at 8:45 a.m., the can opener was observed attached to a stainless steel food preparation counter with a large amount of a sticky black substance on the blade. S16DS confirmed the observation and stated the can opener should be cleaned daily and it had not been.
On 04/24/2023 at 9:10 a.m., the juice machine was observed on a counter in the kitchen. The juice machine filter was observed with a large amount of a brown and black substance. The outside of the juice machines three connectors and tubing were observed with a black substance. The outside of the juice machine had a dry brownish red substance on it. S16DS stated she was not sure when the last time the juice machine was cleaned. She confirmed the observations and stated the juice machine, tubing, connectors, and its filter were not clean and should have been.
On 04/24/2023 at 9:15 a.m., an interview was conducted with S16DS. S16DS confirmed the above findings. She stated 93 Residents were served meals from the kitchen.
Feb 2023
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews and policy review, the facility failed to implement appropriate infection control practices during the provision of resident care as evidenced by failing to ensure st...
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Based on observations, interviews and policy review, the facility failed to implement appropriate infection control practices during the provision of resident care as evidenced by failing to ensure staff appropriately changed gloves and performed hand hygiene for 1 (R1) of 3 (Resident #2, Resident #4, and R1) residents observed for wound care.
Review of the facility's policy labeled Dressing Change Policy and Procedure revealed the following:
Steps in the Procedure:
11. Remove dressing.
12. Perform hand hygiene.
13. Cleanse the area as ordered.
16. Perform hand hygiene. Apply disposable gloves.
18. Dress the area with the prescribed dressing.
On 02/23/2023 at 11:03 a.m., an observation was made of S3LPNWC performing wound care for R1. A bandage was observed on R1's right forearm with yellow drainage. S3LPNWC removed the soiled dressing, cleaned the wound with cleanser and gauze, and dried the wound with a clean gauze. She then proceeded to apply a new bandage to the wound without changing gloves or performing hand hygiene.
On 02/23/2023 at 11:11 a.m., an interview was conducted with S3LPNWC. She stated her gloves would have been considered soiled after cleaning any wound with drainage. She stated she should have performed hand hygiene after soiling her gloves and before applying the new dressing.
On 02/23/2023 at 2:05 p.m., an interview was conducted with S2CN. She stated staff should change gloves and perform hand hygiene during wound care once their gloves are soiled. She stated if staff is cleaning a draining wound, she would consider the gloves to be soiled.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure services provided by the facility met professional standards of quality for 1 (#2) of 3 (#2, #3, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure services provided by the facility met professional standards of quality for 1 (#2) of 3 (#2, #3, and #4) residents reviewed with wounds. The facility failed to ensure accurate documentation and completion of Resident #2's wound assessments and treatments.
Findings:
Review of the facility's policy titled, Standing Orders revealed the following, in part:
3. When implementing a standing order, it must be written in the clinical record on the physician's order sheet and physician notified.
Review of the facility's policy titled, Wound/Skin Management Documentation revealed the following, in part:
1. Upon admission or discovery of a Pressure Ulcer, Other Ulcer (diabetic, arterial, venous) .a Wound/Skin Management Documentation Record or the Wound Assessment Manager is initiated.
2. An evaluation of the skin issue is done and orders for required treatments are obtained.
3. The Wound/Skin Management Documentation must be completed weekly or sooner should a significant change to the wound occur.
Review of the Clinical Record for Resident #2 revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebral Infarction - Unspecified, Other Idiopathic Peripheral Autonomic Neuropathy, Other Specified Depressive Episodes, Vitamin Deficiency - Unspecified, Aphasia, Dysphagia - Unspecified, Pain in Right Leg, Peripheral Vascular Disease, Chronic Kidney Disease - Stage 3, Chronic Congestive Heart Failure, Morbid Obesity Due to Excess Calories, Other Lack of Coordination, Muscle Wasting and Atrophy, and Type 2 Diabetes Mellitus with Hyperglycemia.
Review of the Yearly MDS with an ARD of 11/23/2022 for Resident #2 revealed, in part, she was rarely/never understood and she was totally dependent on staff for bed mobility, transfers, bathing, and dressing.
Review of the Physician Orders for Resident #2 dated January 2023 through February 2023 revealed no documentation of treatment orders to the Right Great, Second, Third, Fourth, and Fifth Toes (consider not capitalizing) prior to 02/23/2023. Further review revealed the following, in part:
(Start/Order Date: 01/18/2023) - Clean Blister/Stage 2 to Plantar of right Foot with Wound cleanser, pat dry, apply Betadine and cover with dry dressing daily.
(Start/Order Date: 02/23/2023) - Clean Diabetic Foot Ulcer to Right Great Toepad with Wound Cleanser, pat dry, apply Betadine, and cover with dry dressing daily.
(Start/Order Date: 02/23/2023) - Clean Diabetic Foot Ulcer to Right 2nd Metatarsal Toepad with Wound Cleanser, pat dry, apply Betadine, and cover with dry dressing daily.
(Start/Order Date: 02/23/2023) - Clean Diabetic Foot Ulcer to 3rd Metatarsal Toepad with Wound Cleanser, pat dry, apply Betadine, and cover with dry dressing daily.
(Start/Order Date: 02/23/2023) - Clean Diabetic Foot Ulcer to 4th Metatarsal Toepad with Wound Cleanser, pat dry, apply Betadine, and cover with dry dressing daily.
(Start/Order Date: 02/23/2023) - Clean Diabetic Foot Ulcer to 5th Metatarsal Toepad with Wound Cleanser, pat dry, apply Betadine, and cover with dry dressing daily.
Review of the Nurses Notes for Resident #2 from January 2023 to February 2023 revealed no documentation of wound assessments or treatments.
Review of the TAR for Resident #2 from January 2023 to February 2023 revealed no documentation of treatments to the Right Great, Second, Third, Fourth, and Fifth Toes.
Review of the Wound Assessment Documentation for Resident #2 revealed no documentation she had wounds to her Right Great, Second, Third, Fourth, and Fifth Toes.
An observation was made of S3LPNWC performing wound care for Resident #2 on 02/22/2023 at 1:45 p.m. Resident #2 was observed to have a Right Plantar Foot Wound and wounds on the Right Great, Second, Third, Fourth, and Fifth Toes.
An interview was conducted with S3LPNWC on 02/22/2023 at 1:52 p.m. She stated Resident #2 had a Right Plantar Foot wound since 01/17/2023. She confirmed Resident #2 had wounds on her Right Great, Second, Third, Fourth, and Fifth Toes. She stated she was unable to determine when the Right Toe Wounds were identified. She confirmed there was no documented assessment for Resident #2's Right Great, Second, Third, Fourth, and Fifth Toe wounds. She stated when a new wound was identified, her process was to measure the wound and add it to the Wound Assessment Manager. She confirmed there were no Physician Orders in Resident #2's Clinical Record for treatment to her Right Great, Second, Third, Fourth, and Fifth Toes. She stated she had been painting Resident #2's Right Toes with Betadine when she performed treatment to her Right Plantar Foot. She stated S5RN performed treatments on Saturdays and Sundays.
A telephone interview was conducted with S5RN on 02/22/2023 at 2:50 p.m. She stated she performed wound care at the facility on the weekends. She confirmed she worked 02/18/2023 and 02/19/2023 and performed Resident #2's wound care. She stated Resident #2 had one wound on the bottom of her right foot. She stated she did not recall any wounds on Resident #2's toes. She stated she did not perform a treatment to Resident #2's Right Great, Second, Third, Fourth, and Fifth Toes because there was not an order for a treatment.
An interview was conducted with S4NP on 02/23/2023 at 9:50 a.m. She stated she received a wound report from the facility each week, and she confirmed Resident #2's Right Toe wounds were not on the wound report. She confirmed the only wound listed for Resident #2 was the Right Plantar Foot. She stated she assessed Resident #2's Right Foot this morning and she had not seen the wounds prior. She confirmed Resident #2 had wounds on the Right Plantar Foot and on each toe of her Right Foot. She confirmed when the wounds were identified, it should have been documented in Resident #2's medical record. She stated if the wounds were not assessed and documented, there was no way to track the progress of the wounds. She stated S3LPNWC should have initiated the treatment order and documented the treatments being completed for Resident #2. She stated she expected a RN to assess Resident #2's wounds every 7 days to track the progress.
An interview was conducted with S6LPN on 02/23/2023 at 10:35 a.m. She confirmed she was Resident #2's nurse. She confirmed there were no treatment orders to Resident #2's Right Toes and she was not aware Resident #2 had wounds on her Right Toes.
An interview was conducted with S1ADM and S2CN on 02/23/2023 at 11:10 a.m. S2CN confirmed there were no Physician Orders for Resident #2's Right Toe Wounds in her clinical record and should have been. S1ADM stated he assessed Resident #2's Right Foot on 01/17/2023, and she had wounds on the bottom of her Right Foot and on all of Right Toes. S2CN confirmed Resident #2's Right Toe Wounds should have been assessed and placed in the Wound Assessment Manager when discovered and reassessed at least every seven days and were not.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 residents received care, consistent with pro...
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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 care, consistent with professional standards of practice, to prevent pressure ulcers for 1(#2) of 5 (#1, #2, #3, #4, #5) residents reviewed for pressure ulcers.
Findings:
Review of the facility's policy titled Pressure Ulcer Prevention and Treatment Guidelines revealed the following, in part:
B. Mobility, Activity, or Sensory Perception
3. Position resident on bed with pillows or other support devices.
6. Elevate heels off bed as indicated (e.g. place pillows under calf to raise heels off the bed or use foam heel lift boots)
9. Avoid positioning the resident on a pressure ulcer.
Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnosis which included Anxiety Disorder, Congestive Heart Failure, Urinary Tract Infection, Type 2 Diabetes, Candidiasis of skin and nail, Major Depressive Disorder, Hypertension and Gastroesophageal Reflux Disease.
Review of the admission MDS with an ARD of 11/30/2022 revealed resident #2 had a BIMS of 13, which indicated he was cognitively intact. He required extensive assistance from staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. He was at risk for pressure ulcer development with one stage two present upon admission.
Review of Resident #2's physician's orders dated 01/04/2023 revealed new treatment orders for a stage 2 pressure ulcer to the left heel. Further review of physician's orders from 11/23/2022 to 01/03/2023, revealed no orders related to wounds on the left heel.
Review of Resident #2's electronic treatment administration record from 11/23/2022 to 01/03/2023 revealed no documentation of treatment for a Stage 2 pressure ulcer or deep tissue injury to the left heel.
Review of the electronic medication administration record from 11/23/2022 through 01/03/2023 revealed Resident #2's last skin assessment was completed on 12/29/2022 with no new skin impairments identified.
Review of Resident #2's Care Plan revealed the following in part:
Onset: 11/23/2022
Problem: Resident is at risk for skin breakdown
Interventions: Turn and reposition residents every 2 hours and as needed
Onset: 11/23/2022
Problem: Resident has Stage 2 fluid filled blister to the right heel
Interventions: Turn every 2 hours and prn, prevent skin contact as much as possible. Use pillows and wedges as needed for positioning, observe skin daily with activities of daily living or bath and report problems to the nurse, weekly head to toe skin assessment.
Onset: 01/04/2023
Problem: Resident is at risk for worsening skin breakdown/pressure ulcers due to diabetes mellitus and continuous removal of heel protectors and/or heel management.
Interventions: Replace heel manager/heel boot when resident takes off or removes item
Review of Resident #2's Nurse Note's from 11/23/2022 through 01/04/2023 revealed no documentation of Resident #2 having pressure ulcers to his left heel.
On 01/03/2023 at 1:10 p.m. an observation was made of Resident #2 in his room. It was noted that a Care Plan Guide was posted on the wall above the resident's bed, which indicated his heels were to be floated. Heel boots were noted to be sitting in a chair near the resident's bed. Resident #2 was not observed to have heel boots on or have his feet floated with a pillow.
On 01/03/2023 at 1:10 p.m. Resident # 2 was unable to be interviewed due to impaired cognitive ability. Resident #2 was unable to verbalize where he was or what the date was. His speech was slow and garbled.
On 01/03/2023 at 1:22 p.m. Resident #2 was observed from the doorway of his room. His feet were noted to be visible and not covered. He was not wearing foam boots and his heels were not floated.
On 01/03/2023 at 1:25 p.m. an interview was conducted with S4LPN. She confirmed she was responsible to care for Resident #2. She reported Resident #2 had a rapid decline in his abilities and was now totally dependent on staff for care. She reported he had skin tears, but no pressure wounds at this time.
On 01/03/2023 at 2:30 p.m. an interview with S5CNA. She confirmed she was familiar with Resident #2. She stated he had declined very rapidly and was now totally dependent on staff for care needs. She stated the care plan guide for Resident #2 was above his bed, and was her guide to know what his care needs were.
On 01/04/2023 at 8:47 a.m. an observation was made of Resident #2 while sitting in a Geri chair. His feet/heels were not observed to be floated or in heel boots.
On 01/04/2023 at 9:00 a.m. and interview was conducted with S5CNA. She stated Resident #2 had a significant decline after having Covid and was now totally dependent on staff for needs. She expressed the facility staff would communicate care needs via the care plan guide which was on a board above the resident's bed.
On 01/04/2023 at 9:10 a.m. an observation was made of S3LPN performing wound care on Resident #2. Resident #2 was observed sitting in his Geri chair with his heels touching the foot rest and heel boots sitting a chair near the bed. S3LPN performed wound care to the resident's left arm, left shin, and right heel. Once wound care was completed S3LPN stated there were no other wounds that required treatment at this time. Surveyor requested left heel to be assessed by S3LPN who then identified a Stage 2 pressure ulcer and deep tissue injury. Immediately following the observation an interview was conducted with S3LPN. She stated the hall nurse was responsible for completing weekly assessments on the residents. She explained she only treated residents with noted skin impairments or treatment needs. She stated she does not routinely perform body audits on the residents and only manages the wounds she is aware of. She confirmed she was not aware of the left heel Stage 2 pressure ulcer or the deep tissue injury. She stated the measurements for the Stage 2 pressure ulcer were 1cm x1cm x 0.2 cm and the deep tissue injury was 1.4cm x1 cm x 0 cm. She confirmed Resident #2's heels should be floated while in the Geri chair or while in bed. She further confirmed Resident #2's heels were not floated nor were the heel boots on when she entered the room to perform wound care. She confirmed they should have been on. She confirmed nursing staff should have assessed the resident's skin and notified her of the left heel pressure ulcers.
On 01/04/2023 at 9:25 a.m. an interview was conducted with S5CNA. S5CNA confirmed she was assigned to care for Resident #2 today. She stated she was never informed Resident #2 required heel boots and his care guide above the bed only stated float heels. She stated floating the heels would mean putting a pillow or pad under the legs to elevate them. She confirmed this was meant to elevate the feet and not to relieve pressure. She stated she bathed the resident this morning and did not notice any new skin concerns.
On 01/04/2023 at 9:25 a.m. S6CNA stated floating a resident's heels would mean to use a pillow/pad under legs to keep them elevated. She stated the pillow/pad was used for elevation and not to relieve pressure.
On 01/04/2023 at 9:30 a.m. an interview was conducted with S4LPN. She stated nurses were to perform weekly skin assessments on the residents which were triggered by the medication administration record. She stated the nurses also relied on the CNA staff to report any new skin impairments. She stated she did not know Resident #2 had a deep tissue injury or Stage 2 pressure ulcer on his left heel.
On 01/04/2023 at 10:37 a.m. a telephone interview was conducted with Resident #2's hospice nurse. She stated both hospice and the facility staff were responsible for skin assessments. She confirmed she was not aware Resident #2 had a Stage 2 pressure ulcer and deep tissue injury to the left heel.
On 01/05/2023 at 9:09 a.m. an interview was conducted with S2LPN. She confirmed she was responsible for providing care for Resident #2. She stated Resident #2 did not have any pressure ulcers at this time.
On 01/05/2023 at 11:39 a.m. and interview was conducted with S7MDS. She reviewed Resident #2's admission information and confirmed heel boots and floating heels was implemented upon admission. She stated the care guide on the wall should reflect this. She further confirmed Resident #2's care plan was updated on 01/04/2023 after the pressure ulcers were identified.
On 01/05/2023 at 12:45 p.m. an interview was conducted with S1DON. The above observations of Resident #2 on 01/03/2023 and 01/04/2023 were reviewed with S1DON. She stated if the care guide on the wall near the bed stated float heels then the residents heels should have been floated while in bed or in the Geri chair. She confirmed, S3LPN, made her aware Resident #2 had a new stage 2 pressure ulcer and deep tissue injury to the left heel which was identified during the surveyor's observation of wound care. She stated the CNAs should understand floating the heels means the heels should not to touch a surface. She confirmed pressure ulcers can develop as a result of a resident heels not being floated.
Apr 2022
6 deficiencies
CONCERN
(D)
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, record review and interview, the facility failed to ensure the resident's call light remained in reach pe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure the resident's call light remained in reach per the facility's policy for 1 (#53) of 3 (#23, #53, #76) investigated for accommodation of needs in a final sample of 18 residents.
Findings:
Review of the facility's policy, Call Light/Bell read in part, Purpose: to provide the resident a means of communication with staff members. Procedure: 1. ensure resident has call light in reach when in resident room or in bathroom .place the call light within the resident's reach before leaving the room.
Review of Resident #53's record revealed she was admitted to the facility on [DATE] with diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Wheezing, Cerebral Infarction, Anxiety Disorder, Primary Generalized Osteoarthritis, Hemiplegia, and Postural Kyphosis.
Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13 indicating she was cognitively intact. The resident had a functional limitation affecting 1 side of her upper and lower extremity. She was always incontinent of bowel and bladder and required total 2 person assistance for toileting.
On 04/25/22 at 09:49 AM, Resident #53 was observed sitting up in her bed eating breakfast with her right hand. The resident's left hand was observed in a fixed position with a closed fist with her fingers straightened over the palm of her hand. The resident's nasal cannula nose piece was observed hanging under her chin. The oxygen concentrator was on and set at 2 liters per minute. The resident stated she needed oxygen on all the time and had removed her nasal cannula to blow her nose. She stated that she needed the staff's assistance to put her nasal cannula back in her nose because she could no longer use her left hand and was unable to put the cannula back in her nose herself. Resident #53 stated that staff never give her the call light so she was unable to call someone to help her. The resident's call bell was observed on the floor at the foot of her bed.
On 04/25/22 at 09:59 AM, during the interview with Resident #53, she stated that her incontinence brief was soiled and that she needed to be changed. The resident stated that she did not have her call light and asked surveyor to call someone to assist her. S2CNA was observed sitting in the hallway and was asked to enter the resident's room. Resident #53 told S2CNA that she needed to be changed. S2CNA responded that her aide would come to assist her when she was done assisting another resident. S2CNA was observed tiding up a few things in the resident's room. S2CNA removed the resident's breakfast tray from table then exited the room without placing the resident's call light in reach. Resident's call light was still observed on the floor at the foot of the bed.
On 04/26/22 at 11:56 AM, an observation was made of Resident #53 lying in her bed eating lunch. The resident's call light was now observed on her bed, at the foot end of the bed, near the resident's feet. Resident #53 stated that she could not see her call light and that staff never give it to her.
On 04/26/22 at 12:05 PM, an interview with S3CNA was conducted in Resident #53 room. S3CNA stated that she was assigned to care for Resident #53. She stated that the resident was not able to use her left hand, it was contracted and in fixed position, but was able to use her right hand. S3CNA stated that Resident #53 was cognitive and physically able to press the call light button. S3CNA observed the resident's call light and confirmed it was on the bed at the resident's feet. S3CNA stated the resident's call light was moved because the resident was eating and she didn't want the call light to get dirty. She stated that the resident could not reach her call light due to her physical limitations. S3CNA confirmed the resident's call light should always be within her reach. Resident #53 stated to S3CNA that her call light is never within reach.
On 04/26/22 at 12:24 PM, an observation of Resident #53 was made with S4LPN. S4LPN stated that Resident #53 was cognitive, able to voice her needs and was physically able to use call bell. She stated that the call light should remain within the resident's reach. S4LPN observed the resident's call light on the bed at the resident's feet at the foot of the bed. S4LPN confirmed the resident was not physical able to obtain the call light from the foot of the bed.
On 04/27/22 at 10:33 AM, S1DON stated that Resident #53 had a congenital disease that caused a deformity to her feet and left hand which is contracted. The resident was incontinent and required assistance with some tasks, but was cognitive, able to voice her needs and physically able use her call light. S1DON confirmed that Resident #53's call light should remain within the resident's reach.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement the resident's care plan by failing to follo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement the resident's care plan by failing to follow the physician's treatment orders for 1 (resident #37) out of 3 (#37, #50, #76) sampled residents receiving wound care out of a total sample of 18 residents.
Findings:
Resident #37. Review of the resident's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's diagnoses included Diabetes, Acute Kidney Failure, Anal Fistula, and Local Infection of the skin and Subcutaneous Tissue.
Review of the resident's physician's orders revealed an order for left inguinal superior abscess: cleanse with hibiclens and cover with dry dressing daily.
On 4/26/2022 at 8:43 am, S12TN (Treatment Nurse) was observed performing wound care. S12TN applied gloves and cleansed the resident's left inguinal superior abscess area with hibicleans. The resident's left inguinal superior area was observed to be reddened. S12TN completed cleansing the left inguinal superior area. S12TN did not cover the left inguinal superior abscess area with a dry dressing as ordered. At the completion of the treatment, S12TN was observed to place bedspread over resident and walked out of resident's room and sanitized hands.
On 4/26/2022 at 9:40 am, S12TN reviewed the treatment orders for the left inguinal superior abscess and confirmed that she did not apply a dry dressing to that area per the physician's order.
On 4/26/2022 at 9:49 am, S1DON (Director of Nurses) reviewed the resident's current physician's treatment orders for wound care and confirmed that a dry dressing should have been applied to the left inguinal superior abscess as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure nail care and facial grooming was provided ...
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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 nail care and facial grooming was provided to residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (#53 and #85) out of 3 (#34, #53, #85) residents investigated for activities of daily living out of a total sample of 18 residents.
Findings:
1. Resident #53
Review of the facility's policy, Nail Care read in part: to promote cleanliness, safety and a neat appearance. Remove any debris from under the nails .trim the nails straight across, and even with the end of the finger or toe. For fingers, remove any sharp edges with the file or emery board. Document all appropriate information in the clinical record.
Review of Resident #53's record revealed she was admitted to the facility on [DATE] with diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Wheezing, Cerebral Infarction, Anxiety Disorder, Primary Generalized Osteoarthritis, Hemiplegia, and Postural Kyphosis.
Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13 indicating she was cognitively intact. The resident had a functional limitation affecting 1 side of her upper and lower extremity. She required total 1 person assistance for personal hygiene and did not reject care.
Review of the resident's physician orders revealed a nursing task dated 12/8/20 to check nails weekly for cleaning and clipping needs.
Review of the resident's care plan revealed Resident #53 needed extensive to total assist with ADLs (Activities of Daily Living) due to impaired joint mobility, functional limited range of motion in upper and lower extremity related to left sided Hemiparesis and Osteoarthritis. Further review revealed Resident #53 rejected care and refused nail care at times. Resident eats with hands causing nails to become soiled with food. Staff should return at a later time and offer care. Resident will be assisted with ADLs.
Review of the resident's MAR (Medication Administration Record) March 2022 - April 2022 revealed check marks for the task check nails weekly for cleaning and clipping needs. Review of the legend on the MAR revealed a check mark indicated administered. There was no documentation of refusals.
Review of Resident #53's progress notes from March 2022 - April 2022 revealed no documentation of refusals for nail care.
On 04/25/22 at 09:49 AM, Resident #53 was observed sitting up in her bed eating breakfast with her right hand. The resident's left hand was observed in a fixed position with a closed fist with her fingers straightened over the palm of her hand. An observation of Resident #53's finger nails revealed thick, dark colored debris packed under all of her finger nails. Her nails were long with uneven edges. The resident stated it had been 2 months since her nails were cleaned and trimmed. She stated that she asked the CNAs (Certified Nursing Assistants) to clean and trim her nails, but the CNAs told her they could not do it. The resident further stated that she wanted her nails cleaned and trimmed.
On 04/25/22 at 10:09 AM, S3CNA entered Resident #53's room and provided the resident's incontinence care and bed bath.
On 04/25/22 at 03:29 PM, an observation was made of Resident #53 in bed asleep. Her finger nails were still observed untrimmed with thick, dark colored debris packed under her nails.
On 04/26/22 at 11:56 AM, another observation was made of Resident #53's nails which looked the same as yesterday. The resident stated that her nails were not cleaned and trimmed yesterday or today. Resident #53 stated she wanted her nails cleaned and trimmed.
On 04/26/22 at 12:05 PM, an observation of Resident #5's nails was conducted with S3CNA. S3CNA stated that Resident #53's nails looked filthy. S3CNA stated that the resident's nails should be cleaned and trimmed on her bath days every Monday, Wednesday, and Friday. She further stated that Resident #53 eats with her hand so her nails should also be cleaned after each meal. S3CNA stated that she was not sure when the last time nail care was provided. She stated that she thought the nurses were supposed to trim the nails and the CNAs were to ensure the nails were kept clean. S3CNA stated that she had not trimmed or cleaned Resident #53's nails yesterday or today nor had she offered to do so. Resident #53 stated to S3CNA that her nails were dirty and she wanted her nails trimmed and cleaned.
On 04/26/22 at 12:24 PM, an observation of Resident #53's nails was conducted with S4LPN. S4LPN confirmed the resident's nails were dirty and long. She stated that she was not sure how long ago it had been since Resident #53's nails were cleaned and trimmed. Resident #53 stated to S4LPN that she wanted her nails trimmed and cleaned.
On 4/26/22 at 12:32 pm, an interview was conducted with S5LPN who stated that the nurses and CNAs shared the responsibility of trimming and cleaning residents' nails. If staff see the resident's nails dirty, they should clean and trim them when needed. Resident #53 refused care at times and the refusals should be documented by staff. Staff should continue to offer care until the resident allowed staff to provide care.
On 04/27/22 at 10:33 AM, S1DON stated that Resident #53 had a congenital disease that caused a deformity to her feet and left hand which is contracted. The CNAs were responsible for trimming and cleaning the residents' nails on bath days and as needed. Nurses were responsible for ensuring that nail care was provided and documented on the MAR. Refusals should be documented by the nurse and CNA in resident's record. The MAR would note refusals with R or N for not administered. Refusals were reviewed and addressed daily.
On 04/27/22 at 11:46 AM, S1DON stated that she could not find any documentation that Resident #53 refused nail care in March 2022 - April 2022. She further stated that S6CNASup (Supervisor) reported that Resident #53 would allow her to clean her nails all the time.
On 04/27/22 at 12:16 PM, an interview was conducted with S6CNASup who stated that the floor CNAs were responsible for cleaning and trimming resident's nails on bath days and as needed. Resident #53 eats with her hands so CNAs should clean nails after meals. CNAs should offer to clean and trim the resident's nails and should report refusals to the nurse and the CNA supervisors so they could attempt to provide nail care. S6CNASup stated staff had not reported to her or the other CNA supervisor that Resident #53 was refusing nail care. She stated she observed Resident #53's nails yesterday and they were dirty and long with jagged edges. She confirmed that the resident's nails were not cleaned and trimmed as they should have been.
2. Resident #85
Review of the resident's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Parkinson's Disease, Encephalopathy, Hemiplegia affecting left non-dominant side, and Chronic Kidney Disease.
Review of the resident's quarterly MDS (Minimum Data Set) dated 3/9/2022 revealed that the resident was coded as being totally dependent for personal hygiene.
Review of the resident's care plan revealed that the resident was dependent for ADLs (Activities of Daily Living).
On 4/25/2022 at 10:20 am, the resident was observed lying down in bed. The resident was observed with poorly groomed and uneven facial hair during this observation.
On 4/26/2022 at 11:58 am, the resident was observed in bed. The resident was observed with poorly groomed and uneven facial hair during this observation.
On 4/26/2022 at 12:00 pm, S6CNASup (CNA Supervisor) was present in the resident's room with the surveyor. During this observation, S6CNASup asked the resident if he liked his facial hair. The resident stated no that he did not like his facial hair and he wanted it shaved off.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents with limited mobility receive appropr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents with limited mobility receive appropriate services and assistance to maintain or to prevent further decrease in range of motion for 1 (#85) out of 4 (#17, #23, #53, #85) residents investigated for mobility out of a total sample of 18 residents.
Findings:
Resident #85. Review of the resident's clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Parkinson's Disease, Encephalopathy, Hemiplegia affecting left non-dominant side, Chronic Kidney Disease, and Hypertension.
On 4/25/2022 at 10:18 am, the resident was observed lying down in bed. The resident's left hand was contracted. The resident's fingers were held in a closed position in his hand. There was no splint or hand roll in place.
On 4/26/2022 at 11:58 am, the resident was observed lying down in bed. The resident's left hand was contracted. The resident's fingers were held in a closed position in his hand. There was no splint or hand roll in place.
Review of the resident's quarterly MDS (Minimum Data Set) dated 3/9/2022 revealed that the resident was coded to have upper and lower extremity impairment on one side.
Review of the care plan revealed that the resident has functional limited range of motion in left upper extremity and has hemiplegia/hemiparesis of left side and that the interventions included PROM (Passive Range of Motion) to upper extremities.
On 4/26/2022 at 12:00 pm, S6CNASup (CNA Supervisor) checked the resident's left hand and was attempting to open his hands and stretch out his fingers and the resident began to groan in pain. S6CNASup confirmed that his left hand was contracted and that there was no splint or hand roll in place.
On 4/26/2022 at 12:05 pm, S13NCM (Nurse Case Manager) confirmed that the resident has impairment to upper extremity on one side. S13CNM stated that the resident did receive PT (Physical Therapy) and was discharged from PT on 12/16/2021. S13NCM stated that the resident was not placed on the restorative program when discharged from PT. S13NCM stated that there was no evidence that the resident was receiving range of motion.
On 4/26/2022 at 12:10 pm, S14CNA (Certified Nursing Assistant) stated that she was not informed to do range of motion on the resident.
On 4/26/2022 at 12:20 pm, S15CNASup stated that the resident was not on the restorative program and that he was not getting range of motion because he was not on the restorative program.
On 4/26/2022 at 12:24 pm, S16LPN (Licensed Practical Nurse) confirmed that the resident was not on the restorative program and that there was no evidence that the resident was receiving range of motion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help prevent and contr...
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Based on record review and interview, the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help prevent and control the spread of an infectious communicable disease, COVID-19, by not ensuring staff appropriately screened visitors and employees prior to them entering the facility. This had the potential to affect 93 of the residents who resided in the facility.
Findings:
Review of the facility document titled Health Screen which read in part, must be completed by essential persons when proceeding through the buffer zone.
Review of the facility document titled Core Principles and Information Sheet COVID-19 infection Prevention which read, in part, screening of all who enter the facility for signs and symptoms of COVID-19 (e.g. temperature checks, questions about and observations of signs or symptoms), and denial of entry of those with signs and symptoms or who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of vaccination status).
Review of the facility's health screen and visitation screens dated 4/2/22 - 4/25/22 revealed multiple incomplete employee health screens and incomplete visitation screens. On some of the employee health screens revealed missing documented temperatures and some failed to answer the screening questions. On multiple visitors screening there were missing and inaccurate temperatures, along with missing answers to screening question.
On 4/25/22 at 3:44 p.m., an interview was conducted with S7ADON (Assistant Director of Nursing) who stated that the ward clerks were responsible for monitoring and screening of visitors and employees. She added that the ward clerks are were also responsible for ensuring that the temperature monitor was operating properly.
On 4/26/22 at 9:40 a.m., an interview was conducted with S8WC (Ward Clerk) who stated that she worked Monday - Friday and alternate weekends with S9WC and S10WC. S8WC stated that her duties were to screen visitors and staff and ensure the forms were filled out completely or the person couldn't enter the facility. S8WC confirmed that some of the visitors and staff forms were not being filled out correctly.
On 4/26/22 at 10:00 a.m., an interview was conducted with S9WC and S10WC. S9WC stated that both she and S10WC along with S8WC worked Monday - Friday and alternate on the weekends, so one of them was always responsible for screening visitors and staff. S9WC stated that if the screening log was not filled in correctly, then the person was not allowed to enter the facility. S10WC confirmed that it was not acceptable for a visitor or employee to not document an accurate temperature or complete the screening questions. S10WC stated that at times the temperature monitor was not working properly. Both S9WC and S10WC confirmed that the forms have to be filled out completely by visitors and employees and some forms were not completed correctly.
On 4/26/22 at 12:20 p.m., a review of the employee and visitors screening forms (date range 4/2/22 - 4/25/22) and interview was conducted with S1DON (Director of Nursing) who observed the incomplete visitor log and employee screening forms. S1DON stated that some of the screening of visitors and employees were not completed correctly. She added that no one was designated to screen the visitors and employees, but usually anyone who was at the desk was supposed to ensure it was completed correctly. S1DON confirmed that staff should have changed that particular temperature monitor out since it was not working properly and ensure the screening logs were being completed correctly by visitors and employees.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure medical exemptions for the COVID-19 vaccine identified which COVID-19 vaccine was clinically contraindicated for 1 (S11CNA) out of 1...
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Based on record review and interview, the facility failed to ensure medical exemptions for the COVID-19 vaccine identified which COVID-19 vaccine was clinically contraindicated for 1 (S11CNA) out of 1 employee with medical exemptions.
Findings:
Review of the facility's COVID-19 Staff Vaccination Status for Providers matrix revealed that S11CNA (Certified Nursing Assistant) had a medical exemption dated 11/16/2021 which failed to reveal which COVID-19 vaccine was clinically contraindicated.
On 4/26/22 at 12:20 p.m., an interview was conducted with S1DON (Director of Nursing), who stated that she was not aware that the type of vaccines that the employee is exempted from had to be checked but confirmed that the exemption form was not filled out completely or correctly.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
Concerns
- • 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (33/100). Below average facility with significant concerns.
- • 58% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Flannery Oaks Guest House's CMS Rating?
CMS assigns FLANNERY OAKS GUEST HOUSE 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 Flannery Oaks Guest House Staffed?
CMS rates FLANNERY OAKS GUEST HOUSE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 58%, which is 12 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Flannery Oaks Guest House?
State health inspectors documented 29 deficiencies at FLANNERY OAKS GUEST HOUSE during 2022 to 2025. These included: 28 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Flannery Oaks Guest House?
FLANNERY OAKS GUEST HOUSE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PLANTATION MANAGEMENT COMPANY, a chain that manages multiple nursing homes. With 130 certified beds and approximately 99 residents (about 76% occupancy), it is a mid-sized facility located in BATON ROUGE, Louisiana.
How Does Flannery Oaks Guest House Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, FLANNERY OAKS GUEST HOUSE's overall rating (1 stars) is below the state average of 2.4, staff turnover (58%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Flannery Oaks Guest House?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can 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?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Flannery Oaks Guest House Safe?
Based on CMS inspection data, FLANNERY OAKS GUEST HOUSE 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 Flannery Oaks Guest House Stick Around?
Staff turnover at FLANNERY OAKS GUEST HOUSE is high. At 58%, the facility is 12 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Flannery Oaks Guest House Ever Fined?
FLANNERY OAKS GUEST HOUSE has been fined $9,750 across 1 penalty action. This is below the Louisiana average of $33,176. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Flannery Oaks Guest House on Any Federal Watch List?
FLANNERY OAKS GUEST HOUSE 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.