The Woodleigh of Baton Rouge
For profit - Limited Liability company
129 Beds
Independent
Data: November 2025
Trust Grade
43/100
#170 of 264 in LA
Photo by The Woodleigh of Baton Rouge
Photo by David Johnson
Photo by The Woodleigh of Baton Rouge
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
The Woodleigh of Baton Rouge has a Trust Grade of D, indicating below-average quality and some concerning issues. Ranking #170 out of 264 facilities in Louisiana places it in the bottom half, while its county rank of #14 out of 25 suggests that only a few local options are better. The facility is worsening, with the number of identified issues increasing from 9 in 2024 to 10 in 2025. Staffing is average, with a 3/5 rating and a turnover rate of 40%, which is better than the state average of 47%. However, the facility has less RN coverage than 93% of state facilities, which is concerning as RNs are crucial for identifying potential problems that CNAs might miss. Specific incidents raised during inspections include a serious case where a resident fell and sustained fractures due to improper transfer techniques by a CNA, resulting in severe harm. Additionally, there were concerns regarding staff competency documentation, as five staff members had no recorded proof of their training and skills assessments, which could impact resident care. These findings highlight both the need for improvement in staff training and the importance of ensuring safe and effective care for residents.
- Trust Score
- D
- In Louisiana
- #170/264
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- $10,748 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 36%
Needs review
9 → 10 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Louisiana average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 40%
Near Louisiana avg (46%)
Typical for the industry
Federal Fines: $10,748
Below median ($33,413)
Minor penalties assessed
The Ugly 25 deficiencies on record
1 actual harm
Jun 2025
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a resident's call light was within reach for 1 (#34) of 34 residents reviewed during the initial pool.
Findings:
Review of the facility's policy titled, Call System, Residents, with a revision date of September 2022, revealed the following, in part:
Policy Statement: Residents are provided with a means to call staff for assistance through a communication system which notifies a staff member or a centralized work station.
Policy Interpretation and Implementation:
1. Each resident is provided with a means to call staff to notify them for assistance from his/her bed, floor, and from toileting/bathing facilities.
Review of Resident #34's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Need for Assistance with Personal Care, Left Hand Contracture, and Left Elbow Contracture.
Review of Resident #34's current Care Plan revealed following, in part:
Problem: Potential for falls related to decreased mobility, history of Cerebrovascular Accident, confusion, history of falls, left Hemiparesis, and medication effects.
Interventions included to keep the call light within reach and to remind the resident to call for assistance when needed.
Problem: Self-care deficit related to needs extensive assistance with Activities of Daily Living, decreased mobility, and use Hoyer lift with transfers related to diagnoses of Left Hemiparesis and Muscle Rigidity.
Interventions included to keep the call light in reach.
Problem: Alteration in elimination related to bowel and bladder incontinence.
Interventions included to keep the call light in reach.
On 06/02/2025 at 8:55 a.m., an observation was made of Resident #34 in her room. She was sitting up in bed. The call light was observed lying on the floor at the foot of the bed. An interview was conducted with Resident #34 at that time, and Resident #34 confirmed she could not reach it on the floor.
On 06/03/2025 at 9:05 a.m., an observation was made of Resident #34 in her room. She was sitting up in bed. The call light was observed lying on the floor at the foot of the bed, and not in the resident's reach.
On 06/03/2025 at 9:10 a.m., an observation was made of Resident #34 with S15CNA. An interview was conducted with S15CNA at that time. S15CNA confirmed Resident #34's call light was on the floor at the foot of the bed, not within reach, and should have been in reach.
On 06/03/2025 at 4:18 p.m., an interview was conducted with S2DON. S2DON was notified of the above findings. S2DON confirmed Resident #34's call light should have been in reach at all times when in her room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 2 (#67 and #78) of 34 residents reviewed in the initial screening for advance directives. This deficient practice had the potential to affect 103 that resided in the facility.
Findings:
Resident #67
Review of Resident #67's clinical record revealed he was admitted to the facility on [DATE].
Review of Resident #67's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, the resident had a Brief Interview for Mental Status (BIMS) of 12 indicating he was cognitively moderately impaired.
Review of Resident #67's physical chart revealed the following documents, in part:
LaPost dated [DATE] and signed by Resident's Power of Attorney and Physician which, indicated Resident #67 was a DNR (Do Not Resuscitate).
Review of Resident #67's [DATE] Physician Orders revealed:
[DATE] Full Code Status.
Review of Resident #67's Electronic Health Record on [DATE] revealed a Full Code Status.
On [DATE] at 1:11 p.m., an interview was conducted with S11LPN. She stated in the situation a code would arise, she would follow Resident #67's LaPost on the physical chart. S11LPN reviewed Resident #67's LaPost and compared it the electronic health record and confirmed the two records did not match.
On [DATE] at 1:29 p.m., an interview was conducted with S2DON. She reviewed the physician's order and LaPost for Resident #67 and confirmed all medical records should reflect Resident #67's end of life wishes and did not.
Resident #78
Review of Resident #78's clinical record revealed he was admitted to the facility on [DATE] and began receiving Hospice Services on [DATE].
Review of Resident #78's Significant Change MDS with an ARD of [DATE] revealed the resident had a BIMS of 13 indicating he was cognitively intact.
Review of Resident #78's physical facility chart on [DATE] revealed the following documents, in part:
LaPost dated [DATE] and signed by the resident and physician which indicated Resident #78 was a full code.
Review of Resident #78's Hospice Binder on [DATE] revealed the following, in part:
La Post dated [DATE] and signed by Resident #78's family member and the physician which indicated Resident #78 was a DNR.
Review of Resident #78's [DATE] Physician Orders revealed:
[DATE]: DNR.
Review of Resident #78's Electronic Health Record on [DATE] revealed a DNR code status.
On [DATE] at 3:53 p.m. an interview was conducted with S8LPN. S8LPN stated in the situation a code would arise she would go to the physical chart to verify a resident's code status. S8LPN reviewed Resident #78's physical chart and confirmed the LaPost was signed as a full code. S8LPN reviewed Residents #78's EHR and confirmed he was listed as a DNR. S8LPN stated she would follow the LaPost and perform CPR on Resident #78. S8LPN reviewed resident's Hospice chart and confirmed Resident #78's LaPost indicated he was a DNR. S8LPN confirmed the charts did not match and should.
On [DATE] at 3:59 p.m., an interview was conducted with Resident #78. Resident #78 confirmed he wished to have CPR if needed.
On [DATE] at 4:11p.m., an interview was conducted with S7ADN. S7ADN reviewed and confirmed Resident #78's physical chart's LaPost was signed for CPR, the Hospice Chart's LaPost was signed for DNR and the EMR indicated Resident #78 was a DNR. S7ADN confirmed that the chart and order should match.
On [DATE] at 4:11 p.m., an interview was conducted with S2DON. S2DON stated in the situation a code would arise she expected staff to refer to the Physician's order in the EHR for a resident's code status. She stated Resident #78's EHR indicated he was DNR. The S2DON confirmed that the EHR and all medical records should match.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were stored safely and were kept locked by leaving medication at the bedside for 1 (#341) of 33 residents observed during the initial screening of residents upon facility entrance.
Findings:
Review of the facility's policy Medication Labeling and Storage, with a revised date of 02/2024, revealed, in part, the following:
Policy Heading
The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity, and light controls. Only authorized personnel have access to keys.
Policy Interpretation and Implementation
Medication Storage
2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.
5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.
Review of Resident #341's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Wheezing and Acute Cough.
Review of Resident #341's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/15/2025, revealed she had a Brief Interview for Mental Status (BIMS) of 15, which indicated she was cognitively intact.
Review of Resident #341's current Physician Orders revealed the following, in part:
Start date: 05/15/2025 Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams (mg)/milliliters (mL), inhale orally three times a day for three days.
An observation was made of Resident #341 on 06/02/2025 at 11:00 a.m. Further observation was made of an unopened package of Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/mL on the bedside table. Resident #341 verified the medication was her medication.
An observation was made of Resident #341 on 06/03/2025 at 9:46 a.m. Further observation was made of an unopened package of Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/mL on the bedside table.
An interview was conducted with S11LPN on 06/03/2025 at 9:53 a.m. She observed and verified the unopened package of Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/mL on Resident #341's bedside table. She confirmed the medication should not have been left on the bedside table. She stated the medication should have been stored in the locked medication cart and it was the nurse's responsibility to ensure medications are stored properly.
An interview was conducted with S2DON on 06/03/2025 at 9:55 a.m. She confirmed medication should not have been left on the resident's bedside table. She stated the medication should have been store in the locked medication cart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provisi...
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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 provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing was properly labeled for 1 (#342) of 5 (#65, #77, #84, #341, and #342) residents reviewed for oxygen therapy.
Findings:
Review of Resident #342's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Chronic Obstructive Pulmonary Disease, Chronic Diastolic Heart Failure, Ischemic Cardiomyopathy, and Asthma.
Review of Resident #342's Physician's Orders revealed the following, in part:
Start date: 05/29/2025: Oxygen at 2 Liters per nasal cannula, as needed for Chronic Obstructive Pulmonary Disease.
On 06/02/2025 at 11:45 a.m., an observation was made of Resident #342's oxygen tubing, which was not labeled with the date.
On 06/03/2025 at 9:47 a.m., an observation was made of Resident #342's oxygen tubing, which was not labeled with the date.
On 06/03/2025 at 9:55 a.m., an observation was made of Resident #342's oxygen tubing with S11LPN. S11LPN confirmed the oxygen tubing was not labeled with the date last changed and should have been. She stated the tubing should have been changed and labeled weekly, and it was the nurse's responsibility to do so.
On 06/03/2025 at 9:59 a.m , an interview was conducted with S2DON. She confirmed nursing staff should have changed and labeled oxygen tubing weekly.
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 observations, interviews, and record review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles. The facili...
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Based on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure:
1. An expired medication was not available for use for Resident #54 in 1 (Cart B) of 2 carts (Cart A and Cart B) reviewed; and
2. An opened medication was labeled with an open date and not available for use in 1 (Cart B) of 2 carts (Cart A and Cart B) reviewed.
Findings:
On 06/02/2025 at 11:15 a.m., an observation was made of Cart B with S6LPN. The following was observed:
One medication card containing 21 tablets of Hyoscyamine Sulfate Sublingual 0.125 mg tablets with a discard after date of 02/28/2025 for Resident #54; and
One bottle of Vitamin D 10 mcg tablets was opened and not labelled with the open date.
On 06/02/2025 at 11:20 a.m., an interview was conducted with S6LPN. She observed the above findings and confirmed the Hyoscyamine Sulfate Sublingual 0.125 mg tablets for Resident #54 were expired and available for use. She also confirmed the bottle of Vitamin D was open with no date to indicate when the bottle was opened.
On 06/02/2025 at 4:00 p.m., an interview was conducted with S2DON. She stated the nurses on the hall were responsible for checking the medication carts for unlabeled and expired medications. She was notified of the above observations made of Cart B. She confirmed Resident #54's Hyoscyamine Sulfate tablets should have been discarded when expired. S2DON further confirmed the bottle of Vitamin D should have been labeled with the date when it was opened.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster.
Findings:
On 06/02/2025 at 9:04 a.m., an observation was ma...
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Based on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpster.
Findings:
On 06/02/2025 at 9:04 a.m., an observation was made of the facility's two outdoor trash dumpsters with S3DM. One of the dumpsters was observed with the door open and a clear plastic bag containing soiled briefs and gloves hanging out of the lid. Scattered trash was observed on the ground around the dumpster including the following: plastic bag, plastic cups, plastic utensils, gloves, one green cloth, empty juice containers, and other unidentifiable paper items.
On 06/02/2025 at 9:10 a.m., an interview was conducted with S3DM. She observed and confirmed the above mentioned observations of the dumpster area. She stated the dumpster door should be kept closed and the surrounding area kept free of trash. She stated maintenance was responsible for keeping the dumpster area clean.
On 06/02/2025 at 10:00 a.m., an interview was conducted with S4MA. He stated he and S5MS were responsible for keeping the dumpster area clean. He stated the dumpster doors should be kept closed and there should be no trash on the ground.
On 06/02/2025 at 10:20 a.m., an interview was conducted with S5MS. He stated maintenance staff were responsible for keeping the dumpster area clean. He confirmed the dumpster doors should be kept closed and there should be no trash on the ground.
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 review, the facility failed to maintain an infection prevention and control program...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S12LPN wore proper Personal Protective Equipment (PPE) while providing urinary catheter care for 1 (#67) of 2 (#13 and #67) residents with indwelling medical devices.
Findings:
Review of the facility's policy, dated 08/2024, titled Enhanced Barrier Precautions, revealed, in part:
Policy Interpretation and Implementation:
2. Enhanced Barrier Precautions (EBP) employ targeted gown and glove use during high contact resident care activities .
3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include: g) device care or use (urinary catheter .)
Review of Resident #67's clinical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms and Urinary Tract Infection.
Review of Resident #67's active physician orders, dated 03/01/2025 to 06/30/2025 revealed, in part:
1. Indwelling Catheter for diagnosis of BPH with retention;
2. Clean indwelling catheter with soap and water daily and as needed.
On 06/02/2025 at 11:59 a.m., an observation was made of Resident #67's room door with no EPB signage observed.
On 06/02/2025 at 12:00 p.m., an interview was conducted with Resident #67. He stated he had a urinary catheter for 3 weeks. An observation was made of a urinary catheter bag attached to Resident #67.
On 06/02/2025 at 12:43 p.m., an interview was conducted with S2DON. She stated any resident with an indwelling catheter should be on Enhanced Barrier Precautions.
On 06/04/2025 at 8:58 a.m., an observation was made of Resident #67's door with no EPB signage observed.
On 06/04/2025 at 10:01 a.m., an observation was made of S12LPN performing urinary catheter care on Resident #67. No gown was worn by S12LPN.
On 06/04/2025 at 10:11 a.m., an interview was conducted with S12LPN. She stated the only PPE needed to conduct urinary catheter care was gloves. She further stated when residents were on EBP precautions a sign was placed on the resident's door. She confirmed she only wore gloves when she performed urinary catheter care on Resident #67.
On 06/04/2025 at 10:27 a.m., an interview was conducted with S7ADN. She stated she was the Infection Preventionist for the facility. She reported all training for infection control was completed by all staff in their electronic training system. She further stated when residents were placed on precautions of any type, signage was placed on the resident's door, a biohazard box was placed in the resident's room, and isolation carts with PPE for staff was placed near the room for use. She confirmed residents with urinary catheters should be on Enhanced Barrier Precautions. She stated staff should wear gown and gloves when providing direct care to a resident on Enhanced Barrier Precautions. She confirmed Resident #67 had a urinary catheter. She confirmed Resident #67 was not on Enhanced Barrier Precautions and should be.
Mar 2025
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the resident assessments accurately reflecte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the assistance required for eating for 1(#1) of 4 (#1, #2, #3, and #4) sampled residents.
Findings:
Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE].
Review of Resident #1's Quarterly MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of 03/02/2025, revealed the resident required setup or cleanup assistance for meals.
On 03/26/2025 at 12:45 p.m., an observation was conducted of Resident #1 in the dining room. Resident #1 is noted with a bib on with S3CNA was feeding the resident. S9CNA held the cup for Resident #1 and placed the straw next to his lips.
On 03/26/2025 at 11:19 a.m., an interview was conducted with S9CNA. She stated Resident #1 returned from the hospital on [DATE] with a sling for his left upper extremity and was dependent on staff for feeding.
03/26/2025 at 12:15 p.m., an interview was conducted with S4CNA. She stated Resident #1 returned from the hospital on [DATE] with a sling for his left upper extremity and was dependent on staff for feeding.
On 03/26/2025 at 11:02 a.m., an interview was conducted with S10PTA. She stated Resident #1 returned from the hospital on [DATE] with a sling for his left upper extremity with limited range of motion and was dependent on staff for eating.
On 03/26/2025 at 11:50 a.m., an interview was conducted with S6MDS. She confirmed the ARD for the Quarterly MDS Assessment was 03/02/2025. She stated Resident #1's MDS assessment is based on the documentation in his electronic health record and the electronic health record should be accurate. She confirmed she was not aware Resident #1 was dependent on staff for meals and his MDS was inaccurately coded for assistance required for eating.
On 03/26/2025 at 1:20 p.m., an interview was conducted with S2DON. She confirmed the MDS assessment was based on the ADL documentation and the ADL documentation should accurately reflect the residents' status.
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
Incontinence Care
(Tag F0690)
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 that a resident that was frequently incontinent was provid...
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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 that a resident that was frequently incontinent was provided services to restore as much normal bowel function as possible for 1 (#1) of 4 (#1, #2, #3 and #4) residents reviewed for Bladder and Bowel Incontinence.
Findings:
Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: Septic Arthritis Of Left Shoulder, History Of Falling, Need For Assistance With Personal Care, and Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Side.
Review of Resident #1's Quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 03/02/2025 revealed the resident was always incontinent of bowel and bladder. Further review revealed Resident #1 was assessed by the facility to have a BIMS of 11, indicating he was moderately cognitively impaired.
Review of Resident #1's Care Plan revealed the following, in part:
Problem: Alteration in elimination related to incontinence of bowel and bladder
Interventions: adult briefs as needed, check every 2 hours, and encourage resident to call for assistance as needed with toileting.
Review of Resident #1's Incident Report Logs from January 2025 to March 2025 revealed the following:
Date: 08/21/2024 at 11:10 a.m.
Description: Resident #1 stated he lost his balance when ambulating to the bathroom. Intervention: Educated to call for assistance.
Date: 10/29/2024 at 8:30 p.m.
Description: Resident #1 was found in the bathroom in front of the toilet. Intervention: Visual sign placed in room and bathroom.
Date: 01/20/2025 at 1:44 a.m.
Description: Resident #1 was found on the floor with his back facing the toilet. Resident #1 stated that he missed the toilet. Intervention: Bedside commode placed over toilet seat for elevation and to assist with sitting and standing.
On 03/24/2025 at 11:32 a.m., an interview was conducted with Resident #1. He stated he was aware of when he needed to have a bowel movement and urinate. He stated he would rather go to the toilet then use the bathroom in his brief but was told by staff to go in the brief and they will clean him up after. Resident #1 stated he did not like having a bowel movement in the brief.
On 03/24/2025 at 11:48 a.m., an interview was conducted with Resident #1's RP. She stated Resident #1 was aware of when he needed to have a bowel movement and urinate but staff told him to use it in the brief and they will clean him up afterwards. She stated Resident #1 was able to use the commode but needed assistance to transfer to the wheelchair and then to the commode. She stated Resident #1 hated using the adult briefs.
On 03/24/2025 at 12:23 p.m., an interview was conducted with S4CNA. She stated Resident #1 could use the commode but she never offered to put Resident #1 on the commode. She stated she was not aware of Resident #1 being on a toileting schedule.
On 03/24/2025 at 4:00 p.m., an interview was conducted with S5LPN. She stated Resident #1 required assistance with toilet transfers and knew when his brief was clean and dirty. She stated she never offered to put Resident #1 on the commode. She stated she was not aware of Resident #1 being on a toileting schedule.
On 03/25/2025 at 3:13 p.m. an interview was conducted with S3CNA. He stated Resident #1 transferred to the commode with assistance. He stated he would assist Resident #1 when he requested to use the commode but he never offered to put Resident #1 on the commode. He stated he was not aware of Resident #1 being on a toileting schedule.
On 03/26/2025 at 11:50 a.m., an interview was conducted with S6LPN. She stated the MDS assessment was determined by speaking with the Resident and ADL documentation from staff. She stated a bowel and bladder program to promote continence would be initiated by the nursing staff and a bowel and bladder program had not been initiated for Resident #1.
On 03/26/2025 at 1:20 p.m., an interview was conducted with S2DON. She stated Resident #1 was able to participate in a bowel and bladder program. She stated there were no current interventions for Resident #1 to promote continence and he did not have a bowel and bladder program.
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
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 review and interviews, the facility failed to ensure Activities of Daily Living (ADL) care was accurately docume...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Activities of Daily Living (ADL) care was accurately documented for 1 (#1) of 4 (#1, #2, #3 and #4) Residents reviewed for ADL care.
Findings:
Review of Resident #1's clinical record revealed that he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses Septic Arthritis of Left Shoulder, Need for Assistance with Personal Care, and Hemiplegia and Hemiparesis Following Cerebral Infarction, Affecting Right Side.
Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/2025 revealed a Brief Interview for Mental Status (BIMS) of 11, indicating the resident had moderate cognitive impairment. Further review revealed the resident required limited set up/cleanup for meals.
Review of Resident #1's Eating ADL log, dated 03/01/2025-03/24/2025, revealed the following:
Eating: Self Performance- How resident eats and drinks
Limited Assistance- Resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance.
Extensive Assistance- Resident involved in activity, staff provide weight bearing support.
Total Dependence- Full Staff Performance.
Resident #1 was coded to require the following assistance on the following days during the 6:00 a.m. to 2:00 p.m. shift:
Limited Assistance - 03/05/2025, 03/11/2025, 03/16/2025 and 03/18/2025
Extensive Assistance - 03/01/2025 through 03/04/2025, 03/06/2025 through 03/09/2025, 03/12/2025 through 03/15/2025, 03/17/2025, and 03/19/2025 through 03/23/2025
Total Dependence - 03/10/2025 and 03/24/2025
On 03/26/2025 at 12:45 p.m., an observation was conducted of Resident #1 in the dining room. Resident #1 is noted with a bib on and staff was feeding the resident. S9CNA picked up and held the cup for Resident #1, while he drank the fluids.
On 03/24/2025 at 12:23 p.m., an interview was conducted with S4CNA. She stated she worked 6:00 a.m. to 2:00 p.m. shift and was assigned to Resident #1. She stated when he returned to the facility on [DATE], he had a sling to his Left arm and his Right arm was affected from a previous stroke. She confirmed he was depended on staff for eating.
On 03/24/2025 at 12:34 p.m. an interview was conducted with S8LPN. She stated she worked on the day shift and was assigned to Resident #1. She stated when he returned to the facility on [DATE], he had a sling to his Left arm and his Right arm was affected from a previous stroke. She confirmed he was dependent on staff for eating.
On 03/25/2025 at 10:02 a.m., an interview was conducted with S7PTD. She stated Resident #1 was currently receiving therapy services. She confirmed Resident #1's Left arm was in a sling and he was unable to feed himself. She stated he had limited movement to the left arm and the right arm was affected from a previous stroke.
On 03/26/2025 at 11:11 a.m., an interview was conducted with S5LPN. She stated she worked on the day shift and was assigned to Resident #1. She stated when he returned to the facility on [DATE], he had a sling to his left arm, and was dependent on staff for eating.
On 03/26/2025 at 11:50 a.m., an interview was conducted with S6MDS. She confirmed she was not aware Resident #1 was dependent on staff for meals. She stated if Resident #1 was being fed by staff, his ADL documentation should be coded as Total Dependence. She reviewed the ADL documentation and confirmed the documentation was not accurate and should be.
May 2024
9 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0726
(Tag F0726)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each nurse aide was competent when transferring a 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 each nurse aide was competent when transferring a resident with the slide board for 1 (#29) of 3 (#29, #61, and #69 ) residents reviewed for falls.
This deficient practice resulted in an actual harm for Resident #29, beginning on 04/02/2024 at 4:30 p.m. when S16CNA inappropriately used the slide board during a transfer, which resulted in Resident #29 falling to the floor. On the morning of 04/03/2024, Resident #29 refused care due to severe pain when she moved. On 04/03/2024 at 12:12 p.m., Resident #29 had X-rays in the facility that revealed a Left Femur Fracture. Resident #29 was transferred to the emergency room and found to have a Left Distal Femur Fracture and a Right Displaced fracture that required surgical interventions.
Review of the Facility's November 2023 Training Materials revealed the following, in part:
Sliding Board Transfer
7. The caregiver should position themselves in front of the patient when performing the transfer, using proper body mechanics.
Review of Resident #29's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included: Displaced Intertrochanteric Fracture of Right Femur on 04/03/2024, Unspecified Fracture of Lower End of Left Femur on 04/03/2024, and Multiple Sclerosis.
Review of the Quarterly MDS with an ARD of 01/02/2024 revealed the provider assessed Resident #29 as having a BIMS of 15, which indicated the resident was cognitively intact. The resident was documented as dependent on staff for assistance with transfers.
Review of Resident #29's most recent Care Plan revealed the facility included the following problems and interventions, in part:
Problem: Potential for falls related to decreased mobility, medication effects, and diagnosis of Multiple Sclerosis
Interventions: Use slide board for transfers
Review of the Facility Incident Report revealed the following, in part:
04/02/2024 at 4:30 p.m.
Description: Resident #29 observed sitting on the floor in front of wheelchair with S16CNA in the room. She denied pain or discomfort at the present time. Head to toe assessment completed, no nodule or skin tears. Resident #29 assisted to chair x 3 assist, NP notified.
04/03/2024- Fracture to left femur to ER for evaluation and treatment.
Review of Resident #29's Nurse's Notes revealed the following, in part:
04/02/2024 at 4:30 p.m., Resident #29 observed sitting on floor in front of wheelchair with S16CNA in the room. She stated while being transferred by S16CNA to chair using the sliding board she slid off the board to the floor. Resident #29 denied pain or discomfort at this time, head to toe assessment completed, and no nodule or skin tears. Resident assisted to chair x 3 assist. NP notified. S23LPN
04/03/2024 at 11:21 a.m., Resident #29 in bed while CNA attempted to assist the resident with changing. Resident #29 stated too much pain to complete the task. NP notified of Resident #29's pain level. NP assessed the resident and ordered X-Ray of bilateral knees, Femur, and hips. Pain medication ordered. Local imaging agency notified. S23LPN
04/03/2024 at 2:30 p.m., Order received per NP to send Resident #29 to emergency room due to left femur fracture.
Review of Resident #29's Hospital Medical Records revealed, in part, the following:
04/03/2024
Reason for Visit: Resident #29 was brought by ambulance from a local nursing home after a ground-level fall the day prior to presentation. Resident #29 received assistance yesterday with incontinent care, attempted transfer with a sliding board and fell. She received Tylenol at the nursing home and on route she received fentanyl.
HPI indicated: CT scan and x-ray of the pelvis and femur with intertrochanteric right femoral fracture. Pain control with Norco, Morphine, and hydromorphone.
Impression indicated acute distal femoral fracture left; acute right femoral fracture.
Review of Resident #29's Radiology Report revealed, in part, the following:
Left Femur CT w/o IV Contrast on 04/03/2024
There is an acute comminuted fracture distal femoral diametaphysis, 2 cm displacement, with anterior angulation/external rotation distal fracture fragment and mild impaction of the fracture fragments. There is an associated hemorrhage at the fracture sites accounting for the soft tissue density. There is mild thigh subcutaneous edema.
Left Hip unilateral 1 view w/ pelvis on 04/03/2024
Impression/Plan: Intertrochanteric right femoral fracture related to ground level fall
Review of Resident #29's Nurse's Notes revealed the following, in part:
04/11/2024 at 1:59 p.m., Report received from local hospital. Resident #29 will be returning to facility with closed fracture of left femur, fracture to right hip, post op closed reduction with nail placement to right femur and post op closed reduction with nail placement to left femur.
Review of Resident #29's facility Nurse Practitioner progress notes revealed the following:
04/12/2024
Hospital follow up
She was recently sent to the emergency department after a ground level fall and imaging at the nursing home showed Left Distal Femur Fracture. In the emergency department she was found to have a Left Distal Femur Fracture and Right Displaced Fracture. Orthopedics was consulted and Resident #29 underwent closed reduction with nail placement of the right femur on 04/04/2024 and underwent nail placement to the left femur on 04/09/2024. Tramodol as needed for pain.
On 05/29/2024 at 9:44 a.m., an interview was conducted with Resident #29. She stated on 04/02/2024, S16CNA transferred her from the bed to the wheelchair via slide board. She stated during the transfer, S16CNA was standing behind her. She stated the slide board was tilted and she slid forward, falling to the ground. She stated she was initially in pain but denied the pain because she was hoping it would get better. She stated the pain did not get better and x-rays were ordered.
On 05/29/2024 at 11:45 a.m., an interview was conducted with S23LPN. She stated on 04/02/2024, S16CNA called her to the room because Resident #29 had a fall. She stated Resident #29 said she fell off the board to the floor. She stated the resident did not initially complain of any pain. She said the resident began to complain of pain on the morning of 04/03/2024 and the NP was notified.
On 05/29/2024 at 2:36 p.m., an interview was conducted with S20PT. She stated Resident #29 should be transferred using the slide board with max assist. She stated during the time she worked at the facility she conducted trainings with staff but could not provide any dates or names of the staff who were trained.
On 05/29/2024 at 2:42 p.m., an interview was conducted with S21PTAD. She stated she worked with the facility's contracted Physical Therapy agency from 2021 until 04/30/2024. She stated in 2021, Resident #29 used the slide board for transfers. She stated she never trained any staff on the use of the slide board.
On 05/30/2024 at 2:45 p.m., an interview was conducted with S26ST. She stated she began working for the facility on 05/01/2024. She confirmed she had not provided any demonstrations to staff since she began on 05/01/2024. She stated an equipment transfer demonstration should be conducted with staff annually at a minimum with a return demonstration.
On 05/30/2024 at 5:12 p.m., an interview was conducted with S16CNA. She stated she received computer training on how to use the slide board/transfer in December 2023, but did not complete a return demonstration to ensure she was transferring with the slide board correctly. She stated Resident #29 used the slide board for transfers. She stated on 04/02/2024, she was transferring Resident #29 to the chair from the bed and Resident #29 fell off the slide board onto the floor. She stated she went immediately to the nurse and informed her of the fall.
On 05/30/2024 at 4:20 p.m., an interview was conducted with S17CNAS. She confirmed she did not watch any staff demonstrate the slide board/transfer prior to staff being assigned to work independently on the hall after orientation or annually.
On 05/30/2024 at 3:01 p.m., an interview was conducted with S2DON. She stated new employees completed orientation in the computer system and would be placed on the floor for 3 days with a CNA, to learn the care residents required. She confirmed new CNA employees did not complete a slide board/transfer competency skills check upon hire or annually. She stated, staff were competent if they had a license or certification. She said she conducted an in-service on safe transfers in November 2023, but staff did not complete a return demonstration to ensure competency. She stated staff verbalized understanding of the training. She confirmed S16CNA did not attend the training in November 2024, but completed the computerized training in December.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to make prompt efforts to resolve grievances for 1 (#3) of 2 (#3 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to make prompt efforts to resolve grievances for 1 (#3) of 2 (#3 and #29) residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #3 reported a missing blanket and clothing to staff.
Findings:
Review of the facility's policy titled, Grievances/Complaints, Filing with a revision date of 04/2017 revealed the following, in part:
Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident .
Policy Interpretation and Implementation:
1. Any resident .may file a grievance or complaint concerning care . or any other concerns regarding his or her stay at the facility.
8. Upon receipt of a grievance and/or complaint, the designee will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.
11. The Administrator will review the findings to determine what corrective actions, if any, need to be taken.
12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems.
a. The Administrator, or his or her designee, will make such reports within 5 working days of the filing of the grievance or complaint with the facility.
Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE].
Review of Resident #3's MDS with an ARD of 04/05/2024, revealed she had a BIMS of 15, which indicated she was cognitively intact.
Review of facility's Grievance Log from December 2023 to May 2024 revealed no documentation the facility logged a grievance for Resident #3's missing clothing and blanket.
An interview was conducted with Resident #3 on 05/28/2024 at 8:42 a.m. She stated about a month ago she reported missing clothing and a blanket to staff on the hall, but could not recall who. She stated the missing clothing items and blanket were sent to the laundry and never returned to her. She stated she made a list of missing items and gave it to S6HS last month. She stated she was missing the following items: matching orange/peach shirt and pair of culottes, beige shorts, red shirt, turquoise shirt and a pair of culottes, and a blanket she received as a gift for her birthday. She stated the facility never reimbursed her for the missing clothing or blanket, nor did the facility replace the items or inform her what they would do about the missing items.
An interview was conducted with S5CNA on 05/29/2024 at 9:05 a.m. She stated the facility cleaned Resident #3's laundry. She stated a couple months ago, Resident #3 reported missing several items of clothing and a blanket. She stated she looked for the missing items, could not find them, and went to the laundry room and notified S6HS of Resident #3's missing items. She stated Resident #3's blanket was never found, but was unsure about the missing clothing.
An interview was conducted with S6HS on 05/29/2024 at 9:32 a.m. He stated Resident #3 reported missing a blanket a few weeks ago, but he did not recall her missing any clothing. He stated he looked for the blanket, but had not found it. He stated missing laundry items that were unable to be located, should be reported to the Administrator, who would then report it as a grievance. He confirmed he had not reported Resident #3's missing laundry items to the Administrator.
An interview was conducted with S7SSD on 05/29/2024 at 2:25 p.m. She stated any staff can report a grievance. She stated when a grievance was reported for missing laundry items she, S2DON or the former Administrator opened a grievance. She stated if the missing laundry items could not be located a grievance should be opened and started the same day it was reported. She stated no staff had reported any grievances for Resident #3's missing clothing or a blanket.
An interview was conducted with S2DON on 05/29/2024 at 3:55 p.m. She stated S7SSD and any department head can open a grievance. She stated S7SSD logged all grievances. She stated she was not aware of Resident #3 missing any clothing items or a blanket. She confirmed no grievances for missing clothing or a blanket had been filed for Resident #3. She stated S6HS should have reported the missing laundry items to the former Administrator when he could not find them.
An interview was conducted with S1CADM on 05/29/2024 at 4:05 p.m. He stated when a resident had a complaint, a grievance should be filed, investigated, and a follow up done with the resident. He stated Resident #3's missing clothing and blanket would have been treated as a grievance, laundry and staff would look for the items, and S7SSD would have completed the grievance form. He stated S6HS should have reported Resident #3's missing laundry items to S7SSD and the former Administrator and a resolution given to Resident #3 within 3 to 5 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure services were provided by the facility to mee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure medications were administered safely and timely by leaving the medications at the bedside for 1 (#64) of 24 residents observed during the initial screening of residents upon facility entrance.
Findings:
Review of the facility's policy titled, Medication Administration Policy with a revision date of 04/2019 revealed the following, in part:
Policy Statement:
Medications are administered in a safe and timely manner, and as prescribed.
Review of Resident #64's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Polyneuropathy, Acquired Absence of Right Leg Above Knee, Acquired Absence of Left Leg Above Knee, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Moderate Protein Calorie Malnutrition, Peripheral Vascular Disease, and Unspecified Pain.
Review of Resident #64's Quarterly MDS with an ARD of 02/20/2024, revealed he had a BIMS of 15, which indicated he was cognitively intact.
Review of Resident #64's current Physician Orders revealed the following, in part:
Start date 07/23/2022 Flomax 0.4 mg give 2 capsules by mouth one time a day.
Start date 05/12/2023 Meloxicam 7.5 mg give 1 tablet by mouth one time a day.
Start date 07/21/2023 Gabapentin 600 mg give 1 tablet by mouth three times a day.
Start date 07/22/2023 Thera Tablet give 1 tablet by mouth one time a day.
Start date 03/25/2024 Methocarbamol 750 mg give 2 tablets by mouth three times a day.
An observation was made of Resident #64 on 05/28/2024 at 8:24 a.m. He was observed awake and alert lying in bed. A plastic medication cup containing 7 pills was observed on the bedside table. He verified the medications in the plastic cup were his morning medications. He stated S3LPN left the medications this morning to take when he was ready, because he was nauseated.
An interview was conducted with S3LPN on 05/28/2024 at 8:35 a.m. She observed and verified the plastic medication cup containing 7 pills on Resident #64's bedside table. She confirmed the medications in the cup were Methocarbamol 750 mg, Gabapentin 600 mg, Mobic 7.5 mg, Flomax 0.4 mg, and Therapeutic Vitamin. She confirmed she did not observe Resident #64 take his morning medications and should have.
An interview was conducted with S2DON on 05/29/2024 at 4:00 p.m. She confirmed medications should not have been left at the resident's bedside and the nurse should have observed Resident #64 take his medications.
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 review, the facility failed to ensure a resident who was unable to carry out ADLs ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#13) of 2 (#13, and #23) residents reviewed for ADL's. The facility failed to trim fingernails for Resident #13.
Findings:
Review of the facility's policy titled, Care of Fingernails/Toenails and dated February 2018, revealed the following, in part:
General Guidelines 1. Nail care includes daily cleaning and regular trimming.
Review of Resident #13's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Non-traumatic Intracerebral Hemorrhage Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus.
Review of Resident #13's Quarterly MDS with an ARD of 03/08/2024 revealed Resident #13 had a BIMS of 15, which indicated intact cognition. Further review revealed Resident #13 required moderate assistance for ADLs.
Review of Resident #13's care plan revealed the following:
Problem: Diagnosis Diabetes Mellitus
Interventions: Nursing to provide nail care
Problem: Self-care deficit related to needs assistance with ADLs
Goal: Resident will be well groomed daily this quarter
Interventions: Assist with ADLs as needed
Review of the current Physician Orders for Resident #13 revealed no orders for nail care.
On 05/28/2024 at 8:37 a.m., an observation was conducted of Resident #13 sitting in his wheelchair outside of the shower room. His fingernails are noted to be 1/2 to 1 cm long with black stuff under multiple fingernails. He stated he was waiting for his shower and would like his nails trimmed and cleaned.
On 05/28/2024 at 2:54 p.m., an observation was conducted of Resident #13 sitting in his wheelchair in his room. His fingernails are noted to be 1/2 to 1 cm long. Resident #13 stated he went to the shower room every other day. He stated he had his shower this morning and his nails were cleaned but were not trimmed. He stated his nails were too long and he wanted them trimmed.
On 05/28/2024 at 3:03 p.m., an interview was conducted with S25CNA. She stated CNAs clean the resident's fingernails and toe nails. She stated nurses trim the resident's fingernails and toenails because the CNA's did not know which residents were Diabetic.
On 05/28/2024 at 3:10 p.m., an interview was conducted with S17CNAS. She stated if a Diabetic resident's fingernails needed to be trimmed she would expect the CNA to report this to the nurse.
On 05/28/2024 at 3:24 p.m., an interview was conducted with S23LPN. She stated if residents were Diabetic, the nurse or wound care nurse would provide fingernail care. She confirmed the CNA had not reported that Resident #13 needed fingernail care.
On 05/30/2024 at 9:56 a.m., an interview was conducted with S10LPN. She stated Resident #13 did not refuse care. She stated the nurse or wound care nurse would complete fingernail care if residents were diabetic. She said fingernails would be assessed daily with normal rounds.
On 05/30/2024 at 10:06 a.m., an interview was conducted with S22CNA. She stated Resident #13 faithfully went to the shower room [ROOM NUMBER] times per week. She stated the nurse or wound care nurse would complete fingernail care for Diabetic residents.
On 05/30/2024 at 2:36 p.m., an interview was conducted with S17CNAS. She confirmed she observed Resident #13's fingernails on 05/28/2024 and they needed to be trimmed, and should have been trimmed prior to getting that long.
On 05/30/2024 at 3:01 p.m., an interview was conducted with S2DON. She stated the process for fingernail care was that any staff could trim the fingernails, regardless if they are Diabetic. She stated fingernails should be trimmed when a resident requested them to be trimmed. She said if a resident requested the nails to be trimmed and they were 1 cm long, then she would expect them to be trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident 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 review, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a nutritional supplement for 1 (#3) of 5 (#3, #35, #44, #64 and #79) residents reviewed for nutritional status.
Findings:
Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnosis, which included Unspecified Protein-Calorie Malnutrition.
Review of Resident #3's MDS with an ARD of 04/05/2024, revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review revealed Resident #3 received a therapeutic diet.
Review of Resident #3's current Physician Orders revealed the following, in part:
Start date 05/17/2024 House Shake Supplement three times a day related to Unspecified Protein-Calorie Malnutrition; give 1 carton strawberry with all meals.
Review of Resident #3's Nutrition Assessment Notes, dated 05/16/2024, revealed, in part, the following:
She is a very picky eater . She is eating meals in her room and is feeding herself. Skin Stage 4 pressure ulcer to right heel . Recommendation: Resume Strawberry House Shakes with all meals related to diagnosis of Unspecified Protein-Calorie Malnutrition.
Review of Resident #3's Care Plan, revealed, in part, the following:
Problem: Alteration in nutrition .
Interventions: Provide supplements as ordered
An observation and interview was conducted with Resident #3 on 05/29/2024 at 7:40 a.m. She stated she had finished eating breakfast. An observation was made of the meal ticket on the breakfast tray with documentation noted for a strawberry Mighty Shake. Resident #3 did not have a Mighty Shake on her tray and had consumed approximately 25% of the meal. She stated she was supposed to get a Mighty Shake with all meals, but did not always get it. She stated she had lost weight over the last few months, and her appetite and weight had been fluctuating.
An interview was conducted with S4CNA on 05/29/2024 at 7:55 a.m. She stated Resident #3 had a decreased appetite and the kitchen was supposed to send a Mighty Shake with her meals. She observed Resident #3's breakfast meal tray, and confirmed the Mighty Shake was not on the tray and should have been.
An interview was conducted with S5CNA on 05/29/2024 at 9:05 a.m. She stated Resident #3 had a decreased appetite and a Mighty Shake was supposed to be sent with her meal trays. She stated Resident #3 did not have a Mighty Shake on her breakfast tray and should have.
An interview was conducted with S3LPN on 05/29/2024 at 10:20 a.m. She stated Resident #3 had a decreased appetite, weight loss, and was placed on Mighty Shakes with all meals. She stated the kitchen staff should have sent a Mighty Shake on Resident #3's breakfast tray this morning. She stated if Resident #3 did not have a Mighty Shake on her meal tray, the CNAs should have went to the kitchen and got one.
An interview was conducted with S8DM on 05/30/2024 at 3:00 p.m. She stated when a resident had weight loss, she sent recommendations to nursing for supplements, who then received an order from the physician. She stated after the supplement was ordered, she updated the resident's meal tickets, and notified the kitchen staff of the new order. She stated the kitchen staff should ensure the supplements were on the meal trays. She stated if the supplement was not placed on the tray, the CNA or nurse on the hall should come get the supplement from the kitchen and provide it to the resident. She stated she resumed the order for Resident #3's Mighty Shake on 05/16/2024, because the resident had lost weight after a hospitalization. She stated a Mighty Shake should have been provided to Resident #3 for each meal.
An interview was conducted with S2DON on 05/29/2024 at 3:55 p.m. She stated the kitchen staff were responsible for sending the Mighty Shake supplements on the resident's meal trays. She verified Resident #3 was ordered Mighty Shakes with all meals and should have had one on her breakfast tray.
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 resident MDS 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 resident MDS assessments accurately reflected the resident's status for 2 of 2 (#13 and #18) residents reviewed for PASRR by failing to correctly code the residents PASRR evaluations.
Findings:
Resident #13
Review of Resident #13's Clinical Record revealed he was admitted on [DATE] with diagnoses which included Major Depressive Disorder, Bipolar Disorder, Persistent Mood Affective Disorder, and Generalized Anxiety Disorder. Further review revealed an approved Level II PASRR.
Review of Resident #13's Annual MDS with ARD of 12/21/2023 revealed question A1500, Resident evaluated for PASRR, was answered as no.
Resident #18
Review of Resident #18's Clinical Record revealed he was admitted on [DATE] with diagnoses which included Schizoaffective Disorder, and Bipolar Disorder. Further review revealed an approved Level II PASRR.
Review of Resident #18's Annual MDS with ARD of 01/04/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no.
On 05/29/2024 at 2:03 p.m., an interview was conducted with S24CM. She stated comprehensive MDS assessments should include if the resident has a state level II PASRR. She confirmed Resident #13 and Resident #18 had an approved state level II PASRR, the MDS did not include the state level PASRR and it should have.
On 05/30/2024 at 3:01 p.m., an interview was conducted with S2DON. She confirmed the MDS assessments should be accurate for residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure nurse staffing data, including resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, wa...
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Based on observation and interview, the facility failed to ensure nurse staffing data, including resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 90 residents residing in the facility.
Findings:
On 05/28/24 at 11:55 a.m., an observation was conducted of the daily nursing staff sheet located behind the nurses' station in the medical record room which was restricted to staff only.
On 05/28/24 at 12:18 p.m., an interview was conducted with S2DON. She confirmed the daily nursing staff sheet was posted behind the nurses' station and was not accessible for residents or visitors to view.
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 4 (#17, #35, #58, and #69) of 5 (#17, #35, #58, #64, and #69) residents reviewed .
Findings:
Resident #17
Review of Resident #17's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Generalized Anxiety Disorder, and Insomnia.
Review of Resident #17's May 2024 Physician's Orders revealed an order written on 10/30/2023 for Lorazepam 1 mg tablet, one tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date.
Review of Resident #17's May 2024 MAR revealed Lorazepam 1 mg tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date.
Resident #35
Review of Resident #35's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Schizoaffective Disorder, Unspecified Mood Disorder, and Anxiety.
Review of Resident #35's May 2024 Physician's Orders revealed an order written on 03/16/2021 for Lorazepam 1 mg tablet, one tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath. Further review revealed the PRN medication had no stop date.
Review of Resident #35's May 2024 MAR revealed an order written on 03/16/2021 for Lorazepam 1 mg tablet, one tablet by mouth every 4 hours as needed for anxiety, insomnia, nausea, or shortness of breath was started on 03/16/2021. Further review revealed the PRN medication had no stop date.
Resident #58
Review of Resident #58's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Major Depressive Disorder, and Schizoaffective Disorder.
Review of Resident #58's November 2023 Physician's Orders revealed an order written on 11/27/2023 for Lorazepam tablet 1 mg, give 1 tablet by mouth every 4 hours as needed for anxiety and/or shortness of breath. Further review revealed the PRN medication had no stop date.
Review of Resident #58's May 2024 Medication Administration Record revealed an order written on 11/27/2023 for Lorazepam tablet 1 mg, Give 1 tablet by mouth every 4 hours as needed for anxiety and/or shortness of breath. Further review revealed the PRN medication had no stop date.
Resident #69
Review of Resident #69's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition and Anxiety Disorder.
Review of Resident #69's May 2024 Physician's Orders revealed an order written on 04/22/2024 for Lorazepam oral tablet 1 mg by mouth every 4 hours as needed for shortness of breath, anxiety and/or trouble sleeping. Further review revealed the PRN medication had no stop date.
Review of Resident #69's May 2024 MAR revealed an order written on 04/22/2024 for Lorazepam tablet 1mg by mouth every 4 hours as needed for shortness of breath, anxiety and/or trouble sleeping. Further review revealed the PRN medication had no stop date.
A telephone interview was conducted on 05/29/2024 at 2:35 p.m. with the pharmacist responsible for completing the facility's pharmaceutical consultation reports for MRR and GDR. He stated all PRN antipsychotic medications including lorazepam required an end date of no longer than 14 days following the start of the medication.
An interview was conducted on 05/30/2024 at 2:56 p.m. with S2DON. She confirmed Lorazepam was an anxiolytic medication used to treat anxiety. She confirmed Resident #17 had an order on 10/30/2023 for PRN Lorazepam 1mg tablet with no stop date. She confirmed Resident #35 had an order on 03/16/2021 for PRN Lorazepam 1mg tablet with no stop date. She confirmed Resident #58 had an order on 11/27/2023 for PRN Lorazepam 1mg tablet with no stop date. She confirmed Resident #69 had an order on 04/22/2024 for PRN Lorazepam 1mg tablet with no stop date.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected most or all residents
Based on interviews and record review, the facility failed to ensure all licensed nursing and certified nursing assistant staff had documented new hire and annual competency demonstrations for all ski...
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Based on interviews and record review, the facility failed to ensure all licensed nursing and certified nursing assistant staff had documented new hire and annual competency demonstrations for all skills related to their expected roles for 5 out of 5 personnel files reviewed. This had the potential to affect all 89 residents residing in the facility.
Findings:
Review of S12CNA's personnel file revealed S12CNA's date of hire was 05/21/2024. Further review revealed no documented evidence of any competencies being completed upon hire.
Review of S13CNA's personnel file revealed S13CNA's date of hire was 01/22/2024. Further review revealed no documented evidence of any competencies being completed upon hire.
Review of S14LPN's personnel file revealed S14LPN's date of hire was 10/08/2021. Further review revealed no documented evidence of any competencies being completed annually.
Review of S15LPN's personnel file revealed S15LPN's date of hire was 03/11/2024. Further review revealed no documented evidence of any competencies being completed upon hire.
Review of S16CNA's personnel file revealed S16CNA's date of hire was 09/30/2022. Further review revealed no documented evidence of any competencies being completed annually.
An interview was conducted with S17CNAS on 05/30/2024 at 4:20 p.m. She confirmed CNAs did not demonstrate competency skills prior to being assigned to work independently on the hall after completing orientation shifts or annually.
An interview was conducted with S2DON on 05/30/2024 at 3:01 p.m. She said she conducted in-service skills trainings regularly on various topics for nursing and CNA staff, which would include lecture training and a skills demonstration by her, S2DON. She confirmed LPN and CNA employees did not demonstrate any competency skills upon hire or annually.
Apr 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain resident's dignity for 1(#72) of 28 residents reviewed du...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain resident's dignity for 1(#72) of 28 residents reviewed during the initial pool process.
Findings:
Review of Resident #72's Medical Record revealed she was admitted to the facility on [DATE]. Further review revealed diagnoses which included Depression, Femur Fracture, Muscle Wasting, Generalized Muscle Weakness, and Other Abnormalities of Gait and Mobility.
Review of Resident #72's MDS with an ARD of 03/17/2023 revealed Resident #72 had a BIMS of 15 which indicated she was cognitively intact. Further review revealed Resident #72 required extensive assistance with bed mobility and ADL's, total dependence for bath, and was always incontinent of bowel/bladder.
Review of Resident #72's current Care Plan revealed, in part:
Self-Care deficit related to needs assistance with ADL's due to decreased mobility and bilateral numbness to hands.
On 04/04/2023 at 9:15 a.m., an interview was conducted with Resident #72. Resident #72 stated S11CNA called her a nag last week while performing care. She stated she reported this to S3SSD on 3/30/2023. Resident #72 became tearful and stated she was scared she would not receive care at night when S11CNA was working on her hall.
On 04/05/2023 at 9:07 a.m., an interview was conducted with S3SSD. S3SSD stated Resident #72 voiced a complaint of S11CNA calling her a nag on 03/30/2023. S3SSD stated that S11CNA should not have called her a nag.
On 04/04/2023 at 10:15 a.m., an interview was conducted with S12CNAS. S12CNAS stated she was informed by S3SSD on 04/03/2023 that S11CNA called Resident #72 a nag, and should not have.
On 04/05/2023 at 10:50 a.m., an interview was conducted with S2DON. S2DON stated staff should not call a resident a nag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development...
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Based on observations, record review, and interviews, 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 disease and infection by 1 (S13CNA) of 2 (S10CNA and S13CNA) staff members failing to perform hand hygiene during dining service.
Findings:
Review of the facility's Handwashing/Hand Hygiene policy revealed the following, in part:
This facility considers hand hygiene the primary means to prevent the spread of infections.
2. All personnel shall follow procedures to help prevent the spread of infections to residents
6. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations:
b. Before and after direct contact with residents
p. Before or after assisting a resident with meals
On 04/03/2023 at 11:50 a.m., an observation was made of S13CNA in the dining area. S13CNA pulled her face mask down, rubbed her nose with her right hand, then without sanitizing her hands, received food a lunch tray from the kitchen distribution window, and hand delivered the food to a resident. S13CNA proceeded to unwrap clear plastic covering over the resident's food plate and placed a second meal in front of another resident. At no point during interaction was hand hygiene performed by S13CNA.
On 04/03/2023 at 11:55 a.m., an observation was made of S13CNA rubbing her nose and mouth areas with her hands, as well as rubbed her eyes with both hands. S13CNA was observed repeating this rubbing gesture three times. Without performing hand hygiene, S13CNA then picked up utensils and placed them next to resident's plate. No hand sanitizer and no washing of hands noted at any time prior to touching resident's utensils, napkin, and food plate.
On 04/03/2023 at 12:05 p.m., an interview was conducted with S13CNA. She stated she did not remember if she performed hand hygiene after touching her nose/mouth/eyes, before touching resident's napkin/utensils, and before touching a second resident. S13CNA stated the facility did have sanitizer on the wall available in the dining room, but she did not use it and she should have.
On 04/04/2023 at 11:40 a.m., an interview was conducted with S12CNAS. She said CNAs and all staff should perform hand hygiene prior to serving plates and assisting residents during dining service and there was a centrally located wall hand sanitizer station right next to food tray pick up window for easy access use.
On 04/06/2023 at 12:42 p.m., an interview was conducted with S2DON. She stated the dining room had sanitizer readily available for staff use during meal times, as well as staff was provided small hand sanitizers to keep in their pockets for use in between resident contacts. She confirmed S13CNA should have properly performed hand hygiene after she pulled her mask covering down, touch nose/mouth/eye areas, and prior to touching resident items during dining service.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 interviews and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (#88) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (#88) of 28 residents reviewed in the final sample. The facility failed to provide a psychiatric consult.
Findings:
Review of the medical record for Resident #88 revealed the resident was admitted to the facility 02/09/2023 and had diagnoses that included Major Depressive Disorder, Anxiety Disorder, and Memory Deficit following Cerebral Vascular Accident.
Review of the baseline MDS (Minimum Data Set) for Resident #88 with an ARD (Assessment Reference Date) of 02/13/2023 revealed that resident had a BIMS (Brief Interview for Mental Status) of 99 which indicated the resident was severely cognitive impaired.
Review of Physician's Orders for Resident #88 revealed the following, in part:
Zoloft 25 mg every day.
Review of the Care Plan for Resident #88 revealed the following, in part:
Problem: Alteration in behavior, refuses care and medications, combative, socially inappropriate/disruptive behavior, and verbally abusive
Interventions: Consult MD as needed, Psych consult as needed, and redirect as needed.
Review of the NP Progress Notes for Resident #88 revealed the following, in part:
02/17/2023 No documentation Resident #88 had any behaviors
Review of the Nurse's Notes for Resident #88 revealed the following, in part:
02/16/2023 at 5:02 p.m. - Nursing assistant notified nurse that resident became combative during care. Resident #88 struck CNA twice while trying to perform a brief change.
02/17/2023 at 10:54 a.m. - During morning medication pass Resident #88 put pills in his mouth with water, swished around, spit out all of the medication and stated get out of my room.
02/17/2023 at 10:58 a.m. - CNA reported Resident #88 hit her during care.
02/17/2023 at 10:02 p.m. - Resident #88 refused skin assessment and threatened to punch staff. Redirected and behavior continued. The resident was given time to calm down.
02/18/2023 at 10:53 a.m. - Resident #88 hit staff during transfer from stretcher to bed when returning from dialysis.
02/20/2023 at 6:08 p.m. - Resident #88 refused morning, afternoon medication and nurse assessment. Resident #88 was combative with staff during morning brief change and tried to kick wound care nurse during treatment.
02/21/2023 at 11:00 a.m. - Resident #88 was combative with staff during care.
04/04/2023 at 1:30 p.m. An interview was conducted with S6LPN. She confirmed she cared for Resident #88 and his behaviors were very erratic and inappropriate. She said he was redirected but sometimes it did not work.
04/06/2023 at 1:44 p.m. An interview was conducted with NP. He confirmed a psych consult was not conducted of Resident #88.
04/06/2023 at 1:48 p.m. An interview was conducted with S19CNA. She stated Resident #88 would fight staff every time they entered his room, staff would leave him alone, and report the behaviors to the nurse.
04/06/2023 a.m. at 1:55 p.m. An interview was conducted with S17RN. She stated Resident #88 was very combative and when he had behaviors she would leave him alone.
04/06/2023 at 2:32 p.m. An interview was conducted with S18MDS. She stated Resident #88's behaviors were reported everyday on the 24 hour report. She stated S3SSD would consult psych if needed. She stated the care plan was effective because he was sent to the hospital on [DATE].
04/06/2023 at 2:37 p.m. An interview was conducted with S3SSD. She confirmed she attended the morning meetings every morning and was responsible for requesting a psych consult if needed. She stated if a psych consult was needed she would speak with the NP for the order. She confirmed a psych consult was never discussed and should have been.
04/06/2023 at 2:43 p.m. An interview was conducted with S2DON. She stated every morning any resident changes were discussed in their meeting. She confirmed Resident #88 had behaviors beginning on 02/10/2023 and continued with behaviors until 02/22/2023 when the resident was sent to the hospital. She further confirmed a psych consult was part of Resident #88's care plan and the resident did not have a psych consult initiated at the facility.
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** Based on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with pr...
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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 treatment and care in accordance with professional standards by failing to ensure documentation was accurate and complete for 2(#58 and #88) of 28 resident reviewed in the final sample.
Findings:
Resident #58
Review of the medical record for Resident #58 revealed the resident was admitted to the facility on [DATE], and had diagnoses which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Renal Dialysis.
Review of Resident #58 Physician's Orders revealed the following, in part:
Local Dialysis Center on Mondays, Wednesdays, and Fridays at 10:30 a.m.
Review of Resident #58's nurses notes revealed there was no documentation on 03/20/2023 of this resident having diarrhea, or missing dialysis.
04/03/2023 at 12:30 p.m., an interview was conducted with Resident #58's. Representative. She stated on the evening of 03/20/2023, she was informed by S8LPN Resident #58 had diarrhea and was not sent to dialysis.
04/04/2023 at 8:56 a.m., an interview was conducted with the local dialysis center staff. Dialysis staff confirmed Resident #58 did not attend dialysis on 03/20/2023.
04/04/2023 at 9:43 a.m., an interview was conducted with S8LPN. She confirmed on 03/20/2023, Resident #58 did not go to dialysis because she had diarrhea. She further confirmed there was no nurse's notes of the diarrhea episodes or that the resident did not attend dialysis.
Resident #88
Review of the medical record for Resident #88 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Major Depressive Disorder, Anxiety Disorder, and Memory Deficit following Cerebral Vascular Accident.
Review of the baseline MDS (Minimum Data Set) for Resident #88 with an ARD (Assessment Reference Date) of 02/13/2023 revealed resident had a BIMS (Brief Interview for Mental Status) of 99, which indicated the resident was severely cognitively impaired.
Review of Physician's Orders for Resident #88 revealed the following, in part:
Zoloft 25 mg every day.
Review of the Care Plan for Resident #88 revealed the following, in part:
Problem: Alteration in behavior, refuses care and medications, combative, socially inappropriate/disruptive behavior, and verbally abusive
Interventions: Consult MD as needed, Psych consult as needed, and redirect as needed.
Review of the NP Progress Notes for Resident #88 revealed there was no documentation on 02/17/2023 of Resident #88 having any behaviors.
Review of the Nurse's Notes for Resident #88 revealed the following, in part:
02/16/2023 at 5:02 p.m. - Nursing assistant notified nurse Resident #88 was combative during care. Resident #88 struck CNA twice while trying to perform a brief change.
02/17/2023 at 10:54 a.m. - During morning medication pass, Resident #88 put pills in his mouth with water, swished around, spit out all of the medication, and stated get out of my room.
02/17/2023 at 10:58 a.m. - CNA reported Resident #88 hit her during care.
02/17/2023 at 10:02 p.m. - Resident #88 refused skin assessment, and threatened to punch staff. Redirected and behavior continued. The resident was given time to calm down.
02/18/2023 at 10:53 a.m. - Resident #88 hit staff during transfer from stretcher to bed when returning from dialysis.
02/20/2023 at 6:08 p.m. - Resident #88 refused morning, afternoon medication, and nurse assessment. Resident #88 was combative with staff during morning brief change, and tried to kick wound care nurse during treatment.
02/21/2023 at 11:00 a.m. - Resident #88 was combative with staff during care.
04/04/2023 at 1:30 p.m. An interview was conducted with S6LPN. She confirmed she cared for Resident #88 and his behaviors were very erratic and inappropriate. She said he was redirected, but sometimes it did not work. She confirmed the family and NP were notified, but it was not documented. She further confirmed the notification should be documented but was not.
04/06/2023 at 1:48 p.m. An interview was conducted with S17CNA. She stated Resident #88 would fight staff every time they entered his room, staff would leave him alone, and report the behaviors to the nurse.
04/06/2023 a.m. at 1:55 p.m. An interview was conducted with S18LPN. She stated Resident #88 was very combative, and when he had behaviors, she would leave him alone.
04/05/2023 at 12:35 p.m., an interview was conducted with S2DON. She stated if a resident had diarrhea, she would expect the staff to document, provide standing orders for antidiarrheal medication, and notify the MD. She confirmed a resident not attending dialysis or if resident had episodes of diarrhea, it should be documented in the nurse's notes and was not documented. She further confirmed Resident #88 had combative behaviors and the NP was notified but it was not documented and should have been documented.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#54 and #57) of 5 (#4, #12, #47, #54, and #57) residents reviewed for ADL's. The facility failed to comb and shampoo hair for Resident's (#54 and #57).
Findings:
Review of the facility's policy, Bath, Bed revealed the following, in part:
Equipment and Supplies
9. Comb and/or hairbrush
Review of the facility's policy, Shampooing Hair revealed the following, in part:
Purpose: The purpose of this procedure is to clean the resident's hair and scalp.
Equipment and Supplies
5. Resident's personal hair care products
After Shampooing:
1.
Comb and style the resident's hair.
Resident #54
Review of the Medical Record for Resident #54 revealed the resident was admitted to the facility on [DATE], and had diagnoses which included, Morbid Obesity, Congestive Heart Failure, Diabetes Mellitus 2, Major Depressive Disorder, and Anxiety Disorder.
Review of the most recent MDS (Minimum Data Set) for Resident #54 with an ARD (Assessment Reference Date) of 03/21/2023 revealed Resident #54 had a BIMS (Brief Interview for Mental Status) of 12, which indicated the resident was moderately cognitively impaired.
Review of the Care Plan for Resident #54 revealed the following, in part:
Problem: Self Care deficit related to required extensive total assistance with ADL's.
Interventions: Morning care including face washed, and hair combed.
Bathe and shampoo hair.
On 04/03/2023 at 9:15 a.m., an observation was conducted of Resident #54. Resident was dressed in a hospital gown with food particles on the gown, greasy and matted hair in the back of the head.
On 04/04/2023 at 9:59 a.m., an observation was conducted of Resident #54. Resident was dressed in a hospital gown with food particles on the gown, greasy and matted hair in the back of the head.
On 04/04/2023 at 2:03 p.m., an observation was conducted of Resident #54. Resident was dressed in a hospital gown with food particles on the gown, greasy and matted hair in the back of the head.
On 04/05/2023 at 12:30 p.m., an observation and interview was conducted with Resident #54. Resident was dressed in a hospital gown with food particles on the gown, greasy and matted hair in the back of the head. She stated she did not receive a bath today, her hair needed to be washed, and was matted in the back.
On 04/05/2023 at 12:55 p.m., an interview was conducted with S9CNA. He stated Resident #54 did not refuse care, and went to the shower room every other day. He could not remember when her hair was washed, but thought it was last month.
On 04/05/2023 at 1:10 p.m., an interview was conducted with S12CNAS. She stated she would expect staff to wash resident's hair every other day, or inform her if the resident refused. She stated she was not aware of Resident #54 refusing to get her hair washed. She stated all residents on her assigned hall go to the shower room. She confirmed morning care included combing the hair and should be done daily.
On 04/06/2023 at 11:50 a.m., an interview was conducted with S14CNA. She confirmed she was assigned Resident #54 and worked the day shift on 04/06/2023. On 04/06/2023, she stated Resident #54 went to the shower room and she shampooed her hair.
On 04/06/2023 at 12:30 p.m., an observation and interview with Resident #54 was conducted. Resident #54 was noted to have her hair combed in the front. Resident lifted head and hair noted not brushed and matted in the back. Resident #54 stated today was the first shower and shampoo she had in 2 weeks. She stated the CNAs tried to comb the back of her hair, but it was painful. She stated she would like her head shaved to get the mats out.
On 04/06/2023 at 12:35 p.m., an interview and observation was conducted with S2DON, ADON, and S12CNAS of Resident #54. S2DON, ADON, and S12CNAS then conducted an observation of Resident #54. They would not confirm Resident #54's hair was matted. S2DON ran her hands through the front right side of Resident #54's hair and stated there were no mats. S2DON further stated if someone stays in the bed they will get mats in their hair. Resident #54 ran her hand on the left side of her hair with administration at bedside and stated her hair was matted, and I just want my head shaved to get the mats out. S2DON, ADON, and S12CNAS did not acknowledge Resident #54's statement that her hair was matted.
On 04/06/2023 at 12:39 p.m., an interview was conducted with S1ADM. He said he would expect the residents to be clean, including clean hair, and the staff had a bath schedule to follow. He confirmed residents should not have matted hair.
Resident #57
Review of the Medical Record for Resident #57 revealed the resident was admitted to the facility on [DATE], and had diagnoses which included Chronic Respiratory Failure, Chronic Debility, Depression, and Type 2 Diabetes Mellitus.
Review of the most recent MDS (Minimum Data Set) for Resident #57 with an ARD (Assessment Reference Date) of 12/27/2022 revealed Resident #57 had a BIMS (Brief Interview for Mental Status) of 11, which indicated the resident was moderately cognitively impaired.
Review of the Care Plan for Resident #57 revealed the following, in part:
Problem: Self Care deficit related to requires assistance with personal hygiene.
Interventions: Morning care including face washed, and hair combed.
Bathe and shampoo hair.
On 04/03/2023 at 12:11 p.m., an observation was conducted of Resident #57 lying in bed with food in his beard, greasy hair, and uncombed tangled, matted hair in the back.
On 04/4/2023 at 8:40 a.m., an interview and observation was conducted of Resident #57 lying in bed with greasy and uncombed tangled, matted hair in the back. He reported he had a bed bath today, but his hair was not washed.
On 04/04/2023 at 12:21 p.m., an observation was conducted of Resident #57 lying in bed with greasy and uncombed tangled, matted hair in the back.
On 04/04/2023 at 3:10 p.m., an interview was conducted with S9CNA. He confirmed Resident #57 required extensive assistance with ADL care, and did not refuse bed baths or ADL care.
On 04/05/2023 at 12:30 p.m., an observation and interview were conducted with Resident #57. His hair was greasy, tangled, and matted. Resident #57 reported he did not remember when they last washed his hair. He stated it hurt to be washed when he had tangles. He confirmed they did not brush his hair today. He stated they do not comb his hair daily, and he is unsure when they combed it last.
On 04/05/2023 at 1:06 p.m., an interview was conducted with S15CNA. He confirmed total bed bound residents got their hair washed with each bed bath. He stated he was not aware of any residents on his assigned hall who refused ADL care. He confirmed ADL care included, brushing and combing hair.
On 04/06/2023 at 11:00 a.m., an observation was conducted of Resident #57 with greasy, tangled hair.
On 04/06/2023 at11:50 a.m., an interview was conducted with S14CNA. She stated the local hospice staff performed Resident #57's bed baths on Tuesday and Thursdays, which included washing his hair.
On 04/06/2023 at 12:00 p.m., an interview was conducted with Resident #57, he reported the local hospice staff gave him a bed bath and washed his hair today. He reported pain during the shampoo because of the tangles.
On 04/06/2023 at 2:30 p.m., a telephone interview with local hospice staff reported both times she saw Resident #57, he appeared very dirty with buildup on his scalp and in his mustache. She reported she has brought her own cleaner to get the buildup out. On 04/06/2023 she observed Resident #57 had ear wax buildup, and dried feces on his skin when she changed his brief. She stated a resident cannot get build up on scalp or mustache overnight. She stated Resident #57 was not getting adequate ADL care by the facility.
On 04/06/2023 at 12:30 p.m., an interview and observation was conducted with S2DON, ADON, and S12CNAS of Resident #57. S2DON stated Resident #57's hair had an underlying oiliness and confirmed his hair was currently oily. She confirmed the facility staff should be bathing him in between the local hospice staff. S2DON stated residents had a comb and extra combs were in storage.
On 04/06/2023 at 12:39 p.m., an interview was conducted with S1ADM. He said he would expect the residents to be clean, including clean hair, and the staff had a bath schedule to follow. He confirmed residents should not have matted hair.
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 F0698
(Tag F0698)
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 residents who required dialysis received such services, con...
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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 who required dialysis received such services, consistent with professional standards, by failing to maintain on-going communication with the dialysis facility for 1 (#58) of 4 (#33, #46, #58, and #390) residents reviewed for dialysis.
Findings:
Review of the Clinical Record for Resident #58 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, End Stage Renal Disease, and Dependence on Renal Dialysis.
Review of the current March Physician's Orders for Resident #58 revealed the following, in part:
Start date: 03/28/2023 Local Dialysis Center on Mondays, Wednesdays, and Fridays at 10:30 a.m.
Review of the Dialysis Communication Binder for Resident #58 from March 2023 to April 2023 revealed no documentation of communication between the facility and the dialysis center for the following dialysis dates: 03/08/2023, 03/10/2023, 03/13/2023, 03/15/2023, 03/17/2023, 03/29/2023, 03/31/2023, 04/03/2023, and 04/05/2023.
Review of the Nurses' Notes for Resident #58 dated 03/02/2023 through 03/30/2023 revealed no documentation of communication between the facility and Resident #58's local dialysis facility.
On 04/04/2023 at 9:43 a.m., an interview was conducted with S8LPN. She stated the facility communicated with Resident #58's dialysis staff through a communication report sheet. She explained the report sheet was sent to the dialysis center with Resident #58, and the dialysis staff sent it back when Resident #58 returned to the facility.
On 04/05/2023 at 9:45 a.m., an interview was conducted with S5LPN who confirmed the facility utilized the dialysis communication report form to communicate with dialysis staff.
On 04/05/2023 at 1:40 p.m., an interview was conducted with S2DON who reported staff were expected to notify the residents' family and MD if dialysis missed and also document in the residents' chart. She also reported staff communicated with dialysis verbally or used the dialysis communication form.
On 04/05/2023 at 11:10 a.m., an interview was conducted with nursing staff at the local dialysis center. She confirmed she took care of Resident #58 at the dialysis center. She said the normal process for communication between Resident #58's facility nurse and the dialysis center was a communication sheet that was sent by the facility. She stated the last few weeks, the resident had attended dialysis with no communication sheet. She stated she asked the facility staff and was told the communication sheet was in Resident #58's blue bag. She confirmed she looked in Resident #58's blue bag, and there has been no communication sheet in the bag.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • 25 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $10,748 in fines. Above average for Louisiana. Some compliance problems on record.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Woodleigh Of Baton Rouge's CMS Rating?
CMS assigns The Woodleigh of Baton Rouge an overall rating of 2 out of 5 stars, which is considered 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 The Woodleigh Of Baton Rouge Staffed?
CMS rates The Woodleigh of Baton Rouge's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Woodleigh Of Baton Rouge?
State health inspectors documented 25 deficiencies at The Woodleigh of Baton Rouge during 2023 to 2025. These included: 1 that caused actual resident harm and 24 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Woodleigh Of Baton Rouge?
The Woodleigh of Baton Rouge is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 129 certified beds and approximately 98 residents (about 76% occupancy), it is a mid-sized facility located in Baton Rouge, Louisiana.
How Does The Woodleigh Of Baton Rouge Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, The Woodleigh of Baton Rouge's overall rating (2 stars) is below the state average of 2.4, staff turnover (40%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Woodleigh Of Baton Rouge?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is The Woodleigh Of Baton Rouge Safe?
Based on CMS inspection data, The Woodleigh of Baton Rouge 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 2-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 The Woodleigh Of Baton Rouge Stick Around?
The Woodleigh of Baton Rouge has a staff turnover rate of 40%, which is about average for Louisiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Woodleigh Of Baton Rouge Ever Fined?
The Woodleigh of Baton Rouge has been fined $10,748 across 1 penalty action. This is below the Louisiana average of $33,186. 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 The Woodleigh Of Baton Rouge on Any Federal Watch List?
The Woodleigh of Baton Rouge 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.