RIVERBEND NURSING AND REHABILITATION CENTER, INC
For profit - Corporation
120 Beds
INSPIRED HEALTHCARE MANAGEMENT
Data: November 2025
Trust Grade
45/100
#152 of 264 in LA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Riverbend Nursing and Rehabilitation Center in Belle Chasse, Louisiana, has received a Trust Grade of F, indicating poor quality and significant concerns about care. Ranking #152 out of 264 facilities in Louisiana places it in the bottom half, and it is the only nursing home in Plaquemines County, meaning families have no better local options. The facility is reportedly improving, with a drop in issues from 16 in 2024 to just 2 in 2025. Staffing is average, with a 54% turnover rate that is similar to state averages, and there are currently no fines against the facility, which is a positive sign. However, serious incidents have occurred, including a resident being physically pushed from their wheelchair, resulting in a fracture, and failures in providing necessary wound care for residents, highlighting significant areas of concern alongside its staffing strengths.
- Trust Score
- D
- In Louisiana
- #152/264
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 43%
Needs review
16 → 2 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 16 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 54%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Chain: INSPIRED HEALTHCARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 39 deficiencies on record
1 actual harm
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to provide a privacy cover for a urinary catheter drainage bag for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #...
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Based on observations, interviews, and record reviews, the facility failed to provide a privacy cover for a urinary catheter drainage bag for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents reviewed with urinary catheters.
Findings:
Review of Resident #1's Care Plan revealed, in part, Resident #1 has a urinary catheter bag related to Urinary Retention, revised on 01/26/2025, with an intervention to keep Resident #1's catheter drainage bag in a privacy cover.
Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 04/16/2025 revealed, in part, Resident #1 had Brief Interview for Mental Status score of 5, which indicated Resident #1 had impaired cognition.
Observation on 05/27/2025 at 11:23AM revealed Resident #1 was in her wheelchair in the dining area. Further observation revealed Resident #1's catheter drainage bag was attached under her wheelchair seat, and yellow urine was visible in the catheter drainage bag.
Observation on 05/27/2025 at 1:41PM revealed Resident #1 was in her room, lying in bed. Further observation revealed Resident #1's catheter drainage bag was attached to the bottom of the bed railing, and her urine was visible in the catheter drainage bag from the doorway. Further observation revealed Resident #1 has a roommate that resided in the room with Resident #1.
Observation on 05/27/2025 at 3:32PM revealed Resident #1 was in her room, lying in bed. Further observation revealed Resident #1's catheter drainage bag was attached to the bottom of the bed railing, and her urine was visible in the catheter drainage bag from the doorway.
In an interview on 05/28/2025 at 9:12AM, S3Licensed Practical Nurse indicated Resident #1 should have a privacy cover for her catheter drainage bag at all times.
In an interview on 05/28/2025 at 10:33AM, S4Certified Nursing Assistant, confirmed Resident #1 did not have a privacy cover over Resident #1's urinary catheter bag on 05/27/2025 during her shift.
In an interview on 05/28/2025 at 2:01PM, S2Director of Nursing, indicated urinary catheter bags should be covered at all times, and confirmed Resident #1's urinary catheter bag should have been covered.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a resident's Foley catheter (a medical device inserted into...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a resident's Foley catheter (a medical device inserted into the bladder to collect urine) was changed according to physician's orders for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for catheter use.
Findings:
Review of Resident #2's medical record revealed, in part, he was admitted to the facility on [DATE] with diagnosis, in part, of urinary retention and had an indwelling Foley catheter.
Review of Resident #2's March 2025 Physician's Orders revealed, in part, to not remove Resident #2's Foley catheter. Further review revealed Resident #2's Foley catheter was to be changed every month by urology.
Review of Resident #2's indwelling catheter Care Plan revealed, in part, Resident #2's catheter was to be changed every month at Resident #2' urology office.
Review of Resident #2's electronic medical record revealed, in part, no documented evidence and the facility was unable to present any documented evidence Resident #2's Foley catheter was changed/replaced in March 2025.
In an interview on 05/29/2025 at 3:50PM, S2Director of Nursing confirmed the above findings and indicated she did not have any documented evidence to present to dispute the above findings.
Oct 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed ensure a resident's right to maintain a homelike envir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed ensure a resident's right to maintain a homelike environment for 1 (Resident #94) of 1 (Resident #94) sampled residents reviewed for resident's rights.
Findings:
Review of Resident # 94's medical record revealed, in part, Resident #94 was admitted to the facility on [DATE] with diagnoses of, in part, malignant neoplasm of the lung, Chronic Obstructive Pulmonary Disease (COPD), Nicotine dependence, weakness, anxiety, and Major Depressive Disorder.
Review of Resident #94's Minimum Data Set with an Assessment Reference Date of 03/12/2025 revealed, in part, Resident #94's Brief Interview for Mental Status (BIMS) summary score was 12.
Review of Resident #94's care plan with a goal date of 12/08/2024 revealed, in part, no care plan for safety or behavior modification with an intervention for locking Resident #94's air conditioning control panel.
Observation on 10/07/2024 at 12:52 p.m. revealed the air conditioning unit in Resident # 94's room was not running. Further observation revealed the control panel cover was closed with a lock on it preventing the air conditioning unit's control panel from being opened.
In an interview on 10/07/2024 at 12:55 p.m., Resident # 94 indicated he had previously asked the staff to remove the lock from the air conditioner controller cover in his room. Resident #94 further indicated he had cancer, frequently got cold, and preferred the room temperature to be warmer.
In an interview on 10/07/2024 at 2:10 p.m., S17Maintenance Supervisor (MS) confirmed the air conditioning unit in Resident #94's room had a lock on the control panel door. S17MS further indicated the lock was placed so Resident #94 could not turn the thermostat up making the room warmer. S17MS further indicated Resident #94 could not control the thermostat as the thermostat cover was locked and only maintenance personnel had the keys to open and adjust the thermostat.
In an interview on 10/10/2024 at 11:27 a.m., S18Social Services Director (SSD) indicated the air conditioner control panel in Resident #94's room was locked because Resident #94 likes the room temperature warmer than his roommate.
In an interview on 10/10/2024 at 2:15 p.m., S1Administrator confirmed there was a lock on Resident #94's air conditioning control panel preventing him from adjusting the temperature in his room. S1Administrator offered no explanation as to why there was no documented evidence for this intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 reviews and interviews, the facility failed to ensure physician's orders were followed for 1 (Resident #42) of 1...
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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 physician's orders were followed for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for physician order compliance.
Findings:
Review of Resident #42's Electronic Medical Record (EMR) revealed, in part, Resident #42 was admitted to the facility on [DATE] with diagnoses of, in part, post operative left knee replacement, pyogenic arthritis, and acute pancreatitis.
Review of Resident #42's written physician's telephone orders dated 10/08/2024 revealed, in part, an order by S21Medical Director for 1 gram of Ceftriaxone 1 gram intramuscular (IM) twice per day for 1 day.
Review of Resident #42's EMR physician's orders dated 10/08/2024 revealed, in part, an order for Ceftriaxone 1 gram IM for 2 doses.
Review of Resident #42's Minimum Data Set with an Assessment Reference Date of 09/20/2024 revealed, in part, Resident #42's Brief Interview for Mental Status (BIMS) summary score was 11, which indicated Resident #42 was moderately cognatively impaired.
Review of Resident # 42's Electronic Medication Administration Record (eMAR) revealed, in part, Ceftriaxone 1 gram IM was administered on 10/08/2024 at 12:45 p.m. Further review revealed, no documented evidence, and the facility could not provide any documented evidence Resident # 42 was administered a second dose of Ceftriaxone 1 gram IM on 10/08/2024 at 10:00 p.m. as ordered.
In an interview on 10/10/2024 at 9:30 a.m., Resident #42 indicated on 10/08/2024 he only received 1 of the 2 doses of Ceftriaxone antibiotic shots the doctor had ordered.
In an interview on 10/10/2024 at 1:31 p.m., S16Licensed Practical Nurse (LPN) indicated she was Resident # 42's nurse on 10/08/2024 during the 6 p.m.-6 a.m. shift. S16LPN further indicated she did not administer Resident # 42's Ceftriaxone 1 gram IM as ordered on her shift.
In an interview on 10/10/2024 at 1:42 p.m., S2Director of Nursing indicated the facility could not provide any documented evidence Resident #42 was administered 2 doses of Ceftriaxone 1 gram IM as ordered and should have.
In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged Resident #42 was not administered 2 doses of IM Ceftriaxone 1 gram as ordered and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide nail care for 1 (Resident #51) of 1 (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide nail care for 1 (Resident #51) of 1 (Resident #51) sampled residents reviewed for activities of daily living (ADLs).
Findings:
Review of the facility's undated policy and procedure titled Care of Fingernails/Toenails revealed, in part, nail care includes daily cleaning and regular trimming.
Review of Resident #51's Electronic Medical Record (EMR) revealed, in part, Resident #51 was admitted to the facility on [DATE] with a diagnosis, in part, of severe vascular dementia with psychotic disturbance, lack of coordination, and cerebral palsy.
Review of Resident #51's Minimum Data Set with an Assessment Reference Date of 12/08/2024 revealed, in part, Resident #51's Brief Interview for Mental Status (BIMS) summary score was 15, which indicated Resident #51 was cognitively intact. Further review of section GG revealed, Resident #51 was dependent on staff for personal hygiene needs.
Review of Resident #51's Care Plan with a goal date of 12/05/2024 revealed Resident #51 was totally dependent on staff for personal hygiene including nail care.
Observation on 10/07/2024 at 10:48 a.m. revealed Resident #51's fingernails extended past the tips of her fingers on both hands with visible dirt underneath the portion of the nails that extended past the nailbed.
In an interview on 10/07/2024 at 10:55 a.m., Resident #51 indicated her nails have not been trimmed since she has been at the facility. Resident #51 further indicated she wanted to have her nails trimmed and had previously asked staff to have them trimmed.
Observation on 10/09/2024 at 9:17 a.m. revealed Resident # 51's fingernails on both hands remained untrimmed with visible dirt underneath the portion of the nail that extended past the nailbed.
In an interview on 10/09/2024 at 9:18 a.m., S14Certified Nursing Assistant (CNA) indicated a resident's nails should be trimmed if they extend past the nail bed.
In an interview on 10/09/2024 at 11:10 a.m., S13Certified Nursing Assistant Supervisor confirmed Resident # 51's fingernails were too long and should have been cleaned and trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's medical record reflected the resident's medica...
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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 a resident's medical record reflected the resident's medical treatment wishes following a cardiopulmonary arrest (sudden unexpected loss of heart function, breathing, and/or consciousness) for 1 (Resident #262) of 4 (Resident #28, Resident #52, Resident #94, and Resident #262) sampled residents investigated for advanced directives.
Findings:
Review of the facility's undated policy/procedure titled LaPOST (Louisiana Physician Orders For Scope of Treatment), revealed, in part, a LaPOST is a physician order form that translates a resident's end of life wishes and goals of care into physician orders that transfer with the resident across health care settings. Further review revealed, when completing a LaPOST Form with a resident, the LaPOST document must be signed by a physician and by the resident or resident's legally recognized personal health care representative.
Review of a LaPOST Fact Sheet dated 02/2024 located on the website https:// la-post.org revealed, in part, the LaPOST document must be signed by a physician and the patient or the patient's personal health care representative in order to be valid.
Review of Resident #262's Electronic Medical Record (EMR) revealed, in part, Resident #262 was admitted to the facility on [DATE].
Review of Resident #262's LaPOST dated [DATE] revealed, in part, Resident #262's wishes for his/her code status was Do Not Resuscitate ([DNR] which instructed a healthcare provider not to perform cardiopulmonary resuscitation [CPR] if a resident's heart stops beating or a resident stops breathing). Further review revealed Resident #262's physician had not signed the above mentioned LaPOST.
Review of Resident #262's [DATE] physician's orders revealed, in part, no order that reflected Resident #262's wishes for a DNR code status.
In an interview on [DATE] at 9:42 a.m., Resident #262's responsible party indicated Resident #262's wishes were to be a DNR code status.
In an interview on [DATE] at 11:24 a.m., S2Director of Nursing indicated the LaPOST was the facility's approved method to determine a resident's code status.
In an interview on [DATE] at 10:57 a.m., S24Agency Licensed Practical Nurse (LPN) (nurse assigned to Resident #262) indicated per the LaPOST in Resident #262's chart, Resident #262's wishes were to be a DNR. S24Agency LPN confirmed Resident #262's LaPOST was not signed by a physician, and indicated it was not a complete order. S24Agency LPN further indicated that she would perform CPR on Resident #262 due to the LaPOST not being completed. S24Agency LPN acknowledged Resident #262's LaPOST should have been signed by a physician so that her wishes for a DNR code status would be implemented.
In an interview on [DATE] at 9:49 a.m., S22Agency LPN (nurse assigned to Resident #262) indicated if a resident wanted their code status to be a DNR on a LaPOST, but it was not signed by a physician, S22Agency LPN would treat the resident as a Full Code (instructed a healthcare provider to perform cardiopulmonary resuscitation [CPR] if a resident's heart stops beating or a resident stops breathing). S22Agency LPN further indicated the facility should have gotten the LaPOST signed by the physician, as that was the resident/resident's responsible party's wishes for a DNR code status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to ensure ongoing communication regarding a resident's condition was completed with the dialysis facility for 1 (Resident #31) of 1 (Resident...
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Based on record review and interviews, the facility failed to ensure ongoing communication regarding a resident's condition was completed with the dialysis facility for 1 (Resident #31) of 1 (Resident #31) sampled residents investigated for dialysis services.
Findings:
In an interview on 10/09/2024 at 2:25 p.m., S10Assistant Director of Nursing (ADON) indicated the facility's staff used the Dialysis Communication sheet to communicate with the dialysis center.
Review of the facility's Dialysis Communication sheets for Resident #31 dated 06/03/2024, 06/14/2024, 06/19/2024, 06/28/2024, 07/01/2024, and 08/14/2024 revealed, in part, there was no documented evidence, and the facility did not present any documented evidence of communication from the dialysis center regarding the dialysis treatment provided and the resident's response to the dialysis treatment.
Review of the facility's Dialysis Communication sheets for Resident #31, revealed, in part, no documented evidence, and the facility did not present any documented evidence of communication between the facility and the dialysis center regarding Resident #31's condition before and after dialysis on 08/21/2024, 08/28/2024, 08/30/2024, 09/02/2024, 09/04/2024, 09/09/2024, 09/13/2024, 09/18/2024, and 09/23/2024.
In an interview on 10/09/2024 at 2:25 p.m., S10Assistant Director of Nursing (ADON) indicated the facility's staff used the Dialysis Communication sheet to communicate with the dialysis center.
In an interview on 10/10/2024 at 2:14 p.m., S2Director of Nursing (DON) indicated the facility's Dialysis Communication sheet was the method used for the facility to communicate with the dialysis center. S2DON further indicated there should be a Dialysis Communication sheet completed by the facility for each dialysis treatment for Resident #31. S2DON acknowledged the facility's Dialysis Communication sheets for Resident #31 should be completely filled out with the above missing information and they were not on 06/03/2024, 06/14/2024, 06/19/2024, 06/28/2024, 07/01/2024, and 08/14/2024. S2DON further indicated she was unable to present any documented evidence the facility communicated with the dialysis center regarding Resident #31 on 08/21/2024, 08/28/2024, 08/30/2024, 09/02/2024, 09/04/2024, 09/09/2024, 09/13/2024, 09/18/2024, and 09/23/2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to maintain a system to periodically reconcile controlled drugs for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a and M...
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Based on interviews and record review, the facility failed to maintain a system to periodically reconcile controlled drugs for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a and Medication Cart b) medication carts reviewed for the reconciliation documentation of controlled substances.
Findings:
Review of the facility's undated policy titled, Controlled Substances, revealed, in part, the nursing staff must count controlled medication at the end of each shift. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together.
Review of the facility's August 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty:
-08/05/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/07/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/09/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/10/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-08/10/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/12/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-08/12/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/23/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/24/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-08/24/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/25/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-08/25/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/26/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-08/27/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-08/29/2024 on the 6:00 p.m. to 6:00 a.m. shift; and,
-08/30/2024 on the 6:00 a.m. to 6:00 p.m. shift.
Review of the facility's September 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty:
-09/01/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-09/08/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-09/08/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-09/11/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-09/11/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-09/12/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-09/12/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-09/13/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-09/16/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-09/17/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-09/17/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-09/21/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-09/22/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-09/26/2024 on the 6:00 p.m. to 6:00 a.m. shift; and,
-09/27/2024 on the 6:00 a.m. to 6:00 p.m. shift.
Review of the facility's October 2024 Medication Cart a Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty:
-10/01/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-10/02/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-10/06/2024 on the 6:00 p.m. to 6:00 a.m. shift; and,
-10/10/2024 on the 6:00 a.m. to 6:00 p.m. shift.
In an interview on 10/10/2024 at 10:00 a.m., S22Agency Licensed Practical Nurse (LPN) indicated the facility's Controlled Drugs-Count Record was supposed to be signed by the off-going and on-coming nurse when they verified the narcotic counts.
Review of the facility's October 2024 Medication Cart b Controlled Drugs-Count Record revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and the nurse going off duty:
-10/01/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-10/02/2024 on the 6:00 a.m. to 6:00 p.m. shift;
-10/02/2024 on the 6:00 p.m. to 6:00 a.m. shift;
-10/03/2024 on the 6:00 a.m. to 6:00 p.m. shift; and,
-10/07/2024 on the 6:00 p.m. to 6:00 a.m. shift.
In an interview on 10/10/2024 at 1:57 p.m., S23LPN indicated there should not have been any undocumented signature areas on the facility's Controlled Drugs-Count Record for off going and on coming nurse signatures.
In an interview on 10/10/2024 at 2:13 p.m., S2Director of Nursing indicated the Controlled Drugs-Count Records should have been signed off with completed signatures of the nurses reconciling the narcotics at shift change.
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 reviews, the facility failed to ensure:
1. Opened insulin (a medication that lowers blood glucose) pens were dated when opened and discarded as required f...
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Based on observations, interviews, and record reviews, the facility failed to ensure:
1. Opened insulin (a medication that lowers blood glucose) pens were dated when opened and discarded as required for 2 (Medication Cart a and Medication Cart b) of 2 (Medication Cart a, Medication Cart b) medication carts observed; and,
2. Heparin (a medication used to prevent blood clots) was stored in a locked compartment and only accessible to authorized personnel.
Findings:
Review of the facility's undated policy titled, Storage/Handling of Medications, revealed, in part, the facility's nursing staff shall be responsible for maintaining medication storage in a safe manner. Further review revealed, the facility shall not use outdated drugs.
1.
Review of the facility's undated policy/procedure titled, Beyond Use Dates of Selected Insulin Products, revealed, in part, Humalog ([Insulin lispro] a type of insulin) pen's beyond use date was after 28 days of the insulin pen being in use. Further review revealed Novolog ([Insulin aspart] a type of insulin) pen's should be discarded after 28 days of use.
Observation on 10/10/2024 at 10:00 a.m. of Medication Cart a revealed:
-Resident #103's open Insulin aspart pen was not labeled with an opened date; and,
-Resident #10's open Insulin lispro pen had an opened date of 08/27/2024.
In an interview on 10/10/2024 at 10:00 a.m., S22Agency Licensed Practical Nurse (LPN) confirmed Resident #103's above mentioned insulin pen had been opened and confirmed the above mentioned insulin pen should have been labeled with an opened date. S22Agency (LPN) further confirmed Resident #10's above mentioned insulin pen was dated 08/27/2024 and should have been discarded.
Observation on 10/10/2024 at 1:25 p.m. of Medication Cart b revealed Resident #78's Insulin lispro had an opened date of 09/01/2024.
In an interview on 10/10/2024 at 1:57 p.m., S23LPN indicated Resident #78's above mentioned insulin pen should have been discarded and not stored in Medication Cart b and available for resident use.
In an interview on 10/10/2024 at 2:13 p.m., S2Director of Nursing indicated the above mentioned insulin pens should have been dated when opened and/or discarded per the facility's policy/procedure.
2.
Review of the facility's undated policy and procedure titled Medication Pass Administration revealed, in part, medications are not to be left in the resident's room.
Review of Resident #42's Minimum Data Set with an Assessment Reference Date of 09/20/2024 revealed, in part, Resident #42's Brief Interview for Mental Status (BIMS) summary score was 11, which indicated Resident #42 was moderately cognatively impaired.
Observation of Resident #42's room on 10/07/2024 at 11:00 a.m. revealed an unused blue syringe labeled Heparin 50 units/5milliliters (mL) flush lying on Resident # 42's bedside table.
In an interview on 10/07/2024 at 11:05 a.m., Resident #42 indicated the blue flush had been sitting on his bed side table for a couple of days.
In an interview on 10/07/2024 at 11:22 a.m., S19Licensed Practical Nurse (LPN) accompanied this surveyor to Resident #42's room and confirmed there was a syringe of 5mL Heparin lying on Resident # 42's bedside table. S19LPN further indicated the syringe of Heparin should not have been left on Resident #42's bedside table.
In an interview on 10/08/2024 at 2:45 p.m., S2Director of Nursing indicated a syringe of heparin should not have been left on Resident #42's bedside table.
In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged a syringe of heparin was found on Resident #42's bedside table and should not have been left on Resident #42's bedside table.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to provide a resident with the correct diet to meet t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to provide a resident with the correct diet to meet the residents needs for 1 (Resident #25) of 1 (Resident #25) sampled residents reviewed for dining services.
Findings:
Review of facility's Resident Nutrition Services Policy revealed, in part, nursing personnel will inspect food trays delivered to ensure that the correct meal has been delivered. Further review revealed if an incorrect meal is delivered, nursing staff will report it to dietary services so a new tray can be issued.
Review of Resident #25's record revealed, Resident#25 was admitted to the facility on [DATE] with diagnoses of, in part, moderate protein-calorie malnutrition, nutritional deficiency, and abnormal weight loss.
Review of Resident #25's October 2024 Physician Orders revealed, in part, a diet order for No Added Salt (NAS), mechanical soft with chopped meat.
Review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/2024 revealed, in part, Resident #25 was on a mechanically altered diet and therapeutic diet.
Review of Resident #25's Certified Dietary Manager's note dated 09/20/2024 at 9:35 a.m., revealed, in part, Resident #25's was a mechanical soft with chopped meat diet.
Observation on 10/08/2024 at 12:36 p.m., revealed Resident #25's lunch meal ticket read Resident #25 was to receive a NAS mechanical soft diet with ground meat and was served sliced carrots, white rice, turkey pot roast with gravy, and a moon pie. Further observation revealed Resident #25 was served a regular diet tray for lunch.
In an interview on 10/08/2024 at 12:37 p.m., S11Certified Nursing Assistant (CNA) indicated Resident #25 is on a mechanical soft with chopped meat diet. S11CNA confirmed Resident #25 should have been served a mechanical soft chopped meat diet. S11CNA indicated Resident #25's lunch tray was not a mechanical soft diet and further indicated the meat was not chopped.
In an interview on 10/08/24 at 1:11 p.m., S12Dietary Supervisor confirmed Resident #25's diet order was a mechanical soft with chopped meat diet. S12Dietary Supervisor indicated Resident #25's turkey pot roast should have been chopped by the kitchen staff before being served and it was not. S12Dietary Supervisor further indicated Resident #25 was not served a diet as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
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:
1. Ensure opened food products stored in the walk-...
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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:
1. Ensure opened food products stored in the walk-in cooler were sealed and labeled with the date the product was opened;
2. Ensure prepared food was stored, cooked, and maintained at the correct temperatures; and,
3. Ensure dishes were cleaned at the correct temperatures with the correct sanitizer levels to prevent foodborne illnesses.
Findings:
1.
Review of the facility's policy and procedure titled Food Label/Dating/Storage Policy dated 08/15/2018 revealed, in part, luncheon meat can be kept for 3-5 days after opening. Further review revealed salad dressing may be kept up to 30 days in the refrigerator or use best by date.
Observation on 10/07/2024 at 12:16 p.m. revealed an opened package of [NAME]-O sliced turkey breast in an unsealed bag with no opening date written on the package or bag. Further observation revealed an opened jar of Culinary Secrets Creamy [NAME] Slaw Dressing without an open date written on it.
In an interview on 10/07/2024 at 12:17 p.m., S12Dietary Supervisor (DS) confirmed the package of [NAME]-O sliced Turkey breast and the jar of Culinary Secrets Creamy [NAME] Slaw Dressing were opened and not dated and should have been.
Observation of the facility's walk in cooler on 10/10/2024 at 8:56 a.m. revealed an opened undated plastic bag containing Hormel Deli sliced ham.
In an interview on 10/10/2024 at 9:00 a.m., S12DS confirmed the plastic bag containing Hormel Deli sliced ham in the facility's walk in cooler was opened and undated and should not have been.
In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged the packages of ham and turkey and the jar of dressing were found opened and undated in the walk-in cooler and should not have been.
2.
Review of the facility's undated policy and procedure titled Preventing Foodborne Illness-Food Handling revealed, in part, the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented.
Review of the facility's Prepared Food Temperature Record dated 10/2024 revealed no entries.
Review of the facility's Record of Refrigeration Temperatures dated 09/2024 through 10/2024 revealed no documented evidence, and the facility could not provide any documented evidence, the facility's walk-in freezer or walk- in cooler's temperatures were monitored and recorded from 09/03/2024 through 10/06/2024.
In an interview on 10/07/2024 at 12:25 p.m., S12Dietary Supervisor (DS) confirmed the facility's walk-in freezer and cooler temperature logs for September and October 2024 were not completed and should have been. S12DS further confirmed the Prepared Food Temperature Record for October 2024 was not completed and should have been.
In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged the facility's walk-in freezer and cooler temperature logs for September and October 2024 were not completed and should have been. S1Administrator further acknowledged the Prepared Food Temperature Record dated 10/01/2014-10/06/2024 was not completed and should have been.
3.
Review of the facility's Dish Machine Temperature Log dated 09/2024 revealed, in part, no entries for 9/22/2024, 9/23/2024, 9/27/2024, 9/28/2024, and 9/30/2024.
Review of the facility's Dish Machine Temperature Log and Sanitizer Test Log dated 10/2024 revealed no entries.
In an interview on 10/07/2024 at 12:25 p.m., S12Dietary Supervisor (DS) confirmed the facility's Dish Machine Temperature Log and the Sanitizer Test Log for October 2024 were not completed and should have been. S12DS further indicated there was no documented evidence, and the facility could not provide any documented evidence the facility's dish machine reached the correct temperature and sanitizer levels to prevent foodborne illness from 10/01/2024 through 10/06/2024.
In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged the facility's Dish Machine Temperature Log and the Sanitizer Test Log dated 10/01/2014-10/06/2024 were not completed and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure accurate documentation was completed in a resident's record for 1 (Resident #42) of 23 (Resident #25, Resident #28, Resident #31, ...
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Based on record reviews and interviews, the facility failed to ensure accurate documentation was completed in a resident's record for 1 (Resident #42) of 23 (Resident #25, Resident #28, Resident #31, Resident #35, Resident #39, Resident #42, Resident #26, Resident #48, Resident #51, Resident #52, Resident #57, Resident #60, Resident #92, Resident #93, Resident #94, Resident #95, Resident #100, Resident #107, Resident #109, Resident #110, Resident #111, Resident #262, and Resident #262) sampled residents reviewed for accurate records.
Findings:
Review of Resident #42's admission orders dated 09/13/2024 and signed by S21Medical Director revealed, in part, flush port of midline every shift with 10 milliliters (mL) of normal saline followed by 3 cubic centimeters (cc) of Heparin.
Review of the facility's standing orders dated 07/2024 revealed, in part, central lines and Peripherally Inserted Central Catheter (PICC) lines will be flushed every shift with 10 mL of normal saline followed by 3 cc of Heparin.
Review of Resident # 42's Electronic Medical Record (EMR) revealed, in part, no documented evidence, and the facility did not present any documented evidence, Resident #42's midline was flushed with 10 ml of normal saline and/or 3 cc of Heparin on 10/04/2024, 10/05/2024, or 10/06/2024.
In an interview on 10/09/2024 at 1:11 p.m., S20Licensed Practical Nurse (LPN) indicated she was Resident #42's nurse on 10/05/2024 and 10/06/2024 during the 6:00 a.m. to 6:00 p.m. shift. S20LPN further indicated she administered 5 cc Heparin flush through Resident # 42's midline during her shift. S20LPN further indicated she could not provide any documented evidence she flushed Resident #42's midline with 5 cc of Heparin.
In an interview on 10/10/2024 at 12:45 p.m., S15LPN indicated she was Resident #42's nurse on 10/04/2024, 10/05/2024, and 10/06/2024 during the 6:00 p.m. to 6:00 a.m. shift. S15LPN further indicated she administered a 10 cc normal saline flush and a 3 cc Heparin flush through Resident # 42's midline during her shifts. S15LPN further indicated she could not provide any documented evidence she flushed Resident #42's midline with 10 cc of normal saline and 3 cc of Heparin.
In an interview on 10/09/2024 at 12:58 p.m., S2Director of Nursing indicated there was no documented evidence, and the facility could not provide any documented evidence, S15LPN and S20LPN documented the administration of the above mentioned flushes on 10/04/2024, 10/05/2024, or 10/06/2024 in Resident #42's record and should have.
In an interview on 10/10/2024 at 2:15 p.m., S1Administrator acknowledged there was no documented evidence, and the facility could not provide any documented evidence, S15LPN and S20LPN documented the administration of the above mentioned flushes on 10/04/2024, 10/05/2024, or 10/06/2024 in Resident #42's record and should have.
Aug 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure wound care treatments were administered to re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure wound care treatments were administered to residents as ordered for 2 (Resident #1 and Resident #3) of 2 (Resident #1 and Resident #3) sampled residents investigated for pressure injuries.
Findings:
Review of the facility's wound care/dressing change policy revised 12/2022 revealed, in part, in preparation to performing wound care, a review of the resident's medical record and/or care plan, current orders, and diagnoses to determine any special resident needs should be completed. Further review revealed, in part, the date and time the dressing was changed, and the name and title of the individual changing the dressing should be recorded in the resident's medical record.
Resident #1
Review of Resident #1's electronic medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses of, in part, Pressure Ulcer of Sacral Region, Stage 4, Muscle Wasting and Atrophy, and Fusion of Spine, Cervical Region.
Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 06/26/2024 (Quarterly) revealed Resident #1 had a Brief Interview for Mental Status score of 15 (cognitively intact). Review of Section GG revealed Resident #1 had upper extremity impairment on both sides, and lower extremity impairments on both sides, and used a wheelchair. Review of Section M revealed Resident #1 had a pressure ulcer, was at risk for developing a pressure ulcer, and was assessed as having one stage 4 pressure ulcer that was present upon admission.
Review of Resident #1's Care Plan revealed, in part, Resident #1 had a stage 4 pressure ulcer to the sacrum. Further review revealed an intervention to follow facility policies/protocol for the prevention of skin breakdown.
Review of Resident #1's August 2024's Physician's Orders revealed, in part, an order with a start date of 06/03/2024 to clean Resident #1's stage 4 sacral pressure ulcer with normal saline, pat dry, apply santyl (an ointment uses to remove damaged tissue from chronic skin ulcers), lightly pack with gauze, and cover with appropriate dressing once a day and as needed.
Review of Resident #1's June, July, and August 2024's electronic Treatment Administration Order (e-TAR) revealed, in part, Resident #1's treatment to his sacrum was not administered daily as per physician's orders.
In an interview on 08/23/2024 at 2:30 p.m., Resident #1 indicated that he had a pressure ulcer to his sacrum. Resident #1 also indicated the nurse treated his wound every Wednesday.
Resident #3
Review of Resident #3's electronic medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with diagnoses of, in part, Alzheimer's Disease, Dementia, Age related debility, and Right Femur Fracture.
Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 07/18/2024 revealed Resident #3 had a Brief Interview for Mental Status score of 8 (moderate cognitive impairment). Further review of Section M revealed Resident #3 was at risk for developing pressure ulcers/injuries.
Review of Resident #3's Care Plan revealed she had a potential for pressure ulcer development related to immobility.
Review of Resident #3's August 2024's Physician's Orders revealed, in part, an order with a start date of 07/29/2024 to provide wound care to Resident #3's right lateral heel, and cleanse with normal saline, pat dry, apply antibiotic ointment, cover with appropriate dressing every Monday, Wednesday, and Friday and as needed until resolved.
Review of Resident #3's July and August 2024's e-TAR revealed, in part, Resident #3's treatment to her right heel was not administered every Monday, Wednesday, and Friday as per physician's orders.
In an interview on 08/27/2024 at 10:08 a.m., upon review of the missing entries on Resident #1's e-TAR for the above months, S2Director of Nursing (DON) indicated that Resident #1's wound care to his sacrum was not completed by the nursing staff daily as ordered, and it should have been completed daily as ordered. S2DON indicated that the nurses assigned to each neighbor pod were responsible for completing Resident #1's wound care daily, and prior to 08/26/2024, the facility did not employ a dedicated Treatment Nurse to provide wound treatments to residents.
In an interview on 08/27/2024 at 1:36 p.m., S2DON confirmed that Resident #3's wound care treatment was not documented as being administered as ordered, and she indicated that wound care treatments should have been completed as ordered.
In an interview on 08/27/2024 at 1:38 p.m., S1Administrator indicated that Resident #1 and Resident #3's wound care treatments were not administered as per Physician's orders and the nurses on each pod should have performed the wound care for Resident #1 and Resident #3 as per Physician's orders and the nurses on each pod should have performed the wound care for Resident #1 and Resident #3 as per physician's orders.
Apr 2024
4 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 F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to respect a resident or a resident's responsible party's right to c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to respect a resident or a resident's responsible party's right to choose a health care services for (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for resident rights.
Findings:
Review of Resident #1's Physician's Communication dated 03/04/2024 revealed, in part, documentation that Resident #1's representative had concerns regarding Resident #1's continued itching and requested that Resident #1 see a dermatologist.
In a telephone interview on 04/11/2024 at 4:17 p.m., Resident #1's responsible party indicated Resident #1's skin rash had kept getting worse despite treatment, and Resident #1's responsible party had requested that Resident #1 be sent to a dermatologist. Resident #1's responsible party further stated no appointment with a dermatologist was made, and no staff from the facility had gotten back to her regarding the above mentioned request. Resident #1's representative indicated Resident #1 was diagnosed with scabies (a contagious, intensely itchy skin condition cause by tiny, burrowing mites) when he was admitted to the hospital on [DATE].
In an interview on 04/11/2024 at 9:41 a.m., S4Social Services Director stated if a resident chooses to see a dermatologist, the nurse would let the resident's physician know of the resident's request, and then S4Social Services Director would call and get an appointment scheduled. S4Social Services Director further stated she knew Resident #1's representative wanted him to go to a dermatologist. S4Social Services Director stated a resident had the right to go to any doctor if they choose to do so.
In an interview on 04/11/2024 at 5:27 p.m., S4Social Services Director stated she could not produce evidence that Resident #1 was scheduled or had seen a dermatologist.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have quarterly care plan meetings with the interdisciplinary team f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have quarterly care plan meetings with the interdisciplinary team for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for care plans.
Findings:
Resident #1
In an interview on 04/11/2024 at 4:17 p.m., Resident #1's responsible party indicated she had only been invited to two of Resident #1's plan of care meetings since Resident #1 was admitted to the facility on [DATE]. Resident #1's responsible party further indicated she had not been to a plan of care meeting at the facility during his last 3 months as a resident.
Review of a letter presented by S4Social Services Director, revealed, in part, Resident #1 was scheduled to have a plan of care meeting on 01/11/2024.
Review of Resident #1's record revealed, in part, no evidence, and the facility did not present any documented evidence, a plan of care meeting was held for Resident #1 between 01/01/2024 and his discharge on [DATE].
In an interview on 04/11/2024 at 5:27 p.m., S4Social Services Director stated that she could find no evidence that a plan of care meeting was held for Resident #1 anytime between 01/01/2024 and his discharge on [DATE] or evidence as to who would have attended the scheduled plan of care meeting.
Resident #2
Review of a letter presented by S4Social Services Director, revealed, in part, Resident #2 was scheduled to have a plan of care meeting on 02/15/2024.
Review of Resident #2's record revealed, in part, no evidence, and the facility did not present any documented evidence, a plan of care meeting was held for Resident #2 between 01/01/2024 to 04/11/2024. Further review revealed Resident #2's last plan of care meeting was held on 11/02/2023.
In an interview on 04/11/2024 at 5:27 p.m., S4Social Services Director indicated she could not find any documentation that a plan of care meeting was held for Resident #2 anytime between 01/01/2024 and 04/11/2024 or evidence as to who would have attended the scheduled plan of care meeting.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to follow the menu for 1 (Resident #3) of 2 (Resident #2 and Resident #3) sampled residents investigated for dietary services in...
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Based on observation, record review, and interview, the facility failed to follow the menu for 1 (Resident #3) of 2 (Resident #2 and Resident #3) sampled residents investigated for dietary services in a total sample of three.
Findings:
Review of the facility's regular diet menu for 04/11/2024 revealed, in part, residents were to be served roasted pork, au gratin potatoes, sliced zucchini, a dinner roll, a brownie, margarine, salt packet, pepper packet, a choice of a beverage, and water.
Observation of the facility's posted lunch menu on 04/11/2024 at 11:22 a.m. revealed, in part, residents were to be served roasted pork loin, mashed potatoes, California blend vegetables, dinner rolls, brownies, salt packet, pepper packet, juice, and water.
Observation on 04/11/2024 at 2:30 p.m., revealed Resident #3's lunch tray did contain a piece of battered and/or fried meat.
In an interview on 04/11/2024 at 2:30 p.m., Resident #3 indicated she did not like the meat she was given today for lunch, as it was either fried chicken or fried pork. Resident #3 further stated she saw the menu for 04/11/2024, and the residents were supposed to be served roasted pork loin today for lunch. Resident #3 further stated that she would have wanted to eat the roasted pork loin.
In an interview on 04/11/2024 at 2:32 p.m., S5Dietary Supervisor confirmed there was a piece of fried/battered pork on Resident #3's lunch tray. S5Dietary Supervisor further indicated residents should have been served the meal as listed on the menu.
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
Quality of Care
(Tag F0684)
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 assess and/or measure a resident's wound weekly for 2 (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 assess and/or measure a resident's wound weekly for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for wound management.
Findings:
Resident #1
Review of Resident #1's hospital discharge record dated 12/29/2023 revealed, in part, Resident #1 had a wound dehiscence (total or partial separation of a wound the was previously closed).
Review of Resident #1's nurse's note dated 12/30/2023, revealed, in part, Resident #1 returned back to the facility with sutures to the left side of his head.
Review of Resident #1's clinical record revealed no documented evidence, and the facility did not present any documented evidence, Resident #1's left scalp incision was assessed and/or measured upon Resident #1's return from the hospital and/or weekly.
In an interview on 04/09/2024 at 1:30 p.m., S2Assistant Director of Nursing (ADON) confirmed there was no evidence of a wound assessment for Resident #1's surgical incision to his left head from 12/2023 to his discharge on [DATE]. S2ADON further indicated there should have been an assessment of Resident #1's surgical incision documented weekly.
Resident #2
Review of Resident #2's February, March, and April 2024 Physician's orders revealed, in part, Resident #2 was to receive wound care to right leg wound from 02/01/2024 to 04/11/2024.
Review of Resident #2's clinical record revealed, no documented evidence, and the facility did not present any documented evidence, Resident #2's right calf venous ulcer was assessed and/or measured weekly except on 04/02/2024.
Review of Resident #2's right calf venous ulcer wound assessment dated [DATE], revealed no documented evidence that Resident #2's right calf venous ulcer was measured.
In an interview on 04/11/2024 at 3:50 p.m., S2ADON confirmed there was no evidence of a wound assessment for Resident #3's right calf venous ulcer except on 04/02/2024. S2DON further confirmed the wound assessment of Resident #2's right calf venous ulcer, dated 04/02/2024, did not have wound measurements documented.
In an interview on 04/11/2024 at 4:00 p.m., S1Director of Nursing (DON) indicated a wound assessment with measurements should have been completed for both Resident #1's left scalp incision and Resident #3's right calf venous ulcer. S1DON further indicated the wound assessment for Resident #3's right calf venous ulcer, dated 04/02/2024, should have wound measurements documented.
Nov 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report an injury of unknown origin to the state agency in a timely ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report an injury of unknown origin to the state agency in a timely manner for 1 (Resident #37) of 2 (Resident #30, Resident #37) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse/Neglect Policy revealed, in part, if the source of injury is unknown and cannot be determined, the incident will be reported by the Administrator to the Department of Health.
Review of Resident #37's medical record revealed, in part, Resident #37 was admitted to the facility on [DATE] with a diagnosis of traumatic subdural hemorrhage (an injury to the head that causes bleeding in the skull). Further review revealed Resident #37 had severely impaired cognition and was dependent on staff for functional mobility.
Review of Resident #37's Incident Report dated 11/13/2023 at 10:00 a.m. revealed, in part, S41Licensed Practical Nurse (LPN) was called into the shower room by a certified nursing assistant (CNA). Further review revealed S41LPN identified multiple bruises of unknown origin on Resident #37. S41LPN indicated Resident #37 was unable to recall the incident due to a diagnosis of dementia (a disease that causes memory loss). The incident report revealed the following description of Resident #37's bruises:
1. left eye brow 2 centimeter (cm) in length and 2 cm in width;
2. the side of his left eye 2 cm in length and 3 cm in width;
3. left forearm 12 cm in length and 6 cm in width;
4. right forearm 10 cm in length and 6 cm in width; and,
5. right great toe 2 cm in length and 3 cm in width.
In an interview on 11/13/2023 at 1:27 p.m., Resident #37 was unable to state how he sustained the bruises.
In an interview on 11/15/2023 at 10:08 a.m., Resident #37's physician stated the bruising and facial swelling was caused by trauma to the area.
In an interview on 11/15/2023 at 10:12 a.m., S4LPN state Resident #37 did not have a fall on her shift and did not know how the bruising occurred.
In an interview on 11/15/2023 at 2:45 p.m., S2DON stated the facility had no documented evidence a staff member observed Resident #37 hitting his head on the table.
Review of the facility's reported incidents revealed, in part, no evidence and the facility did not produce any evidence a facility incident report was completed for Resident #37.
Observation on 11/16/2023 at 2:10 p.m. of the facility's camera footage dated 11/12/2023 revealed, in part, Resident #37 was sitting in his wheelchair at a table in the common area. Further review revealed Resident #37 was leaning forward with his head near the table with no definitive evidence he sustained a self-inflicted injury from the table due to his movements.
In an interview on 11/16/2023 at 2:10 p.m., S1Administrator stated she was pretty sure that Resident #37 acquired the bruising to his face and arms by resting his head on the table and keeping his arms tucked in between his legs and knees while sitting. S1Administrator did not agree that Resident #37's bruising met the definition of an injury of unknown origin and did not agree the bruising should have been reported to the state agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observations and interview, facility failed to post nurse staffing data as required.
Findings:
Observation on 11/13/2023 at 10:20 a.m. revealed the facility's resident census and the total nu...
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Based on observations and interview, facility failed to post nurse staffing data as required.
Findings:
Observation on 11/13/2023 at 10:20 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility.
Observation on 11/14/2023 at 9:50 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility.
Observation on 11/15/2023 at 2:50 p.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility.
In an interview on 11/15/2023 at 2:50 p.m., S16Licensed Practical Nurse stated she was in charge of ensuring the schedule was posted but did not realize the format of the posting did not meet regulations.
In an interview on 11/15/2023 at 2:55 p.m., S4CNA Supervisor stated she was in charge of ensuring the CNA schedule was posted but did not realize the format of the posting did not meet regulations.
In an interview on 11/15/2023 at 3:00 p.m., S3Assistant Director of Nursing confirmed the format of the nurse schedule and the CNA schedule did not meet regulation requirements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to ensure a medication cart had medication properly secured for 1 (Medication Cart d) out of 3 medication carts (Medication Cart d, Medication ...
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Based on observation and interviews, the facility failed to ensure a medication cart had medication properly secured for 1 (Medication Cart d) out of 3 medication carts (Medication Cart d, Medication Cart e, and Medication Cart f) had medication properly secured.
Findings:
Review of the facility's Controlled Substances Policy revealed, in part, controlled substances must be under double lock when the nursing cart is left unattended, therefore, the cart must be locked.
Observation on 11/15/2023 at 12:55 p.m. revealed S17Licensed Practical Nurse (LPN) left Medication Cart d unlocked and unattended while she went to transport a resident off of the unit. Further observation revealed S17LPN left the keys to Medication Cart d on top of the cart. Further observation revealed Medication Cart d was left unlocked and unattended until 1:00 p.m. on 11/15/2023.
In an interview on 11/15/2023 at 1:01 p.m., S17LPN stated she should have not left Medication Cart d unlocked nor left her keys to Medication Cart d on top of the medication cart.
In an interview on 11/15/2023 at 4:30 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) stated the nurses should always lock the medication carts when the nurses leave the medication cart unattended. S2DON/IPfurther stated the nurse should not leave their keys on the top of the medication carts.
In an interview on 11/16/2023 at 10:36 a.m., S1Administrator stated that the nurses should not leave their medication carts unlocked nor should the nurses leave the keys to their medication carts on top of their medication carts and unattended.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide housekeeping and maintenance services by failing to:
1. Ensure walls in the dirty linen room were repaired;
2. Ensure the clean line...
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Based on observation and interview, the facility failed to provide housekeeping and maintenance services by failing to:
1. Ensure walls in the dirty linen room were repaired;
2. Ensure the clean linen room was kept clean and sanitary;
3. Ensure resident's bathrooms were cleaned for 3 (Resident #30, Resident #60, and Resident #88) of 3 resident's bathrooms observed; and
4. Ensure nursing units were cleaned for 2 (POD B and POD C) of 2 nursing units observed.
Findings:
Observation on 11/13/2023 at 10:00 a.m. of the dirty linen room, revealed exposed pipe through a hole in the wall measuring approximately 1 foot (ft.) by 1 ft. directly behind the washing machines. Further observation revealed a second exposed pipe through a hole in the wall measuring approximately 1 ft. by 3 ft. on the right side of the washing machines.
Observation on 11/13/2023 at 10:05 a.m. of the clean linen room, revealed 5 pairs of shoes with dust and lint on them on top of the air conditioner unit. Further observation revealed a folded blanket on the floor on the floor lying directly under a drain pipe coming from the air conditioner unit. Observation of 2 air conditioner units and the piping and wiring coming from the units were covered in dust. Further observation revealed a black substance along the slats of the supply vent of one air conditioner unit.
In an interview on 11/13/2023 at 10:00 a.m., S15Housekeeping Supervisor stated she did not know how long the hole with the exposed pipe behind the washing machine and the hole with the exposed pipe on the right side of the washing machine had been there. S15Housekeeping Supervisor further stated the dust in the clean linen room on top of the air conditioners and along the wiring and piping should not be there and it should be cleaned. S15Housekeeping Supervisor also stated the 5 pairs of shoes that were on top of the a/c unit did not belong there and needed to be removed. S15Housekeeping Supervisor stated water would leak from the air condition unit sometimes and the blanket was on the floor to absorb water if it dripped from the unit. S15Housekeeping Supervisor also stated the black substance that was visible on the air conditioner supply vent should not be there and would be cleaned up.
In an interview on 11/14/2023 at 11:30 a.m., S1Administrator confirmed there was a leak in the dirty linen room approximately 4 months ago and the holes that left pipe exposed in the dirty linen room should have been fixed sooner.
Observation on 11/14/2023 at 8:16 a.m. revealed brown finger prints on the door frame and light switch in Resident #30's bathroom. Further observation revealed Resident #30's bathroom had a foul odor upon entering. Further observation revealed there was a gray fuzzy substance on the vent fan.
Observation on 11/14/2023 at 8:18 a.m. revealed a brown substance was on the floor along the wall outside of Resident #30's room.
Observation on 11/14/2023 at 8:19 a.m. revealed a black substance on the 4 vents in POD C.
Observation on 11/14/2023 at 8:32 a.m. revealed Resident #88's bathroom had a urine like odor upon entering and a bedpan lying on the floor under the sink. Further observation revealed a brown colored substance was on the floor around the toilet and the drain on the floor. Further observation revealed the vent fan on the bathroom wall contained a layer of gray fuzzy substance. Further observation revealed a brown, black fuzzy substance on the air conditioner vent near Resident #88's bed.
Observation on 11/14/2023 at 10:40 a.m. revealed Resident #30's bathroom had a foul odor. Further observation revealed Resident #30's bathroom had a gray fuzzy substance on the vent fan.
Observation on 11/14/2023 at 10:58 a.m. revealed Resident #88's bathroom had a urine like odor upon entering and a bedpan lying on the floor under the sink. Further observation revealed a brown colored substance was on the floor around the toilet and the drain on the floor. Further observation revealed the vent fan on the bathroom wall contained a layer of gray fuzzy substance. Further observation revealed a brown, black fuzzy substance on the air conditioner vent near Resident #88's bed.
Observation on 11/14/2023 at 10:59 a.m. revealed the 4 air conditioner vents in POD B were covered with a black substance.
Observation on 11/15/2023 at 8:05 a.m. revealed a black substance on the 4 air conditioner vents in POD C.
Observation on 11/15/2023 at 8:09 a.m. revealed Resident #30's bathroom had a foul odor. Further observation revealed there was a gray fuzzy substance on the vent fan.
Observation on 11/15/2023 at 8:10 a.m. revealed a brown substance on the floor along the wall outside of Resident #30's room.
Observation on 11/15/2023 at 8:11 a.m. revealed Resident #88's bathroom had a urine like odor upon entering and a bedpan lying on the floor under the sink. Further observation revealed a brown colored substance was on the floor around the toilet and the drain on the floor. Further observation revealed the vent fan on the bathroom wall contained a layer of gray fuzzy substance. Further observation revealed a brown, black substance on the air conditioner vent near Resident #88's bed.
Observation on 11/15/2023 at 8:13 a.m. revealed the 4 air conditioner vents in POD B were covered with black substance.
In an interview on 11/15/2023 at 9:17 a.m., Resident #30 stated the bathroom smells like poop all the time and he would prefer the bathroom to smell clean.
In an interview on 11/15/2023 at 1:37 p.m., S36Housekeeper stated there was a brown substance on the floor around the toilet and the drain in Resident #88's bathroom. S36Housekeep stated she didn't know what the brown substance was. S36Housekeeper also stated she didn't know what the gray fuzzy substance was on the vent fan in Resident #88's bathroom. S36Housekeeper further stated she didn't clean the vent fan. S36Housekeeper stated she didn't know what the brown, black fuzzy substance was on Resident #88's air conditioner vent. S36Housekeeper stated she wasn't responsible for cleaning the air conditioner vents.
In an interview on 11/15/2023 at 1:40 p.m., S43Certified Nursing Assistant (CNA) stated bedpans should be stored in a bag in the resident's bathroom. S43CNA acknowledged there was a bed pan on the floor under the sink in Resident #88's bathroom. S43CNA stated Resident #88 was not using a bedpan and the bedpan should not be in Resident #88's bathroom.
Observation on 11/15/2023 at 1:42 p.m. revealed the 4 air conditioner vents in POD B were covered with black substance.
Observation on 11/15/2023 at 1:43 p.m. revealed Resident #30's bathroom had a foul feces like odor. Further observation revealed there was a gray fuzzy substance on the vent fan.
Observation on 11/16/2023 at 8:36 a.m. revealed Resident #30's bathroom had a foul odor. Further observation revealed there was a gray fuzzy substance on the vent fan.
Observation on 11/16/2023 at 8:37 a.m. revealed a brown substance on the floor along the wall outside of Resident #30's room.
Observation on 11/16/2023 at 8:38 a.m. revealed a black substance on the 4 air conditioner vents in POD C.
Observation on 11/16/2023 at 8:44 a.m. revealed the 4 air conditioner vents vents in POD B were covered with black substance.
In an interview on 11/16/2023 at 9:02 a.m., S31Housekeeper stated she did not know who was responsible for cleaning the air conditioner vents in POD C. S31Housekeeper confirmed Resident #30's bathroom had a brown colored substance smeared on the walls and door frame. S31Housekeeper further stated Resident #30's bathroom had a feces like odor and had smelled like feces for a week.
In an interview on 11/16/2023 at 11:40 a.m., S15Housekeeping Supervisor stated Resident #88's bathroom floor was stained with a brown substance and the vent fan was layered with a gray colored substance that looked like dust. S15Housekeeping Supervisor further stated the bathroom floor and vent fan should be clean to create a home like environment. S15Housekeeping Supervisor confirmed Resident #88's air conditioner vent had a brown and black fuzzy colored substance and it should not have a substance. S15Housekeeping Supervisor confirmed the 4 air conditioner vents in POD B contained a black substance and should not have a substance. S15Housekeeping Supervisor also stated maintenance was responsible for cleaning the vents in the air conditioner units in the resident's room. S15Housekeeping Supervisor also confirmed there was a black substance on the 4 air conditioner vents in POD C and the air conditioner vents should not have a black substance.
Observation on 11/14/2023 at 2:25 p.m., revealed Resident #60's bathroom had one uncontained bed pan with a brownish substance inside and one uncontained regular size bedpan on the bathroom floor.
Observation on 11/15/2023 at 8:34 a.m., revealed Resident #60's bathroom had one uncontained bed pan with a brownish substance inside and one uncontained bedpan on the bathroom floor.
In an interview on 11/15/2023 at 1:28 p.m., S7CNA acknowledged Resident #60's bathroom had two uncontained bedpans on the floor. S7CNA further acknowledged used bed pans should be contained in a bag and labeled or thrown away if not being used.
In an interview on 11/16/2023 at 9:42 a.m., S2Director of Nursing (S2DON) stated she was not aware there were uncontained bed pans on Resident #60's bathroom floor. S2DON further acknowledged that bed pans should be contained in a bag and labeled or discarded if no longer being used.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observations, record reviews, and interviews, the facility failed to ensure residents had comprehensive care plans for 2 (Resident #12 and Resident #50) of 22 residents (Resident #12, Residen...
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Based on observations, record reviews, and interviews, the facility failed to ensure residents had comprehensive care plans for 2 (Resident #12 and Resident #50) of 22 residents (Resident #12, Resident #21, Resident #22, Resident #24, Resident #30, Resident #31, Resident #37, Resident #50, Resident #58, Resident #60, Resident #62, Resident #65, Resident #67, Resident #69, Resident #71, Resident #72, Resident #75, Resident #79, Resident #81, Resident #93, Resident #97, and Resident #102) included in the final investigation sample.
Findings:
Resident #12
Review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/2023 revealed, in part, Resident#12 had Urinary Tract Infections that lasted 30 days.
Review of Resident #12's Care Plan revealed, in part, no documented evidence of problems, goals, or interventions addressing urinary tract infections. There was no documented evidence and the facility did not present any documented evidence of a Comprehensive Care Plan addressing urinary tract infections for Resident #12.
In an interview on 11/16/2023 at 2:15 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) confirmed Resident #12 did not have a care plan that addressed urinary tract infections and stated Resident #12 should have been care planned for urinary tract infections.
Resident #50
Review of Resident #50's November 2023 Physician's orders revealed, in part, an order dated 03/08/2021 for oxygen at 2-5 Liters per Minute continuously via nasal cannula.
Review of Resident #50's care plan revealed, no goals or interventions regarding Resident #50's oxygen use. Further review revealed, no goals or interventions regarding Resident #50 refusing to be administered oxygen via nasal cannula.
In an interview on 11/15/2023 at 4:30 p.m., S2Director of Nursing/Infection Preventionist stated Resident #50 does have an order for continuous oxygen, but is known for taking her nasal cannula off. S2DON/IP further stated Resident #50's plan of care should have addressed her oxygen use or her behaviors of refusing administration of oxygen, and did not.
In an interview on 11/16/2023 at 10:15 a.m., S37Licensed Practical Nurse stated that Resident #50 should have been care planned for her oxygen use or for her behaviors regarding refusal of oxygen administration and was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed ensure portable oxygen cylinders were secured in 1 (Resident #58) of 1 resident's room and 1 (Medication Room x) of 2 medicati...
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Based on observations, interviews, and record review, the facility failed ensure portable oxygen cylinders were secured in 1 (Resident #58) of 1 resident's room and 1 (Medication Room x) of 2 medication rooms (Medication Room x and Medication Room y) observed for safe storage of portable oxygen cylinders.
Findings:
Review of the facility's policy regarding Oxygen Administration revealed, in part, portable oxygen cylinders should be secure in a stand.
Observation on 11/13/23 at 9:25 a.m., revealed Resident #58 had 2 one-half portable oxygen cylinders unsecured on the floor to the right side of her door way.
Observation on 11/14/2023 9:45 a.m., revealed Resident #58 had 2 one-half portable oxygen cylinders unsecured on the floor to the right side of her door way.
Observation on 11/14/2023 at 9:46 a.m., revealed 3 one-half portable oxygen cylinders were in Medication Room x and not secured.
Observation on 11/15/2023 at 8:50 a.m., Resident #58 had 2 one-half portable oxygen cylinders unsecured on the floor to the right side of her door way.
Observation on 11/15/2023 at 3:45 a.m., revealed 3 one-half portable oxygen cylinders were in Medication Room x and not secured.
Observation on 11/16/2023 at 8:51 a.m., Resident #58 had 2 one-half portable oxygen cylinders unsecured on the floor to the right side of her door way.
Observation on 11/16/2023 at 9:10 a.m. revealed 3 one-half portable oxygen cylinders were in Medication Room x and not secured.
In an interview on 11/16/2023 at 9:11 a.m., S3Assistant Director of Nursing (ADON) confirmed 3 one-half portable oxygen cylinders were in Medication Room x and not secured. S3ADON further stated that she was unsure of the policy regarding securement of the one-half portable oxygen cylinders
In an interview on 11/16/2023 at 9:12 a.m., S3ADON confirmed Resident #58 had two one-half portable oxygen cylinders unsecured on the floor to the right side of her door way.
In an interview on 11/16/2023 at 10:36 a.m., S1Administrator stated all portable oxygen cylinders should have been secured in a stand and not unsecured on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure:
1. The nurses were signing as verifying an accurate medication count at the beginning and end of each shift for 3 (Medication Cart...
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Based on record review and interviews, the facility failed to ensure:
1. The nurses were signing as verifying an accurate medication count at the beginning and end of each shift for 3 (Medication Cart d, Medication Cart e, and Medication Cart f) of 3 Medication Carts observed and reviewed for accurate dispensation of controlled medications; and
2. The controlled substances count sheet was reconciled with the medication available for 1 (Medication Cart d) of 3 (Medication Cart d, Medication Cart e, Medication Cart f) medication carts observed for controlled substance reconciliation.
Findings:
Review of the facility's Controlled Substances Policy revealed, in part, the nursing staff must count controlled drugs at the end of the shift with the nurse coming on duty and the nurse going off duty. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Further review revealed the nursing staff must document and report any discrepancies to the Direct or Nursing or designee immediately.
1.
Review of Medication Cart e 's controlled substance binder on 11/14/2023 revealed, in part, the Controlled Drugs-Count Record for Medication Cart e dated November 2023 was missing the signatures of the nurse coming on duty and the nurse going off duty on the morning shift of 11/01/2023, 11/05/2023, and 11/10/2023. Further review revealed the Controlled Drugs-Count Record for Medication Cart e dated November 2023 was missing the signatures of the nurse coming on duty and the nurse going off duty for the night shift on 11/03/2023 and11/05/2023. Further review revealed the Controlled Drugs-Count Record for Medication Cart e dated November 2023 missing the signature of the nurse coming on duty on the morning shift of 11/02/2023, 11/03/2023, 11/07/2023, 11/11/2023, and 11/13/2023. Further review revealed the Controlled Drugs-Count Record for Medication Cart e dated November 2023 was missing the signature off the nurse going off duty on the morning shift of 11/04/2023 and 11/09/2023.
In an interview on 11/14/2023 at 2:20 p.m., S16Licensed Practical Nurse (LPN) stated the Controlled Drugs-Count Record for Medication Cart e should have been signed by both nurses when the controlled substances were counted, and that each day on the Controlled Drugs-Count Record for Medication Cart e should have the signature of the nurse coming on duty and the nurse going off duty two times a day for a total of 4 signatures.
Review of Medication Cart d 's controlled substance binder on 11/15/2023 revealed, in part, the Controlled Drugs-Count Record for Medication Cart d dated November 2023 was missing the signatures of the nurse coming on duty and the nurse going off duty on the morning shift of 11/12/2023 and 11/15/2023. Further review revealed the Controlled Drugs-Count Record for Medication Cart d dated November 2023 was missing the signature of the nurse coming on duty on the morning shift for 11/06/2023, 11/08/2023, 11/10/2023, and 11/11/2023.
In an interview on 11/15/2023 at 1:02 p.m., S17LPN stated she was unaware she had to sign-off on the Controlled Drugs-Count Record for Medication Cart d when she counted the controlled medications with the outgoing or oncoming nurse at shift change.
Review of Medication Cart f 's controlled substance binder on 11/15/2023 revealed, in part, the Controlled Drugs-Count Record for Medication Cart f dated November 2023 was missing the signatures of the nurse coming on duty and the nurse going off duty on the morning shift of 11/12/2023 and 11/13/2023. Further review revealed the Controlled Drugs-Count Record for Medication Cart f dated November 2023 was missing the signatur of the nurse going off duty for the morning shift of 11/01/2023, 11/02/2023, and 11/03/2023. Further review revealed the Controlled Drugs-Count Record for Medication Cart f dated November 2023 was missing the signatures of the nurse coming on duty and the nurse going off duty on the night shift of 11/01/2023, 11/02/2023, and 11/10/2023. Further review revealed the Controlled Drugs-Count Record for Medication Cart f dated November 2023 was missing the signature of the nurse going on duty for the morning shift of 11/07/2023, 11/08/2023, 11/09/2023, 11/20/2023, and 11/14/2023.
In an interview on 11/15/2023 at 3:11 p.m., S30Registered Nurse stated the Controlled Drugs-Count Record for Medication Cart f should be signed when controlled substances are counted by the nurses at shift change.
In an interview on 11/15/2023 at 4:30 p.m., S2Director of Nursing/Infection Preventionist (DON/IP) stated the nurses were to perform a count of the controlled medication with the incoming and outgoing nurse on each shift.
In an interview on 11/16/2023 at 10:36 a.m., S1Administrator stated the incoming and outgoing nurses should have signed the Controlled Drugs-Count Record when they counted the narcotics at shift change.
2.
On 11/15/2022, a reconciliation was completed of controlled substances on medication cart d, and the controlled substance binder for medication cart d revealed the following:
-Review of Resident #38's medication card for Tramadol Hydrochloride (HCL) 50 milligrams (mg) (a medication used to treat pain) revealed Resident #38 had 13 tablets available.
-Review of Resident #38's Individual Narcotic Record revealed, in part, Resident #38 had 15 Tramadol HCL 50 mg tablets available per Resident #38's Individual Narcotic Record.
-Review of Resident #52's medication card for Oxycodone HCL 5mg (a medication used to treat pain) revealed Resident #52 had 6 tablets available.
-Review of Resident #52's Individual Narcotic Record revealed, in part, Resident #52 had 7 Oxycodone HCL 5mg tablets available per Resident #52's Individual Narcotic Record.
-Review of Resident #95's medication card for Lacosamide 100 mg (a medication used to treat seizures) revealed Resident #95 had 56 tablets available.
-Review of Resident #95's Individual Narcotic Record revealed, in part, Resident #95 had 7 Lacosamide100 mg tablets available per Resident #95's Individual Narcotic Record.
-Review of Resident #204's medication card for Oxycodone-Acetaminophen (APAP) 5-325mg (a medication used to treat pain) revealed Resident #204 had 24 tablets available.
-Review of Resident #204's Individual Narcotic Record revealed, in part, Resident #204 had 25 Oxycodone-Acetaminophen 5-325mg tablets available per Resident #204's Individual Narcotic Record.
In an interview on 11/15/2023 at 1:10 p.m., S17LPN stated she should have been signing the controlled medications out on the resident's Individual Narcotic Records as soon as she gave the medication as per the MD order and she did not.
In an interview on 11/15/2023 at 4:30 p.m., S2DON stated when a controlled medication was administered to a resident, the controlled medication should have been reconciled on the individual narcotic record by the nurse as soon as the nurse popped the pill out of the medication card.
In an interview on 11/16/2023 at 10:36 a.m., S1Administrator stated the nurses should have been reconciling controlled medications as soon as the medications were given on the Individual Narcotic Records of the medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and record review; the facility failed to provide dinnerware, cups, plates, and utensils to meet resident's preferences and failed to follow the posted lunch menu dai...
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Based on observation, interviews, and record review; the facility failed to provide dinnerware, cups, plates, and utensils to meet resident's preferences and failed to follow the posted lunch menu daily.
Findings:
Observation on 11/14/2023 at 8:58 a.m. of POD C revealed, in part, breakfast meal was served on disposable plates, eating utensils were plastic, and drinks were served in disposable cups.
During Resident Council interview on 11/14/2023 at 10:30 a.m., Resident #32, Resident #10, and Resident #85 stated that they are being served breakfast, lunch, and dinner with disposable plates, disposable cups, and plastic eating utensils during meals and it is hard to eat and cut meat with plastic utensils. Resident #32, Resident #10, and Resident #85 further stated they would prefer to have non disposable plates and silver ware to use.
In an interview on 11/14/2023 at 10:58 a.m. S26Dietary Aide and S32Dietary Aide stated meals were served on reusable plates, plastic utensils, along with disposable cups to save time due to being short staffed. SD26Dietary Aide further stated there is not enough staff to prepare utensils for resident trays when there are 2 staff member due to call in's.
Observation on 11/14/2023 at 12:00 p.m. of POD G, revealed, in part, lunch meal was served with plastic eating utensils and disposable cups.
Observation on 11/14/2023 at 12:15 p.m. revealed, in part, residents were being served lunch with disposable cups and plastic utensils.
Review of Dietary Menu dated November 15, 2023 revealed, in part, on November 15, 2023 lunch menu was scheduled for meat sauce, spaghetti noodles, Italian blend vegetables, toss salad with dressing, garlic toast half, strawberries and pineapple, margarine, salt/pepper packet, choice of beverage, and water.
Observation on 11/15/2023 at 12:35 p.m. revealed, in part, lunch meal served was chicken tender with honey mustard sauce, mashed potatoes, California blend vegetables, dinner roll, pineapple orange cup, salt/pepper, and juice/water. Further observation revealed the puree meal was chicken and broccoli, and the chopped meal was hamburger steak.
In an interview on 11/15/2023 at 1:25 p.m., S6Dietary Supervisor stated the kitchen was short staffed. S6Dietary Supervisor was called in to work on Saturday, November 11, 2023 due to lack of staff and stated ground meat was not thawed to prepare scheduled meal. S6Dietary Supervisor switched the menu from Saturday, November 11, 2023 to Wednesday, November 15, 2023 menu.
In an interview on 11/16/2023 at 10:45 a.m., S1Administrator stated she allowed the staff to serve residents on paper plates with plastic silverware when they only have two dietary staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on record review, interviews, and observations, the facility failed to ensure:
1. Opened food items were not sealed, labeled, and dated;
2. Scoops were not stored inside the dry goods storage b...
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Based on record review, interviews, and observations, the facility failed to ensure:
1. Opened food items were not sealed, labeled, and dated;
2. Scoops were not stored inside the dry goods storage bins; and
3. Proper use and testing of the three compartment sink.
Review of the facility's policy entitled Food Label/Dating/Storage dated 08/15/2018 revealed, in part, it is the facility policy to ensure proper food labeling, dating, and storage. Further review revealed staff will ensure all canned items and dry goods must be dated upon receipt, and all opened items that cannot be adequately sealed in a container must be stored in plastic sealable bags or containers and labeled/dated.
1.
Observation on 11/14/2023 at 10:40 a.m. of the facility's dry storage area revealed, in part, one bag of dehydrated sliced potatoes, one bag of egg noodles, and one box of brown sugar open to air, not labeled or dated, and were available for resident consumption.
Observation on 11/14/2023 at 10:45 a.m. of the facility's walk in cooler revealed, in part, one bag of shredded mild cheddar cheese, one package of slice cheddar cheese, one block of pasteurized sliced cheese opened to air, not labeled or dated, and were available for resident consumption.
In an interview on 11/14/2023 at 10:40 a.m., S39Dietary Aide stated all of the above mentioned food items should been sealed, labeled, and dated.
Observation on 11/14/2023 at 11:00 a.m. of the facility's single freezer revealed, in part, a disposable cup that contained a frozen purple colored liquid with a green powdery substance on top opened to air and not labeled or dated.
In an interview on 11/14/2023 at 11:00 a.m., S6Dietary Supervisor acknowledged all opened food items should have been sealed, labeled, and dated. S6Dietary Supervisor further stated the cup of purple colored frozen liquid with a powdery green substance should not have been in the single freezer.
2.
Observation of dry storage room on 11/14/2023 at 10:40 a.m. revealed, in part, a scoop was stored in the flour and the rice storage bins.
In an interview on 11/14/2023 at 10:49 a.m., S39Dietary Aide stated the scoops should not have been stored inside the flour and the rice storage bins.
In an interview on 11/14/2023 at 11:00 a.m., S6Dietary Supervisor stated the scoops should not have been in stored inside the flour and the rice storage bins.
3.
Observation on 11/14/2023 at 10:35 a.m. revealed, in part, raw chicken legs and breast, submerged in water inside the sanitization sink of the three compartment sink.
In an interview on 11/14/2023 at 11:00 a.m., S6Dietary Supervisor acknowledged the raw chicken should not have been prepared in the sanitization sink.
Observation on 11/15/2023 at 1:20 p.m. S39Dietary Aide used test strips with an expiration date of May 2023 to test the sanitization level of the three compartment sink
In an interview on 11/15/2023 at 2:40 p.m., S6Dietary Supervisor confirmed the test strips were expired and should not have been used to test the sanitization level of the three compartment sink.
Interview on 11/15/2023 at 4:05 p.m., S1Administrator stated the expired test strips should not have been used to check the sanitizer solution in the three compartment sink. S1Administrator stated opened food items should have been sealed, labeled, and dated and should not have been available for resident consumption. S1Administrator also stated raw chicken should not have been prepared in the sanitizing sink.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to:
1. Ensure staff performed hand hygiene during dining for 6 (S20Certified Nursing Assistant (CNA), S21Licensed Practical Nurse (LPN), S22CNA, ...
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Based on observation and interview the facility failed to:
1. Ensure staff performed hand hygiene during dining for 6 (S20Certified Nursing Assistant (CNA), S21Licensed Practical Nurse (LPN), S22CNA, S23CNA, S24CNA, and S38CNA) of 6 staff observed during dining; and
2. Ensure staff performed hand hygiene during and after incontinence care for 2 (Resident #60 and Resident #69) of 3 (Resident #21, Resident #60, and Resident #69) residents observed for incontinence care.
Findings:
Review of the facility's Handwashing/Hand Hygiene policy revealed, in part, staff must perform hand hygiene before and after direct resident contact, before and after handling food, before and after assisting a resident with meals, before and after assisting a resident with toileting, and after removing gloves.
Review of the facility's Perineal Care policy revealed, in part, after Perineal Care (the washing of the genital and rectal areas of the body) is completed, staff should remove gloves and perform hand hygiene before replacing incontinence items, replacing clothing, repositioning the resident, or making the resident comfortable.
1.
Observation on 11/13/23 at 12:09 p.m. revealed S23CNA moved Resident #60's used cup by grabbing it by the rim, and then went into a drawer to grab a condiment for another resident without performing hand hygiene. Further observation revealed 23CNA entered Resident #72's room to deliver a lunch tray, pulled Resident #72's privacy curtain for the bed, exited Resident #60's room, and poured a cup of orange liquid out of a communal pitcher without performing hand hygiene.
Observation on 11/13/2023 at 12:19 p.m. revealed S20CNA passed a meal tray to Resident #24 while wearing gloves and then assisted Resident #75 with opening a pudding without changing gloves or performing hand hygiene.
Observation on 11/13/2023 at 12:30 p.m. revealed S20CNA entered the dining room wearing gloves, Resident #30 asked her for ice. S20CNA obtained a cup, walked out of the dining room, opened the ice chest, obtained the ice scoop and scooped ice into the cup, then handed the cup to Resident #30.
Observation on 11/14/2023 at 8:56 a.m. revealed S22CNA passed a breakfast tray to Resident #75, then moved Resident #24's wheelchair and locked brakes, then removed gloves, and did not perform hand hygiene. Further observation revealed, S22CNA moved the drink cart, poured a cup of water, and delivered it to Resident #16 without performing hand hygiene.
Observation on 11/14/2023 at 8:58 a.m. revealed S38CNA removed gloves, did not perform hand hygiene, applied clean gloves, poured 2 cups of juice, and carried both cups by the rim to Resident #14.
Observation on 11/14/2023 at 12:04 p.m. revealed S24CNA applied gloves without performing hand hygiene, poured lemonade in cup, carried cup by the rim to Resident #30.
Observation on 11/14/2023 at 12:30 p.m. revealed S22CNA removed gloves from her right pocket and applied gloves without performing hand hygiene. Further observation revealed S22CNA moved Resident #33's wheelchair then removed bread and utensils from package for Resident #33 without performing hand hygiene.
Observation on 11/14/2023 at 12:31 p.m. revealed S24CNA removed gloves from her pocket and applied gloves without performing hand hygiene, repositioned Resident #203's wheelchair, then cut up chicken for Resident #203 without performing hand hygiene.
Observation on 11/14/2023 at 12:33 p.m. revealed S21LPN removed gloves, applied clean gloves without performing hand hygiene, then delivered lunch tray to Resident #16.
Observation on 11/14/2023 at 12:36 p.m. revealed S38CNA was sitting at the table with Resident #24, applied gloves without performing hand hygiene, and then fed Resident #24.
In an interview on 11/14/2023 at 2:08 p.m., S24CNA stated gloves should be changed after serving every table and hand hygiene should be performed before applying gloves and after removing gloves.
In an interview on 11/14/2023 at 2:15 p.m., S23CNA stated she should have performed hand hygiene when she touched Resident #60's used cup or Resident #72's privacy curtain before touching the items for other residents.
In an interview on 11/15/2023 at 1:00 p.m., S2 Director of Nursing/ Infection Preventionist stated she did not know when hand hygiene should be performed.
In an interview on 11/15/2023 at 1:05 p.m., S42Registered Nurse (RN) stated hand hygiene should be performed before applying gloves, before passing a meal tray, after touching food, after removing gloves, after touching a resident or a resident's equipment. S42RN stated it was not appropriate for staff to apply gloves without performing hand hygiene.
2.
Resident #60
Observation on 11/15/2023 at 11:10 a.m. revealed S7CNA performed incontinence care on Resident #60. Further observation revealed, after wiping urine from Resident #60's groin, S7CNA placed a new diaper under Resident #60s buttock and did not change her gloves or perform hand hygiene. S7CNA then applied barrier cream to Resident #60's groin and buttocks and then fastened Resident #60's diaper without changing gloves and performing hand hygiene. S7CNA continued to assist Resident #60 with dressing and then pulled up Resident #60's blanket, adjusted Resident #60's pillow, and used Resident #60's bed remote to adjust the head the bed without removing her gloves or performing hand hygiene.
In an interview on 11/15/2023 at 4:00 p.m., S7CNA stated she should have removed gloves and performed hand hygiene after performing incontinence care but before touching Resident #60's clothes, blanket, pillow, and bed remote.
In an interview on 11/15/2023 at 4:04 p.m., S3Assistant Director of Nursing stated S7CNA should have removed gloves and performed hand hygiene after performing incontinence care but before touching Resident #60's clothes, blanket, pillow, and bed remote.
In an interview on 11/15/2023 at 4:30 p.m., S2Director of Nursing/Infection Preventionist stated the CNA should have removed gloves and performed hand hygiene after performing incontinence care but before touching Resident #60's clothes, blanket, pillow, and bed remote
In an interview on 11/16/2023 at 10:36 a.m., S1Administrator stated the CNA should have removed gloves and performed hand hygiene after performing incontinence care but before touching Resident #60's clothes, blanket, pillow, and bed remote.
Resident #69
Observation on 11/15/2023 at 1:20 p.m. revealed S13CNA removed gloves after she provided Resident #69 with incontinent care and went to the clean cart and obtained more gloves. Observation further revealed S13CNA put gloves into her pocket and placed on a new pair of gloves without having performed hand hygiene.
Observation on 11/15/2023 at 1:28 p.m. revealed S13CNA assisted Resident #69 to the wheelchair and then placed on a new pair of gloves. Observation then revealed S13CNA removed dirty linen from the bed and placed the dirty linen in the hamper. Further observation revealed S13CNA applied on a new pair of gloves without having performed hand hygiene. Observation then revealed S13CNA grabbed clean linen and began to make Resident #69's bed.
In an interview on 11/15/2023 at 1:36 p.m., S13CNA confirmed she did not perform hand hygiene at the above mentioned times. S13CNA stated she should have performed hand hygiene after removing old gloves and prior to placing on new gloves.
In an interview on 11/16/2023 at 9:33 a.m. S3Assistant Director of Nursing stated hand hygiene should have been performed after gloves were removed.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure that medication orders were verified and accurately documented for 2 residents (Resident #1 and Random Resident #4) of 9 sampled r...
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Based on interviews and record reviews, the facility failed to ensure that medication orders were verified and accurately documented for 2 residents (Resident #1 and Random Resident #4) of 9 sampled residents.
Findings:
Resident #1
Review of Resident #1's Physician's Consultation report dated 06/28/2023 revealed, in part: Apply Bactroban to prevent infection.
Review of Resident #1's June 2023 Physician's order revealed, in part, no order was transcribed for Bactroban.
Review of Resident #1's June 2023 electronic Medical Administration Record (eMAR) revealed, in part, no documentation of administration of Bactroban.
In an interview on 08/01/2023 at 03:53 p.m., S1DirectorofNursing (DON) stated the order dated 06/28/2023 to apply Bactroban (Mupirocin) to prevent infection was not clear.
In an interview on 08/01/2023 at 03:54 p.m., S1DON acknowledged that an order is not clear if dosage, frequency, and administration of the medication or if the medication is a new order or there is a change in an order is not written.
Review of Resident #1's June 2023 eMAR revealed documentation of administration of Tobradex eye drops (2 drops) in both eyes four times a day (QID) for 5 days was administered on 06/04/2023 at 10:00 a.m., 4:00 p.m., and 10:00 p.m.; on 06/05/2023 at 04:00 a.m., and 10:00 p.m.
Review of Resident #1's Clinical record revealed, in part, no order for Tobradex (Tobramycin/Dexamethasone) eye drops.
Random Resident #4
Review of Random Resident #4's Physician's telephone order dated 06/03/2023 revealed, in part, Tobradex ophthalmic 2 drops four times a day (QID) in both eyes x 5 days.
Review of Random Resident #4's June 2023 eMAR revealed, in part, Tobradex eye drops (2 drops) in both eyes QID x 5 days was ordered and started on 06/06/2023 at 10:00 a.m.
In an interview on 08/02/2023 at 12:27 p.m., S2RegisteredNurse (RN) acknowledged that the order dated 06/03/2023 for Tobradex eye drops (2 drops) in both eyes (QID) x 5 days was put on Resident #1's eMAR instead of Random Resident #4's eMAR.
In an interview on 08/02/2023 at 01:42 p.m., S1DON stated she just found out today (08/02/2023) about the Tobramycin medication order that was transcribed to Resident #1's medication administration record (MAR) instead of Random Resident #4's MAR.
May 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to:
1. Protect a resident from physical abuse for 1 (Resident #1) of 5...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to:
1. Protect a resident from physical abuse for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents; and,
2. Protect a resident from sexual abuse (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.
This deficient practice resulted in an actual harm for Resident #1 when Resident #2 pushed Resident #1 out of Resident #1's wheelchair and to the floor. Resident #1 required emergency medical evaluation at the hospital which revealed a fracture to Resident #1's proximal femur (bone in the upper leg). Resident #1 was subsequently hospitalized and received surgical intervention to repair the fractured femur on 07/12/2022. Once readmitted to the facility on [DATE], Resident #1 required physical therapy and the administration of pain medication due to pain.
Based on this complaint investigation, abuse was identified to have occurred on 07/11/2022 and on 04/25/2023. The incident on 7/11/2022 resulted in an actual harm for Resident #1.
After the incident on 7/11/2022, there were no subsequent incidents of abuse involving Resident #2 due to having a decline in her condition upon her return to the facility.
The incident on 04/25/2023 resulted in no actual harm with potential for more than minimum harm for Resident #4.
Findings:
Review of the facility's Abuse/Neglect policy dated 01/04/2022 revealed, in part, the purpose of the policy was to ensure the safety and wellbeing of residents was maintained at all times. Review revealed sexual abuse included sexual assault and physical abuse included hitting, slapping, pinching, kicking and other means used to cause physical injury to a resident.
1.
Review of Resident #1's record revealed, in part, Resident #1 was admitted to the Alzheimer's Unit on 10/07/2021 with diagnoses, in part, dementia with behavioral disturbances and altered mental status.
Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/2022 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment.
Review of Resident #2's record revealed, in part, Resident #2 was admitted to the Alzheimer's Unit on 02/20/2022 with diagnoses of, in part, Major Depressive Disorder, Alzheimer's and Bipolar Disorder.
Review of Resident #2's Quarterly MDS with an ARD of 06/23/2022 revealed a BIMS score of 3, which indicated severe cognitive impairment.
Review of Resident #2's Care Plan dated 02/28/2022 revealed Resident #2 had combative behaviors related to cognitive impairment with interventions which included remove resident from the area when behavior was disruptive and approach resident warmly and positively.
Review of the facility's incident and accident log revealed, in part, Resident #1 was found on the floor on 07/11/2022. Further review revealed Resident #1's disposition was documented as Emergency Room.
Review of Resident #1's nurse's notes dated 07/11/2022 at 4:06 p.m. revealed, in part, at 3:45 p.m. a certified nursing assistant (CNA) informed her that Resident #1 was on the floor, lying on her left side. Further review revealed Resident #1 was not able to extend her left leg, and Resident #1 yelled when her left leg was touched. Review also revealed Resident #1's physician was notified, and the physician ordered to send Resident #1 to the emergency room for evaluation. Review of Resident #1's note addendum created on 07/11/2022 at 4:24 p.m. revealed Resident #1's incident occurred due to Resident #1 being pushed down to the floor by another resident.
Review of Resident #2's nurse's note dated 07/11/2022 at 4:29 p.m. revealed, in part, at 3:45 p.m., Resident #2 pushed Resident #1 from her chair to the floor.
Review of Resident #1's medical records revealed, in part, Resident #1 was admitted to the hospital on [DATE] after Resident #1 was pushed out of her wheelchair by another resident. Further review revealed Resident #1's pelvic x-ray obtained on 07/11/2022 revealed a fracture of Resident #1's proximal left femur. Review also revealed Resident #1 required surgical repair of her femur fracture on 07/12/2022.
In an interview on 05/09/2023 at 9:57 a.m., S4Licensed Practical Nurse (LPN) stated she was informed on 07/11/2022 that Resident #2 pushed Resident #1 out of her wheelchair when Resident #1 entered Resident #2's room. S4LPN stated she had completed an assessment of Resident #1 following the fall which revealed Resident #1 had pain to her left leg. S4LPN stated Resident #1 was transferred to the emergency room.
In an interview on 05/09/2023 at 11:59 a.m., S5CNA stated she witnessed Resident #2 push Resident #1 to the floor on 07/11/2022.
In an interview on 05/10/2023 at 1:04 p.m., S1Administrator confirmed the incident between Resident #1 and Resident #2 was resident to resident physical abuse.
2.
Review of the facility's Statewide Incident Management System (SIMS) report revealed, in part, Resident #4 had an incident of sexual abuse that occurred on 04/25/2023.
Review of Resident #4's SIMS report revealed, in part, on 04/25/2023 at approximately 12:00 p.m., Resident #4's aunt notified S6Social Worker that Resident #4's roommate, Resident #3, had put his hands into Resident #4's pants and fondled him. Further review revealed S1Adminitrator wrote: Allegation of sexual abuse was substantiated. Resident #3 did not deny the allegation and confirmed that Resident #4 made him stop.
Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2023 revealed, in part, Resident #4 had a Brief Interview for Mental Status score of 13, which indicated he was cognitively intact.
Review of Resident #3's MDS with an ARD of 02/09/2023 revealed, in part, Resident #3 had a BIMS of 13, which indicated he was cognitively intact.
Review of Resident #3's Care Plan revealed, in part, Resident #3's was care planned for inappropriate sexual behavior on 04/25/2023, the same date he sexually abused his roommate.
In an interview on 05/10/2023 at 8:43 a.m., Resident #4 stated on 04/25/2023 Resident #3 came to his bed and touched his penis while he was sleeping.
In an interview on 05/10/2023 at 9:10 a.m., S6Social Worker stated Resident #3 admitted he touched Resident #4 on his genitals on 04/25/2023.
In an interview on 05/08/2023 at 10:58 a.m., S1Administrator stated she investigated the report of sexual abuse on 04/25/2023 that Resident #3 committed against Resident #4 and it was substantiated.
Dec 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on record reviews and interview, the facility failed to complete an admission assessment within 14 calendar days after admission for 1 (Resident #361) of 21 residents reviewed. This deficient pr...
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Based on record reviews and interview, the facility failed to complete an admission assessment within 14 calendar days after admission for 1 (Resident #361) of 21 residents reviewed. This deficient practice had the potential to affect any of the 105 residents who reside in the facility as per the facility's Resident Census and Conditions of Residents Form (CMS- Form 672).
Findings:
Review of Resident #361's record revealed an admission date of 11/16/2022.
Review of Resident #361's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/23/2022 revealed Section H- Bladder and Bowel was not completed, Section I- Active Diagnoses was not completed and Section M - Skin Conditions was not completed. Further review of the MDS revealed
Section Z, signature of Registered Nurse Assessment Coordinator, was not completed.
In an interview on 12/08/2022 at 3:25pm, S3 Licensed Practical Nurse / MDS Coordinator confirmed the MDS for Resident #361 was not completed. S3LPN/MDS Coordinator stated there are multiple MDS assessments not completed due to increased workload and the inability to keep up the work.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform hand hygiene after removing gloves and provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform hand hygiene after removing gloves and provide wound care by failing to follow the Infection Control guidelines by performing hand hygiene procedures with resident contact for 1 Resident (#58) of 7 residents reviewed for pressure ulcers. This deficient practice had the potential to affect all 103 residents who reside in the facility according to the Resident Census and Conditions Form (CMS 672).
Findings:
Review of the facility's policy and procedure titled, Infection Control Guidelines for all Nursing Procedures revealed the following:
General Guidelines:
3. Employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions.
a. Before and after contact with residents.
b. When hands are visibly soiled with blood or other body fluids.
c. After contact with blood, body fluids, secretions, mucus membranes, or non-intact skin.
d. After handling items potentially contaminated with blood, body fluids, or secretions.
5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials.
Review of the facility's policy and procedure titled Dressing Dry/Clean revealed the following in part:
Steps in procedure:
16. Clean from the least contaminated area to the most contaminated area.
Review of the clinical record revealed Resident # 58 was admitted to the facility on [DATE] with diagnoses in part; Left below the knee amputation and Type 2 Diabetes Mellitus.
Review of the December/2022 Physician's Orders revealed the following:
Left below the knee surgical wound: clean with normal saline, pat dry, lightly pack with foam dressing and cover with appropriate dressing every Monday, Wednesday, Friday, and as needed.
In an observation on 12/7/2022 at 10:05a.m, S7Assistant Director of Nursing (S7ADON)performed wound care to Resident #58's left below the knee surgical wound. Further observation revealed S7ADON removed the soiled dressing from Resident #58's wound. Further observation revealed S7ADON removed soiled gloves and applied another pair of gloves without washing her hands.
In an observation on 12/7/2022 at 10:05a.m., revealed S7ADON cleaned Resident #58's surgical wound from the most contaminated area to the least contaminated area.
In an interview on 12/7/2022 at 10:30a.m., S7ADON stated she did not perform hand hygiene before placing gloves on after removing soiled dressing for Resident #58's wound. S7ADON acknowledged that she should have performed hand hygiene before applying new gloves to clean the wound.
In an interview on 12/8/2022 at 9:29a.m., S2 Director of Nursing was informed that S7ADON was observed performing wound care on a resident without performing hand hygiene after removing gloves. S2 Director of Nursing acknowledged that hand hygiene should have been performed by S7ADON after removing gloves.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to complete Minimum Data Set (MDS) Quarterly Assessments at least every three months for 13 of 13 residents reviewed (Resident# 1, #3, #10, ...
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Based on record reviews and interviews, the facility failed to complete Minimum Data Set (MDS) Quarterly Assessments at least every three months for 13 of 13 residents reviewed (Resident# 1, #3, #10, #24 #28, #30, #42, #46, #53, #77, #85, #89, and #90). The deficient practice had the potential to affect any of the 105 residents who reside in the facility.
Findings:
Review of the following records (Resident #1, #10, #28, #77, #89 - ARD date of 10/6/22), (Resident #3 -ARD date 10/26/22), (Resident #24, #42, #85 -ARD date of 10/19/22), ( Resident #30, 90 - ARD date 10/20/22), (Resident #46-ARD Date of 10/27/22), ( Resident #53- ARD date 10/13/22) revealed no documented evidence of MDS quarterly assessments were completed.
In an interview on 12/7/2022 at 3:20 P.M. with S11LPN stated she is responsible for completing MDS assessments, and stated she got behind due to doing other duties and was aware the MDS assessments were not completed timely.
In an interview on 12/7/2022 at 3:23pm with S3LPN stated she is responsible for completing MDS Assessments, and stated due to increase workload, she got behind with the MDS assessments. MDS Assessments were not completed timely.
In an interview on 12/7/2022 at 3:45 P.M. with S12RN acknowledged that Resident #1, #3, #10, #24, #28, #30, #42, #46, #53, #77, #85, #89, and #90 MDS assessment were not completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observations, record reviews and interviews, the facility failed to maintain accurate records of controlled medication dispensing for 5 (Resident #1, #44, #54, #60 and #93) residents who rece...
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Based on observations, record reviews and interviews, the facility failed to maintain accurate records of controlled medication dispensing for 5 (Resident #1, #44, #54, #60 and #93) residents who received controlled medications. This deficient practice had the potential to affect any of the 105 residents who reside in the facility as per the facility's Resident Census and Conditions of Residents Form (CMS- Form 672).
Findings:
On 12/08/2022 at 1:50pm a reconciliation was completed of controlled substances on Medication Cart D1 and the controlled substance binder for Medication Cart D1 and revealed the following:
Resident #1's medication card for Norco 5-325 had 26 pills and the individual narcotic record count was 27;
Resident #44's medication card for Ultram 50mg had 11 pills and the individual narcotic record count was 13; and
Resident #54's medication card for Endocet 10/325 had 25 pills and the individual narcotic record count was 26.
In an interview on 12/08/2022 at 1:59pm, S4Licensed Practical Nurse (LPN) stated she failed to sign out the medication on the individual narcotic record when it was administered and confirmed the medication cards and the records did not match.
On 12/08/2022 at 2:30pm a reconciliation was completed of controlled substances on Medication Cart D2 and the controlled substance binder for Medication Cart D2and revealed the following:
Resident #60's medication card for Pregarablin 300mg had 59 pills and the individual narcotic record count was 60; and
Resident #93's Xanax 0.5mg had 85 pills and the individual narcotic record count was 88.
In an interview on 12/08/2022 at 2:39pm, S5LPN confirmed the medication count and the number on the individual narcotic record were not the same.
In an interview on 12/08/2022 at 4:30pm, S2 Director of Nursing stated the numbers of pills on the medication card and the number on the individual narcotic sheet should be the same.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure expired medications were not available for administration to residents and failed to properly store controlled drugs. This deficient...
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Based on observations and interviews, the facility failed to ensure expired medications were not available for administration to residents and failed to properly store controlled drugs. This deficient practice had the potential to affect any of the 105 residents who resided in the facility as documented on the facility's Resident Census and Condition of Residents Form CMS-672.
Findings:
Observation on 12/08/2022 at 1:27pm of Medication Room a revealed the following:
A box of 50 adhesive remover wipes with an expiration date of 02/20/2022;
24 packs of Providone Iodine Swabsticks 10% Povidone Iodine with an expiration date of 06/22/2022,
22 packs with an expiration date of 11/22/2022 and 1 pack with an expiration date of 02/22/2022;
5 bottles of Stomahesive Protective Powder with expirations dates of 09/01/2021, 10/01/2022, 11/01/2021, 06/01/2022 and 10/01/2022.
Observation on 12/08/2022 at 1:30pm of the medication refrigerator in Medication Room a revealed the following:
Hepatitis B Vaccine with an expiration date of 08/12/2022.
In an interview on 12/08/2022 at 1:27pm, S4 Licensed Practical Nurse (LPN) stated the nurses are responsible to ensure there are no expired medications available for resident use and confirmed the above documented biologicals were expired.
Observation on 12/08/2022 at 2:11pm of Medication Cart b revealed the following:
A bottle of Famotidine Tablets 10milligrams (mg) with an expiration date of 08/22/2022;
A bottle of B1 100mg tablets with an expiration date of 11/2022;
Meclizine 12.5mg with an expiration date of 07/2022; and
Vitamin D 10micrograms (mg) with an expiration date of 05/2022.
In an interview on 12/08/2022 at 2:12pm, S8 Licensed Practical Nurse (LPN) stated nurses should remove expired medications from the cart and confirmed the above documented medications were expired.
Observation on 12/08/2022 at 2:23pm of the Treatment Cart revealed the following:
7 MPM Excel Silicone Superabsorbent Dressings with an expiration date of 11/26/2020 and 15 Silicone Super-Absorbent Dressings with an expiration date of 04/26/2022.
In an interview on 12/08/2022 at 4:27pm, S2 Director of Nursing (DON) stated no one person in particular was responsible to ensure the carts did not have expired medications.
Observation on 12/08/2022 at 4:25pm revealed the door of S2DON's office was unlocked and open and no one was present in the office. S2DON arrived to her office and showed the surveyors a locked cabinet where Schedule II medications were maintained until destroyed.
In an interview on 12/08/2022 at 4:28pm, S2DON confirmed her office door was not closed and locked and confirmed it should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to serve food at an appetizing temperature. This deficient practice had the potential to affect any of the 105 residents who reside in the fac...
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Based on observations and interviews, the facility failed to serve food at an appetizing temperature. This deficient practice had the potential to affect any of the 105 residents who reside in the facility as per the facility's Resident Census and Conditions of Residents Form (CMS- Form 672).
Findings:
The Resident Council Meeting was held on 12/05/2022 at 3:30pm. During the Resident Council meeting Resident #8 and Resident #14 stated the food was served cold.
On 12/08/2022 at 11:30am, the survey team requested a food tray. The food tray contained a sloppy joe and baked beans . Three surveyors tasted the food and the food was noted to be lukewarm to room temperature.
On 12/08/2022 at 11:45am, S6 Dietary Supervisor and a surveyor obtained a pureed food tray from a hall cart and S6 Dietary Supervisor obtained a temperature of the sloppy joe and it was 93 degrees Fahrenheit and the baked beans were 96.5 degrees Fahrenheit.
In an interview on 12/08/2022 at 3:30pm, S6 Dietary Supervisor confirmed the food was not an appropriate temperature for consumption.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Deficiency Text Not Available
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Deficiency Text Not Available
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
Based on record reviews and interview, the facility failed to transmit Minimum Data Sets (MDS) Assessments timely for 10 of 10 residents reviewed (Resident # 16, #35, #37, #43, #45, #57, #71, #80, #81...
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Based on record reviews and interview, the facility failed to transmit Minimum Data Sets (MDS) Assessments timely for 10 of 10 residents reviewed (Resident # 16, #35, #37, #43, #45, #57, #71, #80, #81, and #94). This deficient practice had the potential to affect any of the 105 residents who reside in the facility as listed on the Resident Census and Conditions Form (CMS 672.
Findings:
Review of Resident #16's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #16.
Review of Resident #35's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #35.
Review of Resident #37's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #37.
Review of Resident #43's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #43.
Review of Resident #45's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #45.
Review of Resident #57's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #57.
Review of Resident #71's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #71.
Review of Resident #80's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #80.
Review of Resident #81's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #81.
Review of Resident #94's clinical record revealed the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted to the clinical record until 12/05/2022.
In an interview on 12/07/2022 at 3:45p.m., S12 RN acknowledged the MDS assessments dated 10/02/2022 through 10/27/2022 were not transmitted until 12/05/2022 for Resident #94.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • 39 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Riverbend, Inc's CMS Rating?
CMS assigns RIVERBEND NURSING AND REHABILITATION CENTER, INC 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 Riverbend, Inc Staffed?
CMS rates RIVERBEND NURSING AND REHABILITATION CENTER, INC's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 54%, compared to the Louisiana average of 46%.
What Have Inspectors Found at Riverbend, Inc?
State health inspectors documented 39 deficiencies at RIVERBEND NURSING AND REHABILITATION CENTER, INC during 2022 to 2025. These included: 1 that caused actual resident harm, 37 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Riverbend, Inc?
RIVERBEND NURSING AND REHABILITATION CENTER, INC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by INSPIRED HEALTHCARE MANAGEMENT, a chain that manages multiple nursing homes. With 120 certified beds and approximately 101 residents (about 84% occupancy), it is a mid-sized facility located in BELLE CHASSE, Louisiana.
How Does Riverbend, Inc Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, RIVERBEND NURSING AND REHABILITATION CENTER, INC's overall rating (2 stars) is below the state average of 2.4, staff turnover (54%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Riverbend, Inc?
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 Riverbend, Inc Safe?
Based on CMS inspection data, RIVERBEND NURSING AND REHABILITATION CENTER, INC 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 Riverbend, Inc Stick Around?
RIVERBEND NURSING AND REHABILITATION CENTER, INC has a staff turnover rate of 54%, which is 8 percentage points above the Louisiana average of 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 Riverbend, Inc Ever Fined?
RIVERBEND NURSING AND REHABILITATION CENTER, INC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Riverbend, Inc on Any Federal Watch List?
RIVERBEND NURSING AND REHABILITATION CENTER, INC 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.