HERITAGE MANOR HEALTH & REHAB
For profit - Limited Liability company
64 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
6/100
#205 of 264 in LA
Photo by Olayiwola O
Photo by Steven Coffey (Blur33)
Photo by Olayiwola O
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Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Heritage Manor Health & Rehab has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. It ranks #205 out of 264 facilities in Louisiana, placing it in the bottom half, and #8 out of 9 in Bossier County, meaning there is only one local option that is better. The overall trend is worsening, with issues increasing from 20 in 2024 to 32 in 2025. Staffing is rated poorly at 1 out of 5 stars, with a turnover rate of 55%, which is close to the state average but still concerning. Additionally, the facility has accumulated $73,487 in fines, indicating compliance problems more severe than 84% of other facilities in Louisiana. On a positive note, the facility provides better RN coverage than 81% of state facilities, which is crucial as RNs can identify issues that other staff might miss. However, specific incidents raise alarms about resident safety: for example, the HVAC system failed, leading to uncomfortable temperatures for multiple residents who appeared flushed and in distress. Furthermore, the facility failed to provide adequate staffing on multiple occasions, meaning residents' basic needs may not be met consistently. Overall, while there are some strengths, the significant weaknesses and issues at Heritage Manor suggest families should proceed with caution.
- Trust Score
- F
- In Louisiana
- #205/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $73,487 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 61 deficiencies on record. Higher than average. Multiple issues found across inspections.
6/100
Bottom 23%
Review needed
20 → 32 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 32 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $73,487
Well above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 61 deficiencies on record
2 life-threatening
Aug 2025
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and an interview, the facility failed to inform and provide written information to residents or resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and an interview, the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 1 (#37) of 2 (#2, #37) residents reviewed for advanced directives. Findings:Review of Resident #37's medical record revealed an initial admission date of 07/12/2023 and a re-entry admission on [DATE] with severe morbid obesity, type 2 diabetes mellitus, unspecified lack of coordination, generalized muscle weakness, pain in left shoulder, and unspecified osteoarthritis. Review of Resident #37's admission Packet revealed an Advance Directive Acknowledgment Form was signed by Resident #37. Further review revealed Resident #37's Advance Directive Acknowledgment Form was incomplete, with no options selected. During an interview on 08/06/2025 at 11:30 a.m. S4 Social Services confirmed Resident #37's Advance Directive Acknowledgment Form was not completed and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure 5 (#1, #6, #7, #8, and #49) of 5 (#1, #6, #7, #8, and #49) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure 5 (#1, #6, #7, #8, and #49) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medications were informed of the risks, benefits, and side effects of psychotropic medication, and allowed to choose the treatment option they preferred prior to the start of the medication. Findings:Resident #1 Review of Resident #1's record revealed an initial admission date of 01/17/2025 with a re-entry admission date of 02/17/2025 with the following diagnoses but not limited to generalized muscle weakness, lack of coordination, difficulty in walking, cognitive communication deficit, severe vascular dementia with agitation, uncomplicated stimulant abuse, and metabolic encephalopathy. Review of Resident #1's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 14 indicating intact cognition. Further review of Resident #1's MDS revealed Resident #1 received antipsychotic and antianxiety. Review of Resident #1's August 2025 Physician Orders revealed:-07/21/2025: Buspirone HCl (Hydrochloride) tablet 5 mg (milligram); Give 10 mg by mouth two times a day for anxiety give 2 tabs-05/29/2025: Clonazepam oral Tablet 1 mg; Give 1 tablet by mouth at bedtime for anxiety-03/04/2025: Donepezil HCl Tablet 10 mg; Give 1 tablet by mouth at bedtime for dementia-02/04/2025: Trileptal Oral Tablet 150 mg; Give 1 tablet by mouth two times a day for moodReview of Resident #1's July 2025 and August 2025 MAR (Medication Administration Records) revealed Resident #1 received Buspirone HCL, Clonazepam, Donepezil HCL, and Trileptal. Review of Resident #1's Chemical Restraint/Psychoactive Drug Consent signed by the resident on 01/17/2025 revealed the consent was incomplete and did not specify whether the resident did or did nor consent to the use of psychoactive medication. During an interview on 08/06/2025 at 10:30 a.m. S4 Social Services confirmed the Chemical Restraint/Psychoactive Drug Consent did not specify whether Resident #1 did or did not consent to the use of psychoactive medication, and it should.Resident #6Review of Resident #6's record revealed an initial admit date [DATE], readmission [DATE], and diagnoses including: unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, and bipolar disorder.Review of Resident #6's Significant Change MDS assessment dated [DATE] revealed the resident had a BIMS of 13 indicating intact cognition. Review of Resident #6's current physician orders revealed orders including: -07/15/2025-Sertraline Hydrochloride Tablet 100 mg (milligram) every evening for depression-05/02/2025-Quetiapine Fumarate Tablet 200mg give 0.5 tablet by mouth at bedtime for psychosis.Review of Resident #6's July 2025 and August 2025 MARs revealed the resident was receiving Sertraline Hydrochloride and Quetiapine Fumarate.Review of Resident #6's Chemical Restraint/Psychoactive Drug Consent signed by the resident 05/05/2025 revealed the consent was incomplete and did not specify whether the resident did or did not consent to the use of psychoactive medication. During an interview on 08/06/2025 at 1:03 p.m. S4 Social Services confirmed Resident #6's Chemical Restraint/Psychoactive Drug Consent did not specify whether the resident did or did not consent to the use of psychoactive medication, and it should.Resident #7 Review of Resident #7's medical record revealed an admission date of 12/09/2014 with diagnoses of, but not limited to, insomnia unspecified; major depressive disorder single episode unspecified; major depressive disorder recurrent unspecified; and bipolar disorder current episode, depressed, severe with psychotic features. Review of Resident #7's physician orders revealed the following orders:-01/27/2025 Risperidone oral tablet 1mg - give 1mg by mouth three times a day.-01/27/2025 Seroquel oral tablet 100mg - give 50mg by moth at bedtime.-01/28/2025 Cymbalta oral capsule delayed release particles 20mg - give 1 capsule by mouth one time a day.-01/27/2025 Temazepam oral capsule 30mg - give 1 capsule by mouth at bedtime. Review of Resident #7's July 2025 and August 2025 MAR revealed documentation of administration of Risperidone, Seroquel, Cymbalta, and Temazepam. Review of Resident #7's medical record failed to reveal consents for use of psychoactive medication therapy had been obtained. During an interview on 08/06/2025 at 3:20 p.m. S3 ADON (Assistance Director of Nursing) provided an incomplete form, with a signature on it, titled Chemical Restraint/Psychoactive Drug Consent with no medication, resident name, diagnosis, and no check indicating whether the resident consented for the use of psychoactive medication. S3 ADON further agreed the consent was incomplete, confirming Resident #7 did not give informed consent for the use of psychotropic medications. Resident #8 Review of Resident #8's record revealed an initial admission date of 03/14/2024, a readmission date of 08/14/2024, and diagnoses including: restlessness and agitation, paranoid schizophrenia, and major depressive disorder. Review of Resident #8's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12 indicating moderately impaired cognition. Review of Resident #8's current physician orders revealed orders including: -07/21/2025-Risperdal oral tablet 3 mg (Risperidone) give 6 mg orally one time a day for Paranoid schizophrenia-01/28/2025- Risperdal oral tablet 4 mg (Risperidone) give 1 tablet by mouth at bedtime-01/28/2025-trazodone hydrochloride 75 mg by mouth at bedtime-01/28/2025-mirtazapine 15mg by mouth at bedtime for major depressive disorderReview of Resident #8's July 2025 and August 2025 MARs revealed the resident was receiving Risperdal, Trazodone, and Mirtazapine. Review of Resident #8's Chemical Restraint/Psychoactive Drug Consent signed by the resident but not dated, revealed the consent was incomplete and did not specify whether the resident did or did not consent to the use of psychoactive medication. During an interview on 08/06/2025 at 1:03 p.m. S4 Social Services confirmed Resident #8's Chemical Restraint/Psychoactive Drug Consent did not specify whether the resident did or did not consent to the use of psychoactive medication, and it should. Resident #49Review of Resident #49's medical record revealed an initial admit date of 12/12/2023 and a re-admission date of 06/02/2025 with diagnoses of but not limited to schizoaffective disorder, bipolar disease, morbid obesity, type 2 diabetes, oglivie syndrome, megacolon, hypomagnesemia, essential hypertension, and functional quadriplegia. Review of Resident #49's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition.Review of Resident #49's August 2025 physician orders revealed an order for Clonazepam 1mg (milligram) by mouth two times a day for anxiety, Olanzapine 20mg one tablet by mouth at bed time for schizophrenia, and Mirtazapine 15mg by mouth at bedtime for depression. Review of Resident #49's August 2025 MAR revealed documentation of the administration of clonazepam, olanzapine and mirtazapine as ordered. Review of Resident #49's medical record failed to reveal any documentation of Resident #49 or Resident #49's representative was informed of the risks, benefits, and side effects of clonazepam, olanzapine, and mirtazapine prior to starting the medication. During an interview on 08/06/2025 at 3:30 p.m., S3 ADON (Assistant Director of Nurses) confirmed Resident #49 was not informed of the risks, benefits and side effects of clonazepam, olanzapine, and mirtazapine prior to starting the medications and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on record review, observations, and interviews, the facility failed to ensure residents received services with reasonable accommodation of resident needs. The facility failed to ensure:1. Reside...
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Based on record review, observations, and interviews, the facility failed to ensure residents received services with reasonable accommodation of resident needs. The facility failed to ensure:1. Resident #54's call light functioned properly and Resident #54's calls for assistance were answered in a timely manner.2. The emergency call light in the hall bathroom between room A and room B had a pull cord in place.
Findings:
1.
Review of Resident #54’s medical record revealed an admit date of 07/31/2025 with a diagnoses of but not limited to spondylosis without myelopathy or radiculopathy lumbosacral region, scoliosis, unspecified and type 2 diabetes.
Review of Resident #54’s Quarterly MDS (Minimum Data Set) dated 07/09/2025 revealed Resident #54 was assessed to have a BIMS (Brief Interview Mental Status) score of 13 indicating intact cognition.
Review of Resident #54’s comprehensive plan of care revealed a problem of: the resident has an ADL (activities of daily living) self-performance deficit with interventions of total dependence with one person assistance for toilet use, total dependence with two person assistance with transfers and encourage resident to use call light to call for assistance.
During an interview on 08/04/2024 at 8:33 a.m., Resident #54 stated, “When I call for help they take a long time to come because my call light does not work, the light does not come on outside of the door.”
Observation on 08/04/2024 at 8:34 a.m. revealed when Resident #54 punched his call light, the light on the outside of Resident #54's door did not light up and no one answered the call light.
Observation on 08/04/2025 at 11:35 a.m. revealed no one was sitting at the nurse’s station. Further observation revealed Resident #54’s room lit up on call system board. An audible buzzing continued unanswered for 15 minutes. Further observation revealed the light outside of Resident #54's door did not lit up to indicate Resident #54 was calling for assistance. Observation also revealed facility staff standing on the hallway not responding to Resident #54's call for assistance.
During an interview on 08/04/2025 at 11:45 a.m. S5Medical Records reported the facility did not have a unit clerk or a ward clerk to answer the call system and the CNA’s (certified nursing assistants) would observe the lights outside of the door and assist residents when they call.
During an interview on 08/04/2025 at 12:00 p.m. S9Maintenance reported he had not been made aware of Resident #54’s call light not working until this morning after the survey had begun.
During an interview on 08/04/2025 at 3:00 p.m. S2DON (Director of Nurses) confirmed Resident #54’s call light was not functioning, and Resident #54’s needs were not accommodated and should have been.
2.
Observation on 08/05/2025 at 11:30 a.m. revealed the bathroom between Room A and Room B, which had 2 entries from the hallway did not emergency call light cord in place.
During an interview on 08/05/2025 at 1:55 p.m. S11LPN (Licensed Practical Nurse) observed the bathroom between Room A and Room B and confirmed there was no emergency call light cord and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure residents who received psychotropic drugs were free from unnecessary drugs for 1 (#7) of 5 (#1, #6, #7, #8, and #49) residents rev...
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Based on record reviews and interviews, the facility failed to ensure residents who received psychotropic drugs were free from unnecessary drugs for 1 (#7) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medication. The facility failed to ensure:1. Pharmacy GDR (gradual dose reduction) requests were conducted and communicated to the physician for consideration.2. Psych NP (Nurse Practitioner) recommendation was communicated to the physician for consideration. Findings: Review of Resident #7's medical record revealed an initial admission date of 12/09/2014 with diagnoses that included, in part, insomnia unspecified; major depressive disorder single episode unspecified; major depressive disorder recurrent unspecified; bipolar disorder current episode, depressed, severe with psychotic features; and anxiety disorder unspecified. Review of Resident #7's 06/18/2025 Quarterly MDS (minimum data set) assessment revealed Resident #7 had a BIMS (Brief Interview Mental Status) score of 11, which indicated moderate cognitive impairment. Review of Resident #7's physician orders revealed the following orders, in part:-01/27/2025 Risperidone oral tablet 1mg (milligram) - give 1mg by mouth three times a day.-01/27/2025 Seroquel oral tablet 100mg (Quietiapine Fumarate) - give 50mg by mouth at bedtime.-01/28/2025 Cymbalta oral capsule delayed release particles 20mg (Duloxetine Hydrochloride) - give 1 capsule by mouth one time a day.-01/27/2025 Temazepam oral capsule 30mg - give 1 capsule by mouth at bedtime. Further review of Resident #7's physician orders revealed Resident #7 had physician orders for Risperidone, Seroquel, Cymbalta and Temazepam prior to 01/27/2025. 1.Review of Resident #7's medical record failed to reveal any pharmacy GDR (gradual dose reductions) requests had been addressed by the physician for Risperidone 1mg TID (three times a day), Seroquel 50mg at bedtime, Cymbalta 20mg daily, or Temazepam 30mg at bedtime. During an interview on 08/07/2025 at 12:15 p.m. S2 DON (Director of Nursing) and S3 ADON (Assistant Director of Nursing) reported they had reviewed documents and no pharmacy GDRs were found for Resident #7's Risperidal, Cymbalta, Seroquel or Temazepam for the last year. 2.Review of 06/20/2025 and 07/11/2025 Psych NP progress notes revealed recommendations to decrease Resident #7's Risperdal to 1mg by mouth BID (twice a day). During an interview on 08/05/2025 at 3:55 p.m. S2 DON reviewed Resident #7's Psych NP progress notes and confirmed they included recommendations to decrease the Risperdal 1mg to BID. S2 DON further reviewed Resident #7's medical record and reported there was no evidence Resident #7's physician had been notified of the recommendation or a physician response to the recommendation had been received. During an interview on 08/05/2025 at 4:10 p.m. S3 ADON confirmed there was no documented evidence that the Psych NP recommendations were sent to Resident #7's physician and did not know if the physician had responded to the recommendation.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide to the resident and/or resident representative written no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide to the resident and/or resident representative written notice which specified the reason for transfer, effective date, location, statement of the resident's appeal rights, and duration of the bed hold policy and failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 4 (#2, #56, #58, #62) of 4 (#2, #56, #58, #62) sampled residents reviewed for discharge and transfer requirements.Findings:Review of the facility's Bed-Hold Policy (undated) revealed in part: Purpose: Ensure that residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility.Procedure1. The facility has a bed-hold policy and readmission policy that outlines the terms and conditions for holding a bed if the resident is transferred out of the facility for any reason. 2. The facility will notify the resident at the time of admission and again prior to a hospital transfer or therapeutic leave of its bed-hold and return policies. 3. Before any transfer, advance notice of the policy is given, usually at the time of admission and also included in the admission packet. Reissuance of the first notice is not required unless the facility's policy changes. 4. The bed-hold notice specifies: a. The duration of the bed-hold policy under the state plan, if any, during which the resident is permitted to return and resume residence in the nursing facility. b. The nursing facility's policies regarding bed-hold periods permitting a resident to return. c. In cases of emergency transfer, notice at the time of transfer means that the resident, family, or representative is provided with written notification within twenty-four (24) hours of the transfer. d. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital.Resident #2 Review of Resident #2's MDS (Minimum Data Set) assessments revealed the resident was discharged to a short-term general hospital on [DATE] and to an inpatient psychiatric facility on 06/05/2025. Review of Resident #2's medical record failed to reveal documentation a written notice of transfer which specified the reason for transfer, effective date, location and statement of the resident's appeal rights, and duration of the bed hold policy when he was transferred to the hospital on [DATE] and 06/05/2025. Resident # 56Review of Resident #56's MDS assessments revealed a discharge on [DATE] and 07/27/2025. Review of Resident #56's medical record failed to reveal documentation a written notice of transfer which specified the reason for transfer, effective date, location and statement of the resident's appeal rights, and duration of the bed hold policy when he was transferred to the hospital on [DATE] and 07/27/2025. Resident # 58Review of Resident #58's medical record revealed a discharge on [DATE] after Resident #58 signed a Release of Responsibility for Discharge AMA (Against Medical Advice) form on 07/18/2025. Resident # 62Review of Resident #62's Discharge MDS dated [DATE] revealed an unplanned discharge to a short term general hospital with a return anticipated. Review of Resident #62's medical record failed to reveal documentation a written notice of transfer which specified the reason for transfer, effective date, location and statement of the resident's appeal rights, and duration of the bed hold policy when he was transferred to the hospital on [DATE]. During an interview on 08/05/2025 at 3:56 p.m. S5 Medical Records reported she did not know who was responsible for providing residents or resident representatives a written notice of transfer including the bed hold policy but maybe the MDS nurse did. During an interview on 08/05/2025 at 3:58 p.m. S6 MDS/Care Plan Nurse reported the nurses sending a resident out to the hospital printed the Transfer/Discharge report and sent it with the resident, but she did not think it contained any information about the bed hold policy. During an interview on 08/05/2025 at 4:10 p.m. S7 LPN (Licensed Practical Nurse) confirmed the nurses sending a resident out to the hospital printed the Transfer/Discharge report and sent it with the resident, but she did not think it contained any information about the bed hold policy. During an interview on 08/05/2025 at 4:14 p.m. S2 DON (Director of Nursing) the Transfer/Discharge report that was printed from the electronic health record and sent with residents on transfer to the hospital did not include the reason for transfer, effective date, location of transfer, that information was relayed to the responsible parties by telephone call. S2 DON further confirmed the Transfer/Discharge report did not include a statement of the resident's appeal rights and duration of the bed hold policy, and did not know it was required. S2 DON further reported the Ombudsman's office was not notified of any residents who had been transferred or discharged , and she did not know they should be. During an interview on 08/05/2025 at 4:32 p.m. S1 Administrator confirmed the Ombudsman's office was not notified of any residents who had been transferred or discharged , and she did not know they should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure resident assessments accurately reflected the residents' s...
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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 resident assessments accurately reflected the residents' status for 2 (#8, #34) of 22 sampled residents reviewed for accurate assessments. The facility failed to accurately assess Resident #8 for insulin administration via injection, and failed to complete Resident #34's discharge assessment.Findings:
Resident #8
Review of Resident #8's record revealed an initial admission date of [DATE], a readmission date of [DATE], and diagnoses including type 2 diabetes mellitus with hyperglycemia.
Review of Resident #8's current physician orders revealed orders including:
-[DATE] Lantus (insulin) Subcutaneous Solution 100 unit/ml (units/milliliter), Inject 32 units subcutaneously two times a day -[DATE] -[DATE] Novolog (insulin) penfill subcutaneous solution cartridge 100 unit/ml, Inject as per sliding scale
Review of Resident #8's quarterly MDS (Minimum Data Set) dated [DATE] revealed Resident #8 was assessed to not have received injections of any type during the 7-day look back period.
Review of Resident #8's [DATE] MAR (Medication Administration Record) revealed insulin injections were received every day.
During an interview on [DATE] at 8:30 a.m. S6 MDS/Care Plan Nurse reviewed Resident #8's [DATE] MAR and confirmed Resident #8 had received insulin injections daily. S6 MDS/Care Plan Nurse further reviewed Resident #8's [DATE] MDS assessment showing no injections of any type were received, and confirmed it was inaccurate.
Resident #34
Review of Resident #34's medical record revealed an admit date of [DATE] and a discharge date of [DATE] with diagnoses of but not limited to rheumatoid arthritis, sepsis, myelodysplastic syndrome, and acute pulmonary edema.
Review of Resident #34's progress note dated [DATE] revealed Resident #34 was on hospice and expired in the facility on [DATE].
Review of Resident #34's medical record failed to reveal a discharge MDS had been completed.
During an interview on [DATE] at 3:15 p.m., S6 MDS/Care Plan nurse confirmed a discharge MDS assessment had not been completed and should have been done when Resident #34 expired in the facility.
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 record review and interviews the facility failed to ensure a resident's plan of care was implemented for 1 (#49) of 5 (#1, #6,#7, #8, #49) residents reviewed for unnecessary medications. The ...
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Based on record review and interviews the facility failed to ensure a resident's plan of care was implemented for 1 (#49) of 5 (#1, #6,#7, #8, #49) residents reviewed for unnecessary medications. The facility failed to ensure resident #49's laboratory tests were done as ordered. Findings: Review of Resident #49's medical record revealed an initial admit date of 12/12/2023 and a re-admission date of 06/02/2025 with diagnoses of but not limited to morbid obesity, type 2 diabetes, Olgilvie syndrome, megacolon, hypomagnesemia, essential hypertension and functional quadriplegia. Review of Resident #49's August 2025 physician's orders revealed orders for: Vitamin D level ordered 12/24/2024Lipid panel annually in May ordered 01/27/2025 Review of Resident #49's medical record failed to reveal laboratory results for a Vitamin D level and annual lipid panel. During an interview on 08/05/2025 at 2:45 p.m. S3ADON (Assistant Director of Nurses) confirmed Resident #49's ordered lab work for a Vitamin D level and an annual lipid panel for May 2025 was not done and should have been
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good gr...
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Based on observations, record review, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 (#54) of 3 (#37, #54, #62) residents reviewed for ADLs (activities of daily living). The facility failed to ensure Resident #54 received nail care and a shave.Findings:Review of Resident #54's medical record revealed an admit date of 07/31/2025 with a diagnoses of but not limited to spondylosis without myelopathy or radiculopathy lumbosacral region, scoliosis, unspecified and type 2 diabetes.Review of Resident #54's Quarterly MDS (Minimum Data Set) dated 07/09/2025 revealed Resident #54 was assessed to have a BIMS (Brief Interview Mental Status) score of 13 indicating intact cognition.Observation on 08/04/2025 at 8:40 a.m. revealed Resident #54 had an unshaved face and fingernails on both hands that protruded past his nail beds. Observation on 08/06/2025 at 9:00 a.m. revealed Resident #54 had an unshaved face and fingernails on both hands that protruded past his nailbeds. During an interview on 08/06/2025 at 9:00 a.m. when asked would you like to be shaved, Resident #54 stated, yes it's been a while since I was shaved, they did not shave me yesterday when I got a bath. When asked, would you like to have your fingernails trimmed, Resident #54 stated, I would like to have my fingernails trimmed.During an interview on 08/06/2025 at 9:00 a.m. S13 CNA (certified nursing assistant) confirmed Resident #54 had not been shaved and should have been.During an interview on 08/04/2025 at 11:45 a.m. S3 ADON (assistant director of nurses) confirmed Resident #54's fingernails should have been trimmed. During an interview on 08/05/2025 at 1:00 p.m. S2 DON (director of nurses) confirmed resident #54 should have been shaved and nail care should been provided by nurses and was not.
CONCERN
(E)
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 record reviews and interview, the facility failed to ensure residents received treatment and care and services in accor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure residents received treatment and care and services in accordance with professional standards of practice for 2 (#6, #8) of 5 (#1, #6, #7, #8, and #49) residents reviewed for unnecessary medications. The facility failed to ensure medications were administered, assessments were conducted, and monitoring was performed as ordered.Findings:Resident #6 Review of Resident #6's record revealed an initial admit date of 05/02/2025, readmission on [DATE], and diagnoses including: methicillin susceptible staphylococcus aureus infection, unspecified site, proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere, bacteremia, osteomyelitis of vertebra, lumbar region, metabolic encephalopathy, essential (primary) hypertension, sepsis, unspecified organism, age-related physical debility, paroxysmal atrial fibrillation, Wernicke's encephalopathy, unspecified psychosis not due to a substance or known physiological condition, chronic metabolic acidosis, adult failure to thrive, major depressive disorder, recurrent severe without psychotic features, other bipolar disorder, cerebral infarction, unspecified, type 2 diabetes mellitus without complications, unspecified cirrhosis of liver, and pressure ulcer of sacral region, stage 4.Review of Resident #6's current physician orders revealed orders including:-07/29/2025-Isolation type- (CONTACT)-07/27/2025 fentanyl patch 72 hour 25 mcg/hr (micrograms per hour), Apply 1 patch transdermally every 72 hours for pain rotate site and remove per schedule-07/24/2025-Oxycodone-Acetaminophen Tablet 10-325 mg (milligrams), Give 1 tablet by mouth every 6 hours for pain-07/23/2025-Morphine Sulfate (Concentrate) Solution 20 mg/ml (milligrams per milliliter), give 0.5 ml by mouth every 4 hours as needed for shortness of breath-07/24/2025-ceftriaxone sodium solution (an antibiotic), reconstituted 1 gram, use 1 gram intravenously in the morning for osteomyelitis until 08/11/2025-07/23/2025-Admit to Hospice. Severe protein calorie malnutrition. Comfort measures only. -07/07/2025-PICC (Peripherally Inserted Central Catheter) line right forearm: monitor for any signs or symptoms of infection every shift-07/24/2025-metronidazole tablet 500 mg, give 1 tablet by mouth every 12 hours for vertebral osteomyelitis until 08/11/2025-06/26/2025-turn and reposition every 2 hours ; if resident refuses to be turned document refusal!! every 2 hours for wound healing-06/02/2025-pain assessment every shift-05/02/2025-Anticoagulants - Check for bleeding & bruising every shift for monitoring-05/02/2025-Side effects:1)Tardive dyskinesia 2)Hypotension 3)Sedation/Drowsiness 4)Increased falls/dizziness 4)Appetite changes/weight change 5)Headache 6)Insomnia 7)Weakness 8)Visual Disturbances 9)Gastrointestinal disturbances 10)Other: see progress notesevery shift for monitoring Put in corresponding code-05/02/2025 - 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexually inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress notes, every shift for type the medication class Put in corresponding code.Review of Resident #6's August 2025 MAR (Medication Administration Record) revealed no documentation of any medication or supplement administration, monitoring of behaviors, pain assessment, monitoring of vital signs, monitoring of PICC line for signs and symptoms of infection, or monitoring for side effects of psychotropic medications had been done on the day shift 08/01/2025.Resident #8Review of Resident #8's record revealed an initial admission date of 03/14/2024, a readmission date of 08/14/2024, and diagnoses including: drug induced subacute dyskinesia (a movement disorder), restlessness and agitation, extrapyramidal and movement disorder, paranoid schizophrenia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, arthritis, chronic back pain, and major depressive disorder.Review of Resident #8's current physician orders revealed orders including:-07/21/2025 Risperdal Oral Tablet 3 mg (milligrams), give 6 mg orally one time a day for Paranoid schizophrenia -01/28/2025 Lantus Subcutaneous Solution 100 unit/ml, Inject 32 unit subcutaneously two times a day for diabetes mellitus-01/28/2025 Check oxygen saturation every shift and record. Notify medical doctor if less than 92%-01/28/2025 Respiratory: Oxygen (O2) - Continuous O2/3liters per nasal cannula -01/28/2025 Assess resident for pain every shift: Non-pharmacological interventions: 1=relaxation, 2=light touch, 3=imagery, 4=exercise, 5=music 6=not applicable, 7=other see progress note. Document corresponding code and pain level in supplemental documentation.Review of Resident #8's August MAR revealed no documentation of any medication administration, pain assessment, or check of Resident #8's oxygen saturation had been done on the day shift 08/01/2025.During an interview on 08/06/2025 at 1:50 p.m. S2 DON (Director of Nursing) reviewed Resident #6 and #8's August 2025 MARs and confirmed no documentation of medication administration, assessments, or monitoring of any kind was done on the day shift 08/01/2025 and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#8, #26, and #59) of 4 (#8,...
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Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 3 (#8, #26, and #59) of 4 (#8, #26, #44, and #59) residents reviewed for respiratory care. The facility failed to ensure oxygen supplies were dated, humidification bottles were not empty, and oxygen concentrator filters were clean. Findings:Review of the facility's undated Oxygen Administration Policy revealed in part:PROCEDURE8. Label humidifier with date and time opened. Change humidifier and tubing per facility policy.10. At regular intervals, check and clean oxygen equipment, masks, tubing and cannula. 11. At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifierDOCUMENTATION GUIDELINESHumidifier should be labeled with the date and time changedResident #8Review of Resident #8's record revealed an initial admission date of 03/14/2024, a readmission date of 08/14/2024, and diagnoses including chronic obstructive pulmonary disease.Review of Resident #8's current physician orders revealed an order dated 01/28/2025 for continuous oxygen at 3LPM/NC (Liters Per Minute per Nasal Cannula). Observation on 08/04/2025 at 6:38 a.m. revealed Resident #8 had continuous oxygen in use. Further observation revealed Resident #8's nasal cannula was not dated. Further observation revealed Resident #8's oxygen concentrator filter area was covered with a thick layer of white buildup. During an interview on 08/04/2025 at 7:09 a.m. S3 ADON (Assistant Director of Nursing) confirmed Resident #8's oxygen cannula was not dated with the date of the last change and should be, and Resident #8's oxygen concentrator filter was dirty and needed to be cleaned. Resident #26Review of Resident #26's record revealed an admit date 0f 12/28/2024 and diagnoses including: chronic obstructive pulmonary disease, acute on chronic systolic (congestive) heart failure, morbid (severe) obesity with alveolar hypoventilation, dependence on supplemental oxygen, and shortness of breath.Review of Resident #26's current physician orders revealed an order dated 02/20/2025 for oxygen 2 to 3 LPM as needed for shortness of breath.Observation on 08/04/2025 at 6:20 a.m. revealed Resident #26 was on oxygen at 3LPM via nasal cannula. Further observation revealed Resident #26's oxygen humidification bottle was empty. Further observation revealed the entire filter area on Resident #26's oxygen concentrator was coated with a thick layer of white buildup.During an interview on 08/04/2025 at 7:09 a.m. S2 ADON confirmed Resident #26's oxygen humidification bottle was empty and needed to be replaced, and the filter area of Resident #26's oxygen concentrator was dirty and needed to be cleaned. Resident #59Review of Resident #59's record revealed an admit date of 07/31/2025 and diagnoses including acute respiratory failure with hypoxia.Review of Resident #59's current physician orders revealed orders including an order dated 08/01/2025 for continuous oxygen at 2 LPM/NC.Observation on 08/04/2025 at 6:53 a.m. revealed Resident #59 had oxygen in use at 2 LPM/NC. Further observation revealed the humidification bottle attached to Resident #59's oxygen concentrator and Resident #59's nasal cannula were not dated.During an interview on 08/04/2025 at 7:09 a.m. S3 ADON confirmed Resident #59's oxygen humidification bottle and nasal cannula were not dated and should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to (1) document least restrictive approaches before i...
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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 (1) document least restrictive approaches before installation of bed rail/side rail, (2) obtain a written order from the physician for bed rails/side rails use, (3) obtain an informed consent from resident from resident or resident representative prior to installation (4) ensure resident care plan included a focus for bed rails/side rails, and (5) ensure maintenance of bed rails/side rails for 1 (#37) out of 1 residents reviewed for accidents. Review of facility's Bed Rail Policy (undated) revealed in part:Purpose: Ensure correct installation, use and maintenance of bed railsProcedure: This facility will attempt to use appropriate alternatives prior to installing a side or bed railIf a bed or side rail is used, this facility must ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements1) Assess the resident for risk of entrapment from bed rails prior to installation.2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails1. The facility will assess the resident's need for bed rails and all factors involved, including alternatives. Alternatives to bed rails will always be attempted before consideration of bed rail application. Documentation In the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident's assessed needs2. After the facility has attempted alternatives to bed rails and determined that these alternatives do not meet the resident's needs, the facility must assess the resident for the risks of entrapment and possible benefits of bed rails. In determining whether to use bed rails to meet the needs of a resident, the following components of the resident assessment should be considered including, but not limited to:Medical diagnosis, conditions, symptoms, and/or behavioral symptoms:Size and weightMobility (in and out of bed)Risk of falling3. After alternatives have been attempted and prior to installation of bed rails, the facility must obtain informed consent from the resident or if applicable, the resident representative for the use of bed rails. The facility should maintain evidence that it has provided sufficient information so that the resident or resident representative could make an informed decision. Information that the facility must provide to the resident, or resident representative include, but are not limited to:What assessed medical needs would be addressed by the use of bed rails;The resident's benefits from the use of bed rails and the likelihood of these benefits;The resident's risks from the use of bed rails and how these risks will be mitigated andAlternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate.The information should be presented to the resident, or if applicable, the resident representative, so that it could be understood and that consent can be given voluntarily, free from coercion.5. When installing and using bed rails, the facility should:Ensure that the bed's dimensions are appropriate for the resident.Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed.Install bed rails using the manufacturer's instructions to ensure a proper fit.Review of Resident #37's medical record revealed an initial admission date of 07/12/2023 and a re-entry admission on [DATE] with the following diagnoses but not limited to morbid obesity, unspecified lack of coordination, generalized muscle weakness, pain in left shoulder, and unspecified osteoarthritis. Review of Resident #37's medical record failed to reveal an attempt for least restrictive approaches before bed rail/ side rail installation. Review of Resident #37's August 2025 physician's orders failed to reveal an order for bed rails/ side rails.Review of Resident #37's Consent for Assistive Devices revealed the consent was incomplete with no resident name and no date. Review of Resident #37's care plan failed to reveal a focus on bed rail/side rail with appropriate interventions. Review of Resident #37's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 15 indicating intact cognition. Observation on 08/04/2025 at 11:21 a.m. revealed the side rail attached to the right side of Resident #37's bed was in the lowered position and was unable to be raised. During an interview on 08/04/2025 at 11:21 a.m. Resident #37 reported the side rail attached to the right side of the bed was broken. Resident #37 reported maintenance came in the room to fix the side rail a couple of weeks ago and it was still not able to be raised.During an interview on 08/05/2025 at 3:30 p.m. S9 Maintenance confirmed Resident #37's side rail did not properly fit the bed. During an interview on 08/06/2025 at 1:30 p.m. S6 MDS (Minimum Data Set) Nurse reviewed Resident #37's medical record and confirmed Resident #37 did not have a physician order for bed rails/side rails and Resident #37's care plan did not include a focus for bed rails/side rails and should. During an interview on 08/06/2025 at 1:30 p.m. S1 Administrator confirmed bed rails/side rails were used for mobility, and residents should be care planned for mobility and assistance with bed rails/side rails. During an interview on 08/06/2025 at 1:30 p.m. S2 DON (Director of Nursing) confirmed Resident #37's consent for assistive devices was incomplete.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure there were a sufficient number of personnel to provide care and respond to each resident's basic needs. The facility failed to provi...
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Based on record review and interview, the facility failed to ensure there were a sufficient number of personnel to provide care and respond to each resident's basic needs. The facility failed to provide the minimum required staffing hours for 1 of 14 days reviewed. Findings: Review of the Facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form for 07/20/2025 to 08/02/2025 revealed hours provided were less than hours required on Sunday 07/20/2025. The census on 07/20/2025 was 53, hours of care required was 124.55, and the hours of care provided was 120.83 revealing negative 3.72 hours of care provided. During an interview on 08/05/2025 at 4:32 p.m. S1 Administrator confirmed the facility did not meet the required minimum staffing hours on Sunday 07/20/2025 and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents' drug regimen was free of unnecessary medications f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents' drug regimen was free of unnecessary medications for 2 (#8, #49) of 5 (#1, #6, #7, #8, #49) residents reviewed for unnecessary medications. The facility failed to monitor for behaviors and side effects of psychotropic medication. Findings:Finding: Resident #8 Review of Resident #8's record revealed an initial admission date of 03/14/2024, a readmission date of 08/14/2024, and diagnoses including: restlessness and agitation, paranoid schizophrenia, and major depressive disorder. Review of Resident #8's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 12 indicating moderately impaired cognition. Review of Resident #8's current physician orders revealed orders including:-07/21/2025-Risperdal oral Tablet 3 mg (milligrams) (Risperidone) give 6 mg orally one time a day for paranoid schizophrenia-01/28/2025- Risperdal oral tablet 4 mg (Risperidone) give 1 tablet by mouth at bedtime-01/28/2025-Trazodone Hydrochloride 75 mg by mouth at bedtime-01/28/2025- Mirtazapine 15 mg by mouth at bedtime for major depressive disorder Review of Resident #8's July 2025 MAR (Medication Administration Record) failed to reveal monitoring for behaviors or effectiveness or side effects of psychotropic medications. Review of Resident #8's August 2025 MAR failed to reveal monitoring for behaviors or effectiveness or side effects of psychotropic medications. During an interview on 08/06/2025 at 4:28 p.m. S2 DON (Director of Nursing) confirmed there was no monitoring of Resident #8's behaviors, effectiveness, or side effects of psychotropic medications and there should be.Resident #49Review of Resident #49's medical record revealed an initial admit date of 12/12/2023 and a re-admission date of 06/02/2025 with diagnoses of but not limited to schizoaffective disorder, bipolar disease, morbid obesity, type 2 diabetes, Ogilvie syndrome, mega colon, hypomagnesemia, essential hypertension and functional quadriplegia. Review of Resident #49's August 2025 physician orders revealed orders for Clonazepam 1mg by mouth two times a day for anxiety, Olanzapine 20mg by mouth at bed time for schizophrenia and Mirtazapine 15mg by mouth at bedtime for depression.Review of Resident #49's August 2025 MAR revealed documentation of the administration of Clonazepam, Olanzapine and Mirtazapine as ordered. Review of Resident #49's medical record and MAR failed to reveal monitoring for behaviors and side effects for prescribed and administered psychotropic medication. During an interview on 08/05/2025 at 1:56 p.m. S3 ADON (Assistant Director of Nurses) confirmed there was no monitoring for behaviors and side effects for prescribed and administered psychotropic medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observations, record reviews and interviews the facility failed to maintain a facility medication error rate of less than 5% by failing to give 3 medications as ordered for 3 (#27, #31, and #...
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Based on observations, record reviews and interviews the facility failed to maintain a facility medication error rate of less than 5% by failing to give 3 medications as ordered for 3 (#27, #31, and #36) residents observed during medication administration. A total of 31 opportunities were observed which included 3 medication errors for a medication error rate of 9.68%.Findings: Observation on 08/05/2025 at 8:06 a.m. of medication administration revealed S3 ADON (assistant director of nurses) did not administer Resident #27's Miralax 17 gm (grams) during medication administration. Review of Resident #27's physician's orders revealed an order for Miralax 17gm by mouth once a day for constipation. Observation on 08/05/2025 at 7:48 a.m. during medication administration revealed S3 ADON did not administer Resident #31's Miralax 17gm during medication administration.Review of Resident #31's Physicians orders revealed an order dated 01/28/2025 for Miralax 17gm 1 scoop two times a day for constipation. Observation on 08/05/2025 at 7:11a.m. during medication administration revealed S3ADON did not administer Resident #36's Omeprazole 20mg (milligrams) during medication administration. Review of Resident #36's Physicians orders revealed an order dated 01/29/2025 for Omeprazole delayed-release 20mg per in the morning per peg tube.During an interview on 08/05/2025 at 8:06 a.m. S11 LPN (licensed practical nurse) reported Resident #27 and Resident #31's Miralax 17gm Powder was out of stock and unavailable for administration during medication administration.During an interview on 08/05/2025 at 7:11 a.m. S3 ADON reported Resident #36's omeprazole was out of stock, and unavailable for administration during medication administration. During an interview on 08/05/2025 at 12:03 p.m. S2 DON (director of nurses) confirmed the facility's medication error rate was greater than 5% and should not have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to follow the prescribed diet for 1 (#1) of 1 (#1) re...
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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 follow the prescribed diet for 1 (#1) of 1 (#1) residents reviewed for Food/Nutrition. Findings:Review of the facility's Policy: Diet Changes and Reports (undated) revealed in part:Purpose: Ensure communication to the dietary department of any changes in the resident's diet, meal service, eating habits and/or changes in the resident's condition.Procedure:1. When a new resident is admitted , or a diet has been changed, the charge nurse shall be responsible for ensuring that the dietary department receives a written notice of the diet order.Review of Resident #1's medical record revealed an initial admission date of 01/17/2025 with a re-entry admission date of 02/17/2025 with the following medical diagnoses: type 2 diabetes mellitus, hyperlipidemia, and cerebral infarction. Review of Resident #1's August 2025 Physician Orders revealed an order dated 07/23/2025 for a CCD (Consistent Carbohydrate Diet) NAS (No Added Salt) diet, Regular texture, Regular/Thin Liquids consistency; for upgraded per patient request after swallow evaluation completed.Review of Resident #1's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 14 indicating intact cognition. Review of Resident #1's Care Plan revealed the potential for impaired nutritional status related to a CCD NAS mechanical soft diet with interventions to explain and reinforce to the resident the importance of maintaining the diet ordered, provide and serve diet as ordered.Review of Resident #1's Psychotherapy Progress Note dated 02/04/2025 revealed in part: Resident #1 stated wanting to have change in her food from being chopped daily to being whole. LCSW (Licensed Clinical Social Worker) informed nursing staff of her concerns.Review of Resident #1's Speech Therapy SLP (Speech Language Pathologist) Evaluation & Plan of Treatment dated 07/23/2025 revealed an evaluation of oral and pharyngeal swallow function; reason for referral: patient requested diet upgrade to regular consistency due to disliking of current mechanical soft. diet. Further review revealed Resident #1 completed the bedside swallow evaluation with no signs or symptoms of aspiration. Review of Resident #1's Diet Requisition Form dated 07/23/2025 revealed Resident #1's diet was upgraded by S14 SLP to Regular texture, Regular/Thin Liquids consistency. During an interview on 08/04/2025 at 11:08 a.m., Resident #1 reported she did not have any swallowing issues and passed a swallowing test with the speech therapist, but continued to be served a soft diet with chopped meats. Observation of Resident #1's dinner tray on 08/05/2025 at 5:00 p.m. revealed Resident #1 was served chopped meats. During an interview on 08/05/2025 at 5:00 p.m. S15 Dietary observed Resident #1's dinner tray and confirmed Resident #1 was served chopped meats. During an interview on 08/05/2025 at 5:00 p.m. S12 Dietary Manager reviewed Resident #1's diet order and reported she thought Resident #1 still had an order for a mechanical soft diet with chopped meats. During a telephone interview on 08/06/2025 at 9:45 a.m., S14 SLP confirmed she completed an evaluation on 07/23/2025 that revealed Resident #1 was safe on a regular consistency diet, and Resident #1 was upgraded to a regular diet and diet orders should have been changed to a Regular diet. During an interview on 08/06/2025 at 11:10 a.m. S2 DON (Director of Nursing) confirmed dietary had not been notified of the change in Resident #1's diet and should have been.
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 reviews, observations, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility...
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Based on record reviews, observations, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure:1. Food was stored in accordance with professional standards for food service safety. 2. High Temperature Dishwasher met wash cycle and rinse cycle temperature recommendations. This deficient practice had the potential to affect the 54 residents who received meals on 08/04/2025 as per S12Dietary Manager. Findings:1.Review of undated Policy: Storage of Food in Refrigeration revealed, in part,:Purpose: Ensure food needing refrigeration is properly stored to prevent food-borne illness.Procedure: 4. All containers must be labeled with the contents and date food item was placed in storage.5. Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to 3 days and then must be discarded.6. Food items that remain sealed from the supplier may be held until the expiration date if unopened. Observation of the facility's refrigerator on 08/04/2025 at 7:45 a.m. with S12Dietary Manager revealed the following undated items:-Box of with bacon in unsealed and open plastic wrap -Sliced lunchmeat with no label that appeared sealed but was leaking juices.-3 loose cabbage heads in a box.-3 ziploc bags of chopped lettuce that had brown on it and was in a box.-Box of cubed ham-Box of prepared biscuits wrapped in plastic.-Flour tortillas that had been opened and were wrapped in plastic wrap.-Partially used bag of hot dog buns.-Partially used bag of hamburger buns. During an interview on 08/04/2025 at 7:48 a.m. S12 Dietary Manager observed the items from the refrigerator and confirmed they were undated and should have been dated when they were received and dated when they were opened and were not. S12 Dietary Manager further confirmed the bacon and loose cabbage should have been in a sealed wrap or container and were not. Observation of the facility's freezer on 08/04/2025 at 7:49 a.m. with S12 Dietary Manager revealed the following undated items:-Foil pan of lasagna with foil over the pan.-Partially used unsealed eggrolls loose in a box.-Partially used open bag of frozen corn in a box. During an interview on 08/04/2025 at 7:50 a.m. S12 Dietary Manager observed the items in the freezer and confirmed they were undated and should have been dated upon receipt, dated when opened and stored in a sealed container and were not. 2.Review of the facility's Dish Machine Temperature Log Sheets (updated 7/28/2010) indicated the following:*Wash Cycle: Wash temps should be a minimum of 150 degrees.*Rise Cycle: Rinse temps should be a minimum of 180 degrees not higher than 195 degrees. Observation on 08/04/2025 at 8:10 a.m. revealed S12Dietary Manager ran a dishwasher cycle on the High Temperature Dishwasher. The dishwasher wash cycle revealed a wash temperature of 140 degrees Fahrenheit and a rinse cycle temp showing it was stuck at 175 degrees Fahrenheit and never budged, even when the dishwasher was off. During an interview on 08/04/2025 at 8:15 a.m. S12Dietary Manager confirmed the wash cycle temperature should have been at least 150 degrees and was not. S12Dietary Manager further confirmed the rinse cycle temp needle never moved from where it stayed at 175 degrees, which was below the 180 degrees Fahrenheit required.
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 record review and interview the facility failed to ensure a water management program had been implemented to minimize the risk of Legionella and other opportunistic pathogens. Findings:Review...
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Based on record review and interview the facility failed to ensure a water management program had been implemented to minimize the risk of Legionella and other opportunistic pathogens. Findings:Review of policies provided by the facility failed to reveal a Water Management Plan was in place and monitoring was being conducted for waterborne illnesses. During an interview on 08/06/2025 at 7:45 a.m. S8Maintenance and S9 Maintenance reported they would conduct water temperature checks only. During an interview on 08/06/2025 at 1:30 p.m. S8 Maintenance and S9 Maintenance reported they had just received a Water Management Program and had picked up a test today to conduct the monitoring. S8 Maintenance and S9 Maintenance further confirmed they had not been aware of this program and had not been conducting any testing on the water, other than water temperatures.
Jun 2025
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the walk-in refrigerator and freezer leaking water and in need of ...
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Based on observation and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the walk-in refrigerator and freezer leaking water and in need of repair. This deficient practice has the potential to affect any of the 51 residents consuming food from the kitchen according to S3 Dietary Manager.
Findings:
Observation on 06/10/2025 at 8:45 a.m. revealed;
1. water dripping from the water sprinkler into a bucket inside the walk-in refrigerator,
2. water running from the condenser into a bucket and onto the floor in the walk-in freezer,
3. a wooden palate on the floor of the freezer, and
4. ice buildup on the wall and floor of the freezer.
During an interview on 06/10/2025 at 9:00 a.m. S2 [NAME] reported the freezer had not been working for approximately one month and water had been leaking from around the condenser, causing water to freeze and build up ice on the floor. S2 [NAME] further reported the walk-in refrigerator had a drip around the sprinkler.
During an interview on 06/10/2025 S3 Dietary Manager confirmed water was leaking from the sprinkler in the walk-in refrigerator and from the condenser in the freezer. S3 Dietary Manager reported the water from the condenser in the freezer leaked into a bucket, ran down the wall, and built up ice on the floor. The wooden palate was on the floor for safety. S3 Dietary Manager reported the leaks have been present approximately a month and the S1 Administrator and S5 Maintenance were aware.
During an interview on 06/11/2025 at 2:30 p.m. S1 Administrator acknowledged the kitchen findings and confirmed the repairs had not been completed and should have been.
During an interview on 06/11/2025 at 3:20 p.m. S5 Maintenance Supervisor acknowledged the kitchen findings and confirmed the repairs had not been completed.
May 2025
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to conduct a significant change MDS (Minimum Data Set) for 1 (#1) of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to conduct a significant change MDS (Minimum Data Set) for 1 (#1) of 3 (#1, #2, #3) sample residents after changes were noted that had an impact on the resident's health status and required interdisciplinary review and revision of the care plan.
Findings:
Review of resident #1's electronic medical records revealed a re-entry admission from a behavior hospital on [DATE].
Review of resident #1's Discharge summary dated [DATE] from a local behavioral hospital revealed diagnoses of vascular dementia severe with agitation, bipolar disorder, current episode depressed moderate, medical diagnoses hypertension, atrial fibrillation, acute post procedural hematoma of skin and subcutaneous tissues following other procedure wedge compression fracture of T11-T12 vertebra. Stressors are problems with primary support group, problems related to social environment and housing problems, other psychosocial and environment problems. Prognosis as guarded.
Review of resident #1's hospital discharge summary revealed Neurosurgery was consulted his evaluation revealed that resident #1 would be best served to be conservatively managed with a TLSO (thoracic lumbar and sacral orthosis) brace pain management therefore neurosurgical in indication as needed.
Review of resident #1's current Physician orders dated 05/23/2025: OT (occupational therapy) to evaluate and treat as indicated. OT to provide skilled therapy services 5 times week for 30 days to address therapeutic exercises, therapeutic activities, self-care, neuromuscular re-education, group therapy, and modalities as indicated.
Review of resident #1's Comprehensive Plan of Care revealed a problem with actual falls on 05/05/2025 with some of the interventions 05/2025 x-ray left wrist, resident moved to different room, and sent to emergency room for psychiatric evaluation.
During an interview on 05/27/2025 at 2:10 p.m. S7 LPN (Licensed Practical Nurse) S7 LPN reported resident #1 had decline over the last few months, he is bored and had nothing to do.
During an interview on 05/28/2025 at 9:10 a.m. S1 DON (Director of Nursing) reported a significant change assessment and the MDS should have been updated by S4 MDS (Minimum Data Set) nurse. S1 DON reported there is a system failure and started putting in to place last Thursday 05/22/2025 Performance Improvement Plan that is to be completed weekly. S1 DON reported the Care Plans are not being updated. S1 DON reported she had talked with S4 MDS Nurse about updating care plans and completing MDS assessments.
During an interview on 05/28/2025 at 09:30 a.m. S4 MDS nurse reported she usually complete a significant change assessment when it is time to do the MDS. S4 MDS nurse reported she was going to complete a significant change assessment for resident #1 on 05/26/2025. S4 MDS nurse reported she did not complete a significant change assessment or update the care plan since his readmit from the Behavior Hospital. S4 MDS nurse reported a significant change assessment is usually completed when a resident have a change in ADLs (Activities of Daily Living). S4 MDS reported resident #1 wearing a brace, having therapy and using a wheelchair does indicate there should be a significant change assessment.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure standing orders were implemented for 1 (#3) of 3 (#1, #2, #3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure standing orders were implemented for 1 (#3) of 3 (#1, #2, #3) residents reviewed. The facility failed to ensure S5 Physician's standing orders for a chest x-ray were completed.
Findings:
Review of S5 Physician's nursing home standing orders revealed:
COVID (corona virus disease) Protocol Standing Orders: Chest X-ray AP (Anteroposterior)/Lateral
Review of Resident #3's face sheet revealed an admission date of 05/02/2025 with the following medical diagnoses but not limited to right wrist ganglion metabolic encephalopathy, cellulitis to the right upper limb, repeated falls, other specified disorders of tendon-right shoulder, and mild cognitive impairment uncertain etiology.
Review of Resident #3's record failed to reveal results of admit chest x-ray ordered on 05/02/2025.
During an interview on 05/28/2025 at 9:30 a.m. S2 ADON (Assistant Director of Nursing) confirmed Resident #3 was admitted to the facility on [DATE] and she called local imaging company for an admission standing order chest x-ray not for Resident #3's hand or wrist as he was not complaining of pain or did not have any swelling to his right wrist. S2 ADON reviewed Resident #3's electronic health record and confirmed Resident #3's admission standing order chest x-ray was not done.
During an interview on 05/28/2025 at 2:10 p.m. S1 DON (Director of Nursing) confirmed the admission standing orders for a chest x-ray was not done and should have been done.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure nursing staff had appropriate competencies and skill sets t...
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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 nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 3 (#1, #2, #3) sample residents. This is evidenced by the facility failing to continue monitoring and assessment of a resident (#1) after a fall to identify any complications or changes in the resident condition.
Findings:
Review of facility Falls- Clinical Protocol Policy (undated) revealed in part-
Monitoring and Follow-up
The staff, with the physician's guidance, will follow-up on any fall with associated injury until the resident is stable and delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall.
Review of resident #1's hospital records dated 05/07/2025 revealed in part - current active problems: Compression fracture of thoracic vertebra (Acute), Compression fracture of T9 vertebra (chronic), Subcutaneous hematoma (Acute), Closed wedge compression fracture of T11 vertebra (Chronic), Combative behavior(Acute), Macrocytic(Acute).
Review of resident #1's most recent quarterly MDS (Minimum Data Set) dated 04/14/2025 a BIMS (Brief Interview for Mental Status) score of 03 indicating cognitive impairment.
Review of resident #1's nursing progress note dated 05/05/2025 at 09:00 a.m. S6 LPN (Licensed Practical Nurse) documented she was called at the nurses station by resident #2 stating that his roommate resident #1 was trying to hit him with the PT (physical therapy) barbell. S6 LPN went to the room and pushed the door open and found resident #1 lying on his left side on the floor. S6 LPN and staff lifted him to his wheelchair. S6 LPN examined resident, he was able to move all extremities, but complained of pain in his left wrist and arm. S6 LPN notified resident #1's physician, he gave the ok to give him 2 extra strength Tylenol. ____ Imaging came and did an x-ray to the left arm.
Review of resident #1's records failed to reveal any documentation that continue monitoring and assessment for injuries including pain had been completed prior to resident #1 being transferred out to a local hospital emergency room on [DATE] for a psych evaluation.
Review of resident #1's May 2025 EMAR (Electronic Medication Administration Record) failed to reveal any documentation that 2 extra strength Tylenol was administered as ordered by physician.
Further review of resident #1's nursing progress note dated 05/06/2025 at 9:08 p.m. revealed resident #1 was sent out to a local emergency room for a psych evaluation.
Review of resident #1's record revealed a service date of 05/06/2025 at 5:15 p.m. to the hospital emergency room.
Resident #1 was admitted in patient to the hospital on [DATE]. Resident #1's ED (Emergency Department) notes dated 05/07/2025 at 4:14 p.m. Resident #1 diaper change, black and blue bruise noted to coccyx area. Resident noted to be in pain when being turned called nurse at transferring facility. Nurse at transferring facility reported resident #1 fell 2 days ago and complained of wrist pain and wrist was x-rayed and nothing else.
During an interview on 05/28/2025 at 11:00 a.m. S2 ADON (Assistant Director of Nursing) reported after reviewing resident #1's medical records there was no documentation that revealed continued monitoring and assessments had been completed after resident #1 fall on 05/05/2025. S2 ADON agreed continue monitoring and assessment of resident #1 after the fall should have been completed and it was not.
May 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to complete required reporting to the State Survey and Certification Agency in accordance with State law in a timely manner for 1 (#2) of 3 (...
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Based on record reviews and interviews the facility failed to complete required reporting to the State Survey and Certification Agency in accordance with State law in a timely manner for 1 (#2) of 3 (#1, #2, and #3) sampled residents incidents that required reporting to be submitted. The facility failed to report an allegation of an inappropriate sexual relationship between a staff member and a resident in a timely manner to the State Survey and Certification Agency.
Findings:
Review of facility's Abuse Prevention Program (undated) revealed in part:
Policy statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.
Policy Interpretation and Implementation:
As part of the resident abuse prevention, the administration will:
7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.
Review of facility's Abuse Prevention Policy (revised February 2014) revealed in part:
Policy: The facility is committed to protecting the resident from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.
Definitions:
Abuse: Willful infliction on injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident.
Sexual Abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident.
Investigation: The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection of any alleged victims to prevent harm during the continuance of the investigation. The Executive Director, or designee, shall report any allegations, neglect or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act of the Department of Health as required.
Reporting: .Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency, APS (Adult Protective Services), and local law enforcement as requirement). Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident.
Review of Resident #2's face sheet revealed a admit date of 07/17/2024 with the following diagnoses: multiple fractures left/right foot, medical cuneiform of right foot, right toes, second metatarsal bone, left foot, nasal bones, unspecified lumbar vertebra, 1st, 2nd, 3rd metatarsal bone of the right foot, cuboid bone of right, anterior process of right calcaneus, 3rd, 4th, 5th metatarsal bone of the left foot, subsequent encounter for fracture with routine healing, subsequent encounter, multiple fractures of ribs, right/left side, unspecified fracture of fourth lumbar vertebra) bipolar disorder, current episode depressed, moderate, insomnia, unspecified, nightmare disorder, muscle weakness (generalized), difficulty in walking, lack of coordination, and dislocation of right hip.
Review of Resident #2's State and Quarterly MDS (Minimum Data Set) dated 03/14/2025 revealed a BIMS (Brief Interview of Mental Status) of 15 out of 15 indicating cognitively intact.
Review of facility's State Survey and Certification Agency Reporting Reports from December 2024 through May 2025 failed to reveal any allegations of a sexual/inappropriate relationship between a staff member and resident.
Review of facility's Incident log from 02/06/2025 through 05/06/2025 failed to reveal any incidents involving Resident #2.
Review of facility's investigation documentation dated 04/24/2025 revealed written employee statements were taken and life safety rounds were done in regards to an allegation of an inappropriate sexual relationship between a resident and facility employee.
During an interview on 05/05/2025 at 10:00 a.m. S1 Administrator reported there was a rumor that was going around from S5 MDS coordinator to S2 Director of Clinical Operations about a facility employee possibly having a sexual relationship with a resident. S1 Administrator acknowledged not reporting the incident to the State Survey and Certification Agency because it was a rumor and she heard about it in passing from an employee and not from another resident. S1 Administrator reported there was not an incident report for this incident, the only results of investigation would be available in S6 CNA (Certified Nurse Assistant) personnel file.
S1 Administrator reported both Resident #2 and S6 CNA denied having a sexual relationship. S1 Administrator reported Resident #2 had a high BIMS and had the right to have a relationship. S1 Administrator reported S6 CNA was in-serviced on not starting a relationship with a resident while being employed at the facility.
During an interview on 05/05/2025 at 11:00 a.m. S2 Director of Clinical Operations reported hearing the rumor of an employee and resident having sexual relations but could not recall where she heard it. S2 Director of Clinical Operations reported maybe the rumor was heard from the Administrator. S2 Director of Clinical Operations reported S1 Administrator was responsible for submitting reports with an allegation of abuse to the State Survey and Certification Agency. S2 Director of Clinical Operations confirmed the allegation of an inappropriate sexual relationship between Resident #2 and S6 CNA was not reported to the State Survey and Certification Agency. S2 Director of Clinical Operations reported an internal investigation was completed and it was found there was nothing to report, just staff talking among themselves.
During an interview on 05/06/2025 at 10:15 a.m. S5 MDS (Minimum Data Sets) Nurse reported overhearing a rumor a resident and staff member might be messing around. The next day S1 Administrator called her to ask had she heard of the rumor going around. S5 MDS reported she did not report it because it was overheard and no names were mentioned and she thought it was just gossip.
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
Based on record reviews and interviews the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to prom...
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Based on record reviews and interviews the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 resident (#3) of 2 residents (#1, #3) reviewed with pressure ulcers. The facility failed to ensure pressure ulcer treatments were performed as ordered and failed to measure and stage pressure ulcers according to professional standards of practice.
Findings:
Review of Resident #3's medical record revealed and admit date of 02/20/2025 with diagnoses that included in part, stage 4 pressure ulcer sacral region, stage 3 pressure ulcer unspecified hip, personal history healed physical trauma, non-pressure chronic ulcer of right thigh with unspecified severity, pressure ulcer right hip stage 4, pressure ulcer unspecified site stage 2, burn 2nd degree right knee, burn 3rd degree right knee, patient's noncompliance with other medical treatment and regimen for other reason, and contracture of muscle multiple sites.
Review of Resident #3's May 2025 Physician Orders revealed the following wound orders dated 04/07/2025:
-Right Mid Back: cleanse with Dakin's. Pat dry. Apply skin prep to peri (perineal) area. Apply calcium alginate to open area and cover with dry dressing daily until resolved and PRN (as needed).
-Sacrum: Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply calcium alginate to open area and cover with dry dressing daily until resolved. PRN one time a day and every 1 hours as needed.
-Left Hip: Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply calcium alginate to open area and cover with dry dressing QD (every day) until resolved. PRN soilage/dislodgement one time a day and as needed.
-Left Knee: Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply calcium alginate to open area and cover with dry dressing daily until resolved. PRN.
-Right 5th Toe: Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply calcium alginate to open area and cover with dry dressing daily until resolved. PRN one time a day and every 1 hours as needed.
-Left Buttock: Cleanse with Dakin's. Pat dry. Apply ski prep to peri area. Apply calcium alginate to open area and cover with dry dressing daily until resolved. PRN one time a day.
-Left Medial Lower Leg: Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply calcium alginate to open area and cover with dry dressing daily until resolved. PRN one time a day.
-Right Medial Foot: Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply santyl, then calcium alginate to open area and cover with dry dressing daily and PRN one time a day every other day and every 1 hours as needed.
-Right Ankle: Cleanse with Dakin's pat dry. Apply skin prep to peri area. Apply calcium alginate to open area and cover with dry dressing QOD (every other day) until resolved and PRN one time a day every other day.
-Right Inferior Lower Leg: Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply collagen to open area and cover with dry dressing QOD until resolved and PRN.
-Right Hip. Cleanse with Dakin's. Pat dry. Apply skin prep to peri area. Apply calcium alginate to open area and cover with dry dressing QOD until resolved. PRN soilage/dislodgement.
Further review of Resident #3's May 2025 Physician Orders revealed an order dated 04/29/2025 to admit to ___ hospice services.
Review of Resident #3's April 2025 Treatment Administration Record (TAR) failed to reveal treatments for Resident #3's Right Mid Back, Sacrum, Left Hip, Left Knee, Right 5th Toe, Left Buttock, and Left Medial Lower Leg pressure ulcers were performed daily as ordered on 04/08/2025, 04/11/2025, 04/18/2025, 04/20/2025, 04/21/2025, 04/23/2025, 04/25/2025, and 04/29/2025. Further Review of Resident #3's April 2025 TAR failed to reveal treatments for Resident #3's Right Medial Foot, Right Ankle, Right Inferior Lower Leg, and Right Hip pressure ulcers were performed every other day as ordered on 04/11/2025, 04/21/2025, 04/23/2025, 04/25/2025, and 04/29/2025.
Review of Resident #3's medical record revealed Resident #3's pressure ulcers were measured and staged weekly by an outside wound care Nurse Practitioner (NP) with the exception of measurements and staging performed 04/11/2025 and 04/30/2025. Resident #3's medical record failed to reveal Resident #3's pressure ulcers were measured and staged by a Registered Nurse on 04/11/2025 and 04/30/2025 in the absence of the outside wound care NP.
During an interview on 05/05/2025 at 11:45 a.m. S4 LPN (Licensed Practical Nurse)/Wound Care/ADON (Assistant Director of Nursing) reported she and the weekend RN (Registered Nurse) performed wound care to the residents in the facility with wounds. S4 LPN/Wound Care/ADON reported an outside wound care NP saw all residents with pressure ulcers and did measurements and staging weekly. S4 LPN/Wound Care/ADON reported Resident #3 was admitted to hospice last week and the hospice RN would start measuring and staging Resident #3's pressure ulcers weekly.
During an interview on 05/06/2025 at 9:25 a.m. S4 LPN/Wound Care/ADON reported weekly pressure ulcer measurements and staging were performed in the absence of the outside wound care NP by the DON (Director of Nursing).
During an interview on 05/06/2025 at 3:00 p.m. S4 LPN/Wound Care/ADON reviewed Resident #3's medical record and reported she performed wound care on Resident #3 on 04/11/2025 and 04/30/25 with the DON. S4 LPN/Wound Care/ADON reported she documented the pressure ulcer measurements and staging done by the DON on those dates and had not measured and staged the wounds. S4 LPN/Wound Care/ADON failed to provide documentation the DON signed confirmation of wound measurements and staging done on 04/11/2025 and 04/30/2025.
During an interview on 05/06/2025 at 3:10 p.m. S3 Interim DON reported she had not performed any wound care and had not measured or staged any pressure ulcers since she began working as the interim DON on 04/07/2025.
During an interview on 05/07/2025 at 2:30 p.m. S7 DON reported her first day at the facility was 05/05/2025 and she was not yet aware of her specific roll for pressure ulcer measuring and staging in the facility.
During an interview on 05/06/2025 at 2:48 p.m. S2 Director of Clinical Operations reviewed Resident #3's April 2025 TAR and confirmed it failed to reveal treatments for Resident #3's Right Mid Back, Sacrum, Left Hip, Left Knee, Right 5th Toe, Left Buttock, and Left Medial Lower Leg pressure ulcers were performed daily as ordered on 04/08/2025, 04/11/2025, 04/18/2025, 04/20/2025, 04/21/2025, 04/23/2025, 04/25/2025, and 04/29/2025. S2 Director of Clinical Operations further acknowledged Resident #3's April 2025 TAR failed to reveal treatments for Resident #3's Right Medial Foot, Right Ankle, Right Inferior Lower Leg, and Right Hip pressure ulcers were performed every other day as ordered on 04/11/2025, 04/21/2025, 04/23/2025, 04/25/2025, and 04/29/2025. S2 Director of Clinical Operations confirmed an outside wound care NP measured and staged resident's pressure ulcers weekly with S4 LPN/Wound Care/ADON. S2 Director of Clinical Operations reported if the NP were not present for any reason to measure and stage wounds weekly, then she would perform the measurements and staging of the wounds with S4 LPN/Wound Care/ADON and sign behind her in confirmation. S2 Director of Clinical Operations reported she had not performed any wound care and had not measured or staged any pressure ulcers in the facility. S2 Director of Clinical Operations further reviewed Resident #3's medical record and acknowledged there was no documentation an RN had measured and staged Resident #3's pressure ulcers on 04/11/2025 and 04/30/2025 and should have.
Apr 2025
9 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 F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's advanced directive was honored for 1 (#1) of 5...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's advanced directive was honored for 1 (#1) of 5 ( #1, #2, #3, #4, and #5) sampled residents.
Findings:
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Review of the provider's Cardiopulmonary Resuscitation (CPR) policy (undated) revealed in part: Procedure-Delegate another individual to check the resident's orders and advance directives for CPR or no CPR order.
Review of the provider's Advance Directives policy (revised [DATE]) revealed in part:
The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.
Definitions-Do Not Resuscitate (DNR) indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation or other life-sustaining treatments or methods are to be used.
If the resident has an advance directive:
1. If the resident or the resident's representative has executed one or more advance directives, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff.
2. The director of nursing or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care.
3. The resident's wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings.
8. The nurse supervisor is required to inform emergency medical personnel of a residents advance directive regarding treatment options and provide such personnel with a copy of the advance directive or POLST when transfer from the facility via ambulance or other means is made.
Refusing or Requesting Treatment:
1. The resident has the right to refuse medical or surgical treatment, whether or not he or she has an advance directive.
a. A resident will not be treated against his or her own wishes.
Review of Resident #1's record revealed an admit date of [DATE] and diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, congestive heart failure, Atherosclerotic heart disease of a native coronary artery, dependence on supplemental oxygen, presence of a cardiac pacemaker, type 2 diabetes mellitus, acute respiratory failure with hypercapnia (high levels of carbon dioxide in the blood), and nicotine dependence.
Review of Resident #1's physician orders revealed an order dated [DATE]- Do NOT Resuscitate (DNR) ordered by S9 MD (Medical Doctor), and an order dated [DATE]-Do NOT Resuscitate ordered by S10 MD.
Review of Resident #1's quarterly MDS (Minimum Data Set) assessments with an ARD (Assessment Reference Date) of [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating she was cognitively intact.
Review of Resident #1's comprehensive care plan revealed the resident was care planned as DNR-no life sustaining measures to be provided.
Review of Resident #1's DNR DO NOT RESUSCITATE ORDER signed by Resident #1 on [DATE], signed by S9 MD [DATE] revealed in part: On this 10th day of October, I Resident #1 communicated to my physician my willful and voluntary desire that my dying shall not be artificially prolonged. I requested my Physician to order and by signing this document he/she does so order that: IN the event of respiratory or cardiac arrest or other system failure that will result in death, all persons are to forgo resuscitation attempts of any type. It is my intention that this order be honored by my family, physician, and all others involved in my care as the final expression of my legal right to refuse medical interventions. By my signature below, I acknowledge that I understand CPR constitutes as an extraordinary measure and should NOT be done.
Review of Resident #1's LaPOST (Louisiana Physician Orders for Scope of Treatment) signed by resident [DATE] and by S9 MD on [DATE] revealed the resident had selected DNR/Do Not Attempt Resuscitation (Allow Natural Death).
Review of Resident #1's nursing notes revealed a noted dated [DATE] at 1:35 a.m. by S11 LPN (Licensed Practical Nurse): at 1:35 a.m. writer was called to resident room and resident was noted to be in respiratory distress. Breathing treatment was attempted by writer but resident was not responding to it. Oxygen was increased from 2 liters to 4.5 liters per nasal cannula. At 1:40 a.m. 911 was called. Resident was noted to have pulse. At 2:00 a.m. 911 arrived and assessed resident. 911 initiated CPR code status. 2:10 .a.m. 911 left with resident on stretcher to hospital.
During an interview on [DATE] at 7:53 a.m. S12 RN (Registered Nurse) reported she was working the early morning hours of [DATE] at around 1:30 a.m. when Resident #1 began having trouble breathing and 911 was called when the resident was not improving after having a breathing treatment and increasing her oxygen. S12 RN reported EMS (Emergency Medical Services) started CPR when they arrived and confirmed she did not tell EMS staff Resident #1 had a DNR order.
During a telephone interview on [DATE] at 9:06 a.m. S11 LPN reported she was the nurse assigned to care for Resident #1 on [DATE]. S11 LPN confirmed she called 911 when Resident #1 was in respiratory distress that was not improving with treatment and increased oxygen. S11 LPN confirmed EMS initiated CPR as soon as they got there. S11 LPN further confirmed she did not tell EMS staff the resident had a DNR order. S11 LPN further reported in her haste to get Resident #1 out of the facility to the hospital she did not look at the code status and should have.
During the survey, in-service records and monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to surveyors entering the facility:
Corrective actions were initiated on [DATE] with a completion date of [DATE] with ongoing monitoring still in place. Corrective actions included policy reviews, staff inservice education which included a review of the facility's CPR/Advance Directives policies, printing the resident's LaPost, Advance Directives, orders, MAR (Medication Administration Record), and face sheet to send with a resident when transported to the hospital, and communicating a resident's code status to EMS staff when 911 was called. The latest inservice was conducted on [DATE]. Corrective actions further included discussions in the daily quality assurance meetings with the interdisciplinary team, ongoing weekly monitoring of code status for all new admissions by S13 Social Worker, and ongoing weekly monitoring of resident records by S14 Medical Records to ensure resident code status was in all of the required areas of the medical record and documents including code status were provided to transport personnel.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record reviews the facility failed to develop and implement a comprehensive, resident centered plan of care for 2 (#3, #4) out of 5 (#1, #2. #3, #4, #5) sampled r...
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Based on observations, interviews and record reviews the facility failed to develop and implement a comprehensive, resident centered plan of care for 2 (#3, #4) out of 5 (#1, #2. #3, #4, #5) sampled residents.
Findings:
Resident #3
Review of Resident #3's medical record revealed an admit date of 02/14/2025 with diagnoses including but not limited to: Type 2 diabetes mellitus with diabetic chronic kidney disease, morbid obesity, congestive heart failure, generalized edema, dependence on renal dialysis.
Review of Resident #3's MDS (Minimum Data Set) assessments dated 03/04/2025 a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating the resident was cognitively intact.
An observation on 04/07/2025 at 8:55 a.m. revealed Resident #3 had an indwelling urinary catheter draining cloudy urine and a right chest wall dialysis access site.
During an interview on 04/07/2025 at 8:55 a.m. Resident #3 reported he was admitted to the facility with the urinary catheter and with the dialysis access site in his right chest wall.
Review of Resident #3's comprehensive care plan failed to reveal any problems, goals, or approaches for the care for the resident's indwelling catheter or right chest wall dialysis site.
During an interview on 04/10/2025 at 10:40 a.m. S2 Interim DON (Director of Nursing) confirmed Resident #3's care plan did not include any problems, goals, or approaches for the care of the resident's indwelling catheter or right chest wall dialysis site and it should.
Resident #4
Review of Resident #4's medical record revealed an initial admit date of 05/27/2022 with the following diagnoses which included but not limited to: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, acute and chronic respiratory failure, moderate protein-calorie malnutrition and encounter for attention to gastrostomy.
Review of Resident #4's MDS revealed no BIMS score due to Resident #4 was rarely/never understood. Further review revealed Resident #4 was marked as having a feeding tube.
An observation on 04/10/2025 at 8:05a.m.with S3 LPN (Licensed Practical Nurse)/Treatment Nurse revealed Resident #4 had a PEG (Percutaneous Endoscopic Gastrostomy) tube.
Review of resident #4's comprehensive care plan failed to reveal any problems, goals, or approaches for PEG tube care.
During an interview on 04/10/2025 at 12:37 p.m. S5 MDS Nurse confirmed Resident #4 was not care planned for a PEG tube and should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (#4, #5) of 5 (#1, #2, #3, #4, #5)...
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Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (#4, #5) of 5 (#1, #2, #3, #4, #5) sampled residents with peg tubes (a feeding tube inserted through the abdomen and into the stomach). The facility failed to ensure accurate skin assessments that reflected a peg tube site for Residents #4 and #5.
Findings:
Review of the facility's Wound Assessment Policy (no revision date) revealed: Weekly skin review should be done on each resident in PCC [Point Click Care (Electronic Health Record)]. Residents with pressure areas will be reassessed and evaluated by the treatment nurse and assisting RN Registered Nurse) in weekly clinical meeting.
Resident #4
Review of Resident #4's medical record revealed an initial admit date of 05/27/2022 with the following diagnoses which included but not limited to: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, acute and chronic respiratory failure, moderate protein-calorie malnutrition and encounter for attention to gastrostomy.
Review of Resident #4's MDS (Minimum Data Set) revealed no BIMS (Brief Interview of Mental Status) score due to Resident #5 was rarely/never understood. Further review revealed Resident #4 was marked as having a feeding tube.
Review of Resident #4's physician orders revealed an order dated 01/27/2025 to clean Resident #4's PEG (Percutaneous Endoscopic Gastrostomy) tube site with wound cleanser, pat dry, and apply dry dressing every day and PRN (as needed) for soilage, every day.
Review of Resident #4's 2025 TAR (Treatment Administration Record) revealed: Review of the 2025 TAR revealed: clean peg tube site with wound cleanser, pat dry and apply dry dressing every day and PRN (as needed) for soilage, with a start date of 01/28/2025.
Review of Resident #4's Consulate Weekly Skin Integrity Review (skin review assessment) failed to reveal documentation of a peg tube wound on the following dates: 03/03/2025, 03/18/2025, 03/25/2025 and 04/01/2025.
Resident #5
Review of Resident #5's medical record revealed an initial admit date of 05/07/2024 with the following diagnoses which included but not limited to: Closed fracture of the right femur, congestive heart failure, hemiplegia affecting the right dominant side, cerebral infarction due to thrombosis of left middle cerebral artery, unspecified dementia.
Review of Resident #5's MDS revealed no BIMS score due to Resident #5 was rarely/never understood. Further review revealed Resident #5 was marked as having a feeding tube.
Review of Resident #5's physician orders revealed an order dated 02/08/2025 to clean Resident #5's PEG tube site with wound cleanser, pat dry, and apply dry dressing every day and PRN for soilage, every day.
Review of Resident #5's 2025 TAR revealed: Review of the 2025 TAR revealed: clean peg tube site with wound cleanser, pat dry and apply dry dressing every day and PRN for soilage, with a start date of 02/09/2025.
Review of Resident #5's Consulate Weekly Skin Integrity Review failed to reveal documentation of a peg tube wound on the following dates: 03/07/2025, 03/14/2025, 03/21/2025, 03/28/2025, and 04/03/2025.
During an interview on 04/09/2025 at 12:43 p.m. S3 LPN/Treatment Nurse reviewed Resident #4's Consulate Skin Integrity Reviews and acknowledged the assessment did not accurately reflect Resident #4's peg tube on 03/03/2025, 03/18/2025, 03/25/2025 and 04/01/2025 and should have. S3 LPN/Treatment Nurse further reviewed Resident #5's Consulate Skin Integrity Reviews (skin assessment) and acknowledged the assessment did not accurately reflect Resident #5's peg tube on 03/07/2025, 03/14/2025, 03/21/2025, 03/28/2025, and 04/03/2025 and should have.
During an interview on 4/9/25 at 3:45 p.m. S3 LPN/Treatment Nurse reported she was just clicking when completing skin assessments in Resident #4 and #5's electronic medical records, and confirmed the skin assessments did not accurately reflect Resident #4 and #5's peg tubes.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional...
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Based on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#3) of 5 (#1, #2, #3, #4, and #5) sampled residents.
Findings:
Review of the provider's Catheter Care, Indwelling Catheter policy (undated) revealed in part:
Purpose-to prevent urinary tract infection, reduce urethral irritation.
-Assessment guidelines may include, but are not limited to: color, consistency, amount of urine
-Documentation Guidelines-Documentation includes: date, time, procedure, condition of the perineum and catheter insertion site, any unusual condition or change in condition, color, amount, consistency and odor of urine, notification of the physician of any condition change, intake and output and evaluation of intake and output, signature and title.
-Care Plan Documentation Guidelines-record the catheter care as an approach under the appropriate underlying problem on the resident's care plan.
Review of Resident #3's record revealed an admit date of 02/14/2025 and diagnoses including but not limited to: morbid obesity, type 2 diabetes mellitus with chronic kidney disease, diabetic foot ulcers, congestive heart failure, generalized edema, dependence on renal dialysis, and malignant neoplasm of hepatic flexure.
Review of Resident #3's MDS (Minimum Data Set) assessments dated 03/04/2025 a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating the resident was cognitively intact. Further review revealed Section H Bowel and Bladder-Indwelling Catheter was marked No.
An observation on 04/07/2025 at 8:55 a.m. revealed Resident #3 had an indwelling urinary catheter draining cloudy urine.
During an interview on 04/07/2025 at 8:55 a.m. Resident #3 reported he was admitted to the facility with the urinary catheter.
Review of Resident #3's physician Active Orders as of 04/09/2025 failed to reveal an order for an indwelling urinary catheter. Further review revealed an order dated 03/26/2025 for Doxycycline Hyclate (an antibiotic) 100mg (milligrams) by mouth every morning and at bed time for infection for 10 days (completed 04/04/2025).
Review of Resident #3's March 2025 and April 2025 MAR (Medication Administration Record) failed to reveal any catheter care or monitoring of the color, character, or amount of Resident #3's urine.
Review of Resident #3's comprehensive care plan revealed he was care planned for a UTI (urinary tract infection) with interventions including monitoring for and reporting any signs and symptoms of a UTI. Further review revealed no interventions related to the presence of an indwelling urinary catheter.
Observation on 04/08/2025 at 7:45 a.m. revealed Resident #3 lying in bed with his eyes closed, urinary catheter draining cloudy yellow urine.
During an interview on 04/10/2025 S6 LPN (Licensed Practical Nurse) reviewed Resident #3's active physician orders and confirmed there was not an order for the resident's indwelling urinary catheter and there should be. S6 LPN further confirmed there was no documentation of monitoring of the Resident #3's urine for color, character, and amount and there should be. S6 LPN further reported Resident #3 completed a round of antibiotics on 04/04/2025 for an infection but did not know if it was for a skin infection or a UTI. S6 LPN further confirmed the resident's care plan did not include any problems, goals, or approaches for his indwelling urinary catheter and it should.
During an interview on 04/10/2025 at 8:07 a.m. S15 CNA (Certified Nursing Assistant) reported Resident #3 had a urinary catheter that she emptied at the end of her shift or before him going to dialysis, but there was nowhere for her to document how much urine she emptied from his catheter or what it looked and smelled like. S15 CNA further reported she did catheter care every day, but there was nowhere for her to document it.
During an interview on 04/10/2025 at 10:40 a.m. S2 Interim DON (Director of Nursing) confirmed there was no physician order for Resident #3's indwelling urinary catheter, no monitoring of the color, character, or amount of his urine, and no documentation of catheter care and there should be.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record review, the facility failed to ensure appropriate care and services had been provided for 1 (#3) of 1 (#3) residents reviewed for Dialysis out of a total o...
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Based on observations, interviews and record review, the facility failed to ensure appropriate care and services had been provided for 1 (#3) of 1 (#3) residents reviewed for Dialysis out of a total of 5 sampled residents. The facility failed to ensure Resident #3 was accurately assessed and monitored for the care of his dialysis access site.
Findings:
Review of Resident #3's record revealed an admit date of 02/14/2025 and diagnoses including but not limited to: type 2 diabetes mellitus with chronic kidney disease, and dependence on renal dialysis.
An observation on 04/07/2025 at 8:55 a.m. revealed Resident #3 had a dressing in place to his right chest wall.
During an interview on 04/07/2025 at 8:55 a.m. Resident #3 reported his dialysis access site was in his right chest wall where the dressing was.
Review of Resident #3's MDS (Minimum Data Set) assessments dated 03/04/2025 a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating the resident was cognitively intact. Further review of section O-Special Treatments, Procedures, and Programs revealed the resident was not coded for receiving hemodialysis.
Review of Resident #3's physician Active Orders as of 04/09/2025 revealed orders including:
-02/17/2025-Hemodialysis every Monday, Wednesday, and Friday;
-02/14/2025-Hemodialysis- Assess site (right arm) for bruising/bleeding/symptoms of infection; and
-02/14/2025-Check AV (arteriovenous) shunt each shift-assess for bruit (an audible swishing sound) and thrill (a palpable vibration) every shift for monitoring
Review of Resident #3's March 2025 and April 2025 MAR (Medication Administration Record) revealed:
-monitoring of AV shunt for bruit and thrill
-no monitoring of any kind for Resident #3's right chest wall hemodialysis access site
Review of Resident #3's comprehensive care plan failed to reveal any interventions related to his dialysis access site.
During an interview on 04/10/2025, S6 LPN (Licensed Practical Nurse) reported Resident #3's dialysis access site was in in right chest wall and did not have a thrill or bruit like a graft in the arm would. S6 LPN reported Resident #3 did not have a right arm dialysis access site. S6 LPN reviewed Resident #3's active physician orders and confirmed his order was for monitoring of a right arm dialysis access graft. S6 LPN confirmed she had been documenting monitoring of a right arm graft having a thrill and bruit and should not have. S6 LPN further confirmed there was no documented monitoring of any kind of Resident #3's right chest wall dialysis access and there should be. S6 LPN further confirmed the resident's care plan did not include monitoring of his right chest wall dialysis access site and should.
During an interview on 04/10/2025 at 10:08 a.m. Resident #3 reported he used to have a right arm graft but it was removed about 3 months ago.
During an interview on 04/10/2025 at 10:40 a.m. S2 Interim DON (Director of Nursing) confirmed there was no monitoring of Resident #3's right chest wall dialysis access site and there should be.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure medical records were accurately documented for 2 (#3, #5) o...
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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 medical records were accurately documented for 2 (#3, #5) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility failed to ensure accurate documentation of weekly skin assessments for Resident #3 and #5, and accurate documentation of dressing changes for Resident #5.
Findings:
Review of the facility's Wound Assessment Policy (no revision date) revealed: Weekly skin review should be done on each resident in PCC [Point Click Care (Electronic Health Record)]. Residents with pressure areas will be reassessed and evaluated by the treatment nurse and assisting RN (Registered Nurse) in weekly clinical meeting.
Resident #3
Review of Resident #3's medical record revealed an admit date of 02/14/2025 and diagnoses including but not limited to: Type 2 Diabetes Mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with foot ulcers, Fournier gangrene, generalized edema, complete traumatic amputation of right foot.
Review of Resident #3's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating Resident #3 was cognitively intact.
Review of Resident #3's physician orders revealed an order dated 02/17/2025-weekly skin sweeps.
Review of Resident #5's Consulate Weekly Skin Integrity Reviews revealed weekly skin assessments including assessments dated 02/21/2025, 02/24/2025, and 02/28/2025.
Review of Resident #3's progress notes revealed the resident was in the hospital from [DATE] to 03/03/2025.
During an interview on 04/09/2025 at 3:43 p.m. S3 LPN (Licensed Practical Nurse)/Treatment Nurse reviewed Resident #3's Consulate Weekly Skin Integrity Reviews for 02/21/2025, 02/24/2025, and 02/28/2025 and confirmed she had completed them for a time period the resident was out of the facility in the hospital and should not have. S3 LPN/Treatment Nurse further reported that was me just clicking and she shouldn't have done that.
Resident #5
Review of Resident #5's medical record revealed an initial admit date of 05/07/2024.
Review of Resident #5's medical record revealed the following diagnoses which included but not limited to: Closed fracture of the right femur, congestive heart failure, hemiplegia affecting the right dominant side, cerebral infarction due to thrombosis of left middle cerebral artery, unspecified dementia.
Review of Resident #5's MDS revealed no BIMS score due to Resident #5 was rarely/never understood.
Review of Resident #5's physician orders revealed an order dated 02/08/2025 to clean Resident #5's Peg Tube (Percutaneous Endoscopic Gastrostomy) site with wound cleanser, pat dry, and apply dry dressing every day and PRN (as needed) for soilage, every day.
Review of Resident #5's Consulate Weekly Skin Integrity Review dated 04/04/2025 revealed Resident #5's current skin condition was marked yes for skin intact.
Review of Resident #5's April 2025 TAR (Treatment Administration Record) revealed Resident #5's Peg Tube site dressing was changed on 04/05/2025 and 04/06/2025 by S3 LPN/Wound Care Nurse.
Review of Resident #5's progress notes dated 04/03/2025 at 11:14 p.m. revealed Resident #5's right hip x-ray report came in, indicating that resident has a displaced acute appearing fracture noted of the femoral neck. Resident #5 was sent out to the emergency room via ambulance. A phone order was received to send Resident #5 out to the emergency room.
Review of Resident #5's progress notes revealed Resident #5 was in the hospital on [DATE], 04/04/2025, 04/05/2025, 04/06,2025 and returned from the hospital to the facility on [DATE].
During an interview on 04/09/2025 at 12:43 p.m. S3 LPN/Treatement Nurse reviewed Resident #5's Consulate Skin Integrity Reviews (skin assessment) and confirmed she could not have done a skin assessment of Resident #5 on 04/04/2025 due to the resident being hospitalized from [DATE] to 04/07/2025. S3 LPN/Wound Care Nurse further acknowledged the documentation on 04/04/2025 was not accurate.
During an interview on 04/09/2025 at 4:20 p.m. S3 LPN Treatment Nurse reviewed Resident #5's April 2025 TAR and acknowledged Resident #5's Peg tube site dressing changes on 04/05/2025 and 04/06/2025 were not accurate. S3 LPN/Treatment Nurse further confirmed Resident #5 was in the hospital on those dates.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and control program help prevent the development and transmission of communicabl...
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Based on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and control program help prevent the development and transmission of communicable diseases and infections for 2 (#3 and #4) of 5 (#1, #2, #3, #4, and #5) sampled residents as evidenced by failing to ensure:
1. Staff wore appropriate PPE (Personal Protective Equipment) when providing high contact patient care for Resident #3, and #4 who were had Enhanced Barrier Precautions (EBP) in place;
2. Followed appropriate hand hygiene during wound care and incontinence care for Resident #3; and
3. Followed accepted infection control principals during wound care and incontinence care for Resident #3.
Findings:
Resident #4
Review of Resident #4's medical record revealed an initial admit date of 05/27/2022 with diagnoses including but not limited to: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, acute and chronic respiratory failure, moderate protein-calorie malnutrition and encounter for attention to gastrostomy.
Review of Resident #4's physician orders revealed and order dated 01/27/2025 for EBP utilized when performing high-contact resident care activities related to PEG (percutaneous endoscopic gastrostomy) tube every shift.
An observation on 04/09/2025 at 2:31 p.m. revealed S3 LPN (Licensed Practical Nurse)/Treatment Nurse changed the PEG tube dressing of Resident #4. S3 LPN/Treatment Nurse failed to wear a protective gown while changing the PEG Tube dressing of Resident #4.
Resident #3
Review of Resident #3's medical record revealed an admit date of 02/14/2025 and diagnoses including but not limited to: Type 2 Diabetes Mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with foot ulcers, Fournier gangrene, generalized edema, complete traumatic amputation of right foot.
Review of Resident #3's MDS (Minimum Data Set) assessments dated 03/04/2025 a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating the resident was cognitively intact.
Review of Resident #3's active physician orders revealed orders including:
-04/08/2025-Sacrum: cleanse with wound cleanser. Pat dry. Apply skin prep to perineal area. Apply hydrocolloid dressing to open area every 3 days and as needed until resolved.
-03/23/2025-left heel diabetic foot ulcer: cleanse with wound cleanser. Pat dry. Apply skin prep to perineal area. Apply betadine to escar and calcium alginate to granular tissue, then cover with ABD (abdominal dressing) pad, then wrap with kerlix every other day until resolved and as needed.
-03/23/2025-right foot diabetic foot ulcer: cleanse with wound cleanser. Pat dry. Apply skin prep to perineal area. Apply betadine to escar and calcium alginate to granular tissue, then cover with ABD (abdominal dressing) pad, then wrap with kerlix every other day until resolved and as needed.
-02/17/2025-EBP every shift related to dialysis port/wounds/foley catheter
Observation on 04/10/2025 at 9:45 a.m. revealed S3 LPN/Treatment Nurse perform wound care to Resident #3's bilateral diabetic foot ulcers and his sacral moisture associated wound assisted by S15 CNA (Certified Nursing Assistant) and observed by S2 Interim DON (Director of Nursing). S3 LPN/Treatment Nurse and S15 CNA failed to don a protective gown prior to providing this high contact resident care. S3 LPN/Treatment Nurse was observed performing care to Resident #3's left leg diabetic foot ulcer removing the soiled dressing while leaning her upper body against the bed and soiled bed linens. S3 LPN/Treatment Nurse removed her gloves and donned a clean pair of gloves without sanitizing her hands and began cleaning areas of the foot moving from one area to another with the same section of the gauze. There was bloody drainage from the foot. S3 LPN/Treatment Nurse changed gloves again without sanitizing her hands, and began applying betadine with a swab moving from one area of the foot to another area with the same swab. S3 LPN/Treatment Nurse repeated the process on the right foot again without sanitizing her hands between glove changes and moving from one area of the right foot to another with the same section of the gauze and with the same betadine swab. S3 LPN/Treatment Nurse's upper body and clothing was touching Resident #3's bed linens which were soiled with drainage from the wounds as well as touching the soiled dressings. S3 LPN/Treatment Nurse was further observed to be wearing a bracelet with dangling charms which was outside of her gloves and was repeatedly touching the soiled linens.
Resident #3 was then rolled to his left side toward S15 CNA to perform care to his sacral moisture associated wound. S15 CNA was observed to use her upper body against the Resident #3's body to assist in positioning. Resident #3 had had a bowel movement (BM), so S3 LPN/Treatment Nurse cleaned the BM before performing the sacral wound care. S3 LPN/Treatment Nurse's bracelet with dangling charms repeatedly came into contact with the inside of Resident #3's soiled incontinence brief throughout the incontinence care. S3 LPN/Treatment Nurse then proceeded to remove her soiled gloves, don a clean pair of gloves, and initiate wound care to Resident #3's sacrum without sanitizing her hands. S3 LPN/Treatment Nurse further proceeded to apply wound cleanser from the edges of the wound to the center and pat back and forth across the wound/red macerated areas. S3 LPN/Treatment Nurse and S15 CNA then proceeded to change the resident's soiled linens with both their unprotected upper bodies touching the soiled linens.
During an interview on 04/10/2025 at 10:37 a.m. S3 LPN/Treatment Nurse confirmed she did not don a protective gown prior to performing wound care on Resident #3 involving contact with soiled linens and dressings and should have. S3 LPN/Treatment Nurse further confirmed she did not sanitize her hands between glove changes when moving from dirty to clean tasks and should have. S3 LPN/Treatment Nurse confirmed she should have used a clean section of gauze for each area cleansed and should have used a separate betadine swab for each area of the feet and did not. S3 LPN/Treatment Nurse reported she thought her bracelet with dangling charms had been inside her gloves, and she should have taken it off before providing high contact care to Resident #3. S3 LPN/Treatment Nurse further confirmed she did not don a protective gown when performing PEG tube care to Resident #4 on 04/09/2025 and should have.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on record reviews and interviews the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to e...
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Based on record reviews and interviews the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs. The facility failed to:
1. provide the minimum required staffing hours for 20 of 37 days reviewed and
2. ensure a licensed nurse was designated as a charge nurse for each shift.
Findings:
Review of the facility completed Nursing Personnel Staffing Pattern Reporting Forms for 03/01/25 to 04/06/2025 revealed insufficient staff below the required minimum hours for the following dates:
03/08/2025: negative 14.93 hours
03/09/2025: negative 23.28 hours
03/11/2025: negative 1.07 hours
03/16/2025: negative 17 hours
03/18/2025: negative 0.29 hours
03/23/2025: negative 16.15 hours
03/24/2025: negative 14.56 hours
03/25/2025: negative 23.05 hours
03/26/2025: negative 7.52 hours
03/27/2025: negative 3.71 hours
03/28/2025: negative 1.83 hours
03/29/2025: negative 6.45 hours
03/30/2025: negative 4.67 hours
03/31/2025: negative 15.74 hours
04/01/2025: negative 12:81 hours
04/02/2025: negative 6.12 hours
04/03/2025: negative 37.1 hours
04/04/2025: negative 6.63 hours
04/05/2025: negative 15.48 hours
04/06/2025: negative 22.53 hours
During an interview on 04/07/2025 at 7:35 a.m. S6 LPN (Licensed Practical Nurse), S7 LPN, and S8 LPN were all at the nursing station and reported the administrator was not in facility. S6 LPN, S7 LPN, and S8 LPN were further asked who was in charge for the shift, and they replied they did not have a charge nurse.
During an interview on 04/07/2025 at 8:15 a.m. S1 Administrator was asked who the charge nurse was on duty, and she was unable to answer the question.
During an interview on 04/07/25 at 12:20 p.m. S4 HR (Human Resources) confirmed the facility had insufficient staffing levels for the above dates that did not meet the required minimum staffing hours.
During an interview on 04/07/2025 at 3:28 p.m. S1 Administrator confirmed the facility had insufficient staffing levels for the above dates that did not meet the required staffing hours, and said they were due to a lack of CNAs (Certified Nursing Assistants). S1 administrator confirmed there was no charge nurse assigned for each shift. S1 Administrator further reported the average daily census was 60-62 residents and the facility had no staffing waivers.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review and interviews, the provider failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 2 of 37 days reviewed for RN hours, and failed t...
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Based on record review and interviews, the provider failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 2 of 37 days reviewed for RN hours, and failed to have a DON (Director of Nursing) for 33 consecutive days. This deficient practice had the potential to affect any of the 59 Residents residing in the facility according to the facility's detailed census report.
Findings:
Review of the facility completed Nursing Personnel Staffing Pattern Reporting Forms for 03/01/2025 to 04/06/2025 revealed no RN coverage 04/02/2025 and 04/03/2025.
During an interview on 04/07/2025 at 7:35 a.m. S6 LPN (Licensed Practical Nurse), S7 LPN, and S8 LPN were all at the nursing station and reported the administrator was not in facility and they did not currently have a DON.
During an interview on 04/07/2025 at 8:15 a.m. S1 Administrator reported they did not currently have a director of nursing.
During an interview on 04/07/25 at 12:20 p.m. S4 HR (Human Resources) confirmed the facility did not have an RN on duty 8 consecutive hours for every day during the time frame of 03/01/2025 to 04/06/2025.
During an interview on 04/07/2025 at 3:28 p.m. S1 Administrator confirmed there was no RN on duty for 04/02/2025 and 04/03/2025 and there should have been. S1 Administrator further reported the facility did not have a DON from 03/06/2025 to 04/07/2025 and should have. S1 Administrator further reported the average daily census was 60-62 residents and the facility had no staffing waivers.
Dec 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
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure quarterly statements were provided for 2 (#1, #3) of 5 (#1, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure quarterly statements were provided for 2 (#1, #3) of 5 (#1, #2, #3, #4, #5) residents whose personal funds accounts were reviewed. The facility failed to provide quarterly statements to residents and their responsible parties.
Findings:
Review of the facility's Personal Funds Policy revealed the following:
Purpose: Ensure that each individual record is established for each resident on which only those transactions involving: his/her personal funds are recorded and maintained.
1. The facility must establish and maintain a system that ensures a full and complete and separate accounting, according to generally accepted accounting principles, of each residents personal funds entrusted to the facility on the resident's behalf.
2. The individual financial record must be available to the resident through quarterly statements and upon requests.
Resident #1
Review of resident #1's electronic health record revealed resident #1 was admitted to the facility on [DATE] with a diagnoses of but not limited to; dementia, without behavioral disturbance, type 2 diabetes, ulcerative proctitis, hypertension, muscle weakness, heart disease and anemia.
Review of resident #1's MDS (minimum data set) revealed resident #1 had a BIMS (brief interview mental status) score of 99 indicating resident #1 was rarely/never understood.
During a phone interview on 12/17/2024 at 1:24 p.m. resident #1's responsible party reported she had not received statements quarterly for resident #1. Resident #1's responsible party further reported only receiving 1 statement by mail since resident #1 had been in the facility.
Resident #3
Review of resident # 3's electronic health record revealed resident # 3 was his own responsible party.
Review of resident #3's MDS dated [DATE] revealed resident #3 had BIMS score of 10 indicating moderately impaired cognition.
During an interview on 12/19/2024 at 9:00 a.m. resident #3 reported he had never received a statement regarding the balance of his account.
During an interview on 12/19/2024 at 11:30 a.m. S3 Social Services reported she was not aware of any residents that had received statements from their account and further stated she did not know this was required.
During an interview on 12/17/2024 at 3:30 p.m. S2 BOM (Business Office Manager) reported it was her practice to have statements mailed quarterly to resident's responsible parties and give residents statements by placing them in their rooms. S2 BOM confirmed she was not able to provide documented evidence of the provision of quarterly statements to resident's responsible parties and to residents in the facility who were their own responsible party.
During an interview on 12/19/2024 at 2:00 p.m. S1 Administrator confirmed the facility was unable to provide documented evidence of the provision of quarterly statements to resident's responsible parties and to residents in the facility who were their own responsible party.
Jul 2024
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident assessments accurately reflected the resident's stat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#44) of 2 (#1, #44) residents reviewed for accidents. The facility failed to ensure the post-fall assessment was accurately completed for fall risk.
Findings:
Review of undated Risk Evaluations policy revealed in part:
Policy: Residents will have Risk Evaluations performed upon admission/readmission, quarterly, annually and with significant change in status.
-Risk evaluations for falls, evaluation of pressure ulcer risk, evaluation of elopement risk, evaluation of smoking risk, evaluation of dehydration risk:
5. For residents who score at risk, develop a preventative care plan for that risk area.
6. Physical Therapy/Occupational Therapy/Dietary/Nursing are to review the appropriate Risk Evaluations on admission/readmission with a significant change, quarterly and annually to identify high risk residents.
7. The completed evaluation is to be stored in the Medical Record under assessments.
Review of Resident #44's medical record revealed an admit date of 07/14/2023 with diagnoses that included in part peripheral vascular disease, psychoactive substance abuse, difficulty walking, unsteadiness on feet, lack of coordination, and low back pain.
Review of Resident #44's comprehensive care plan revealed Resident #44 was at risk for falls with falls on 12/31/2023, 04/06/2024 and 07/09/2024.
Review of Resident #44's post-fall risk assessment dated [DATE] revealed Resident #44 was low risk for falls.
During an interview on 07/16/2024 at 9:20 a.m. S2 DON (Director of Nursing) reviewed resident #44's post-fall risk evaluation for 07/09/2024 and confirmed it was incorrect and fall precautions should have been implemented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record reviews, observations and interviews, the facility failed to ensure a resident who was unable to complete their ADLs (activities of daily living) received the necessary services to mai...
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Based on record reviews, observations and interviews, the facility failed to ensure a resident who was unable to complete their ADLs (activities of daily living) received the necessary services to maintain proper grooming for 1 (#29) out of 1 (#29) residents reviewed for ADLs. The facility failed to ensure Resident #29 received nail care.
Findings:
Review of facility's Fingernails/Toenails Care (undated) revealed in part:
Policy: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections.
Responsibility: Nursing Assistant or Licensed Nurse
Key Procedural Points:
5. Stop and report to the charge nurse any evidence of ingrown nails, infections, pain, or if nails are too hard or too thick to cut with ease.
Review of Resident #29's medical diagnoses revealed: morbid (severe) obesity (07/13/2023), lack of coordination (07/26/2023).
Review of Resident #29's July 2024 physician orders revealed an order dated 06/13/2024: clean, cut, and trim fingernails and toenails every week document any refusal; every Thursday.
Observation on 07/15/2024 at 8:28 a.m. revealed Resident #29's toenails on both feet were thick, dark, long and had grown over the nail bed.
During an interview on 07/15/2024 at 8:28 a.m. Resident #29 reported her last podiatrist visit was about 8 months ago.
Observation on 07/16/2024 at 10:00 a.m. with S2 DON (Director of Nursing) revealed Resident #29's toenails on both feet were thick, dark, long and had grown over the nail bed.
During an interview on 07/16/2024 at 10:00 a.m. S2 DON confirmed Resident #29's toe nails needed to be trimmed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility failed to accommodate the needs of 5 (#23, #29, #31, #50, & #...
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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 accommodate the needs of 5 (#23, #29, #31, #50, & #54) of 29 sampled residents. The facility failed to ensure:
(1) Two (#31, #50) residents call lights were in reach.
(2) One (#54) resident call light was functioning.
(3) Incontinence briefs were readily available for 2 (#23, #29) residents
Findings:
(1)
Resident #31
Review of Resident #31's medical record revealed Resident #31 was admitted to the facility on [DATE].
Review of Resident #31's 05/15/2024 Quarterly MDS (Minimum Data Set) revealed Resident #31 had a BIMs (Brief Interview Mental Status) score of 06 which indicated severe cognitive impairment and did not have any functional impairment to upper or lower extremities.
Observation on 07/14/2024 at 8:15 a.m. revealed Resident #31's call light was wedged between the foot of mattress and foot of bed.
During an interview on 07/14/2024 at 8:15 a.m. Resident #31 reported he did not know where his call light was and confirmed it was out of reach.
During an interview on 07/14/2024 at 9:26 a.m. S11 CNA (Certified Nursing Assistant) observed Resident #31's call light and confirmed it was out of Resident #31's reach.
Resident #50
Review of Resident #50's medical record revealed Resident #50 was admitted to the facility on [DATE].
Review of Resident #50's 05/07/2024 Quarterly MDS revealed Resident #50 had a BIMs score of 08 which indicated moderate cognitive impairment and did not have any functional impairment to upper or lower extremities.
Observation on 07/14/2024 at 8:55 a.m. revealed Resident #50's call light cord was dangling from bed rail and call button was touching the floor and not within reach.
During an interview on 07/14/2024 at 9:21 a.m. S11 CNA observed Resident #50's call light and confirmed it was out of Resident #50's reach.
(2)
Resident #54
Review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE].
Review of Resident #54's 06/20/2024 admission MDS revealed Resident #54 had a BIMs score of 15 which indicated Resident #54 was cognitively intact and had an impairment on one of his upper extremities.
Observation on 07/14/2024 at 9:37 a.m. revealed Resident #54 was seated on side of bed and call light with cord was wrapped around call light box on wall.
During an interview on 07/14/2024 at 9:38 a.m. Resident #54 reported he had informed staff that his call light was not working about 3 days ago and maintenance had been by to look at it and told him it did not work but nothing else had been done. Resident #54 further reported he had become aware the call light did not work when he was not feeling well one night and attempted to use the call light and no one responded.
During an interview on 07/15/2024 at 8:08 a.m. S19 Maintenance reported he had looked at Resident #54's call light last Thursday or Friday and had to get a part to fix it.
(3)
Resident #23
Review of Resident #23's medical record revealed an admit date of 05/13/2016 with diagnoses that include in part severe morbid obesity, acute kidney failure, Chronic kidney disease stage 3, anxiety disorder, edema, gout, and essential hypertension.
Review of Resident #23's MDS dated [DATE] revealed Resident #23 was cognitively intact with a BIMS score of 15.
During an interview on 07/14/2024 at 9:00 a.m. Resident #23 reported he has had to buy his own briefs the last 2 times because he was told the diaper orders did not come in and it cost him over 130 dollars.
During an interview on 07/16/2024 at 10:00 a.m. S2 DON (Director of Nursing) reported she ordered supplies and there had been an issue with ordering and receiving supplies on time including diapers.
Resident #29
Review of Resident #29's medical record revealed an admit date of 07/29/2023 with diagnosis that inlcuded in part acute kidney failure.
Review of Resident #29's Quarterly MDS dated [DATE] revealed a BIMS of 15 out of 15 indicating cognitively intact. Further review of Resident #29's Quarterly MDS revealed Resident #29 had an indwelling catheter and was always incontinent of bowel.
Review of Resident #29's Care Plan revealed incontinence of bladder (requires assistance with toileting) with approaches: resident uses disposable briefs. Change every 2 hours and as needed. Clean perineal area with each incontinence episode.
During an interview on 07/15/2024 at 8:19 a.m. Resident #29 reported the facility had been out of incontinence briefs for the past 2 weeks and was not currently wearing an incontinence brief.
During an interview on 07/16/2024 at 10:00 a.m. Resident #29 reported she did not have on an incontinence brief.
During an interview on 07/16/2024 at 10:00 a.m. S2 DON reported she ordered supplies and there had been an issue with ordering and receiving supplies on time including diapers.
Observation on 07/16/2024 at 10:00 a.m. revealed a black plastic bag of medium diapers, (2) boxes of medium diapers, and (1) box of XL (extra large) diapers in S2 DON's office.
During an interview on 07/16/2024 at 10:00 a.m. S2 DON reported Resident #29 needed bariatric incontinence briefs and the facility did not have any bariatric incontinence briefs available.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice had the potential to affect the total census o...
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Based on record reviews and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice had the potential to affect the total census of 58 residents in the facility according to Long-Term Care Facility Application for Medicare and Medicaid dated 07/14/2024.
Findings:
Review of facility's Filing Grievances/Complaints policy (undated) revealed in part:
Policy statement: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made.
Policy Interpretation and Implementation:
1. Any resident, his or her responsible party may file a grievance or complaint concerning medical care, behavior of other residents, staff members, theft of property, etc. without the fear of threat of reprisal in any form.
3. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident.
5. Upon receipt of written grievance and/or complaint, the social services director will investigate the allegations and submit a written report of such findings to the administrator within 24 hours of receiving the grievance and/or complaint.
6. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, needs to be taken.
7. The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or designee, within 3 working days of the filing of the grievance or complaint with the facility.
During an interview on 07/14/2024 at 1:57 p.m. resident council members present reported staff do not take the time to listen to their issues or concerns and/or act promptly on issues brought to their attention in resident council meetings. Resident council members reported staff do not inform then why they are not acting or responding promptly to the resident issues/ concerns. Resident council members present reported the staff do not respond in a timely manner. Residents reported feeling like staff respond sometimes it may take a month or two to get an answer to issues/concerns.
Review of facility's resident council minutes from the last 3 months May 2024 and July 2024 provided by S2 Activity Director revealed a repeated issue regarding medication pharmacy:
05/08/2024:
Issue: resident concerned about medicine.
Action taken: explained to resident about changes in new pharmacy
07/11/2024:
Issue: Resident complained about narcotic medicine
Action taken: explained during meeting
During an interview on 07/14/2024 at 3:02 p.m. S22 Activities Department reported there has been ongoing issues with pain medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure residents were provided information regarding formulation of advance directive upon their admission for 4 (#8, #17, #23, #50) of 24...
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Based on record reviews and interviews the facility failed to ensure residents were provided information regarding formulation of advance directive upon their admission for 4 (#8, #17, #23, #50) of 24 initial pool residents.
Findings:
Review of undated Advance Directives Policy revealed in part:
Policy: It is the policy of the Facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so.
2. Upon admission the facility will provide each resident medically deemed competent or resident's representative, who does not have an existing Advance Directive, with written information and instruction regarding the right to make Advance Directives prior to the initiation of care or at any requested time.
a. The resident may revise or revoke an Advance Directive at any time.
c. The resident's instructions, the resident's receipt of written information, and the existence or non-existence of the resident's Advance Directive must be documented in the resident's record.
Responsibility:
All Facility Employees, Monitored by Social Services Director and Executive Director.
Procedure:
1. The Facility/Staff who admits the resident to the Facility will provide the resident or personal representative with an information packet containing:
a. Advance Directives Information Sheet.
b. A copy of literature regarding planning in advance for your medical treatment and appointing a health care agent.
c. Advanced Directive Health Care Forms.
2. Each resident or personal representative, will be asked if the resident has any Advance Directives.
a. Whether or not an Advance Directive exists shall be documented in the Resident's medical record.
b. If any Advance Directive exists, a copy will be requested and filed in the resident's record.
c. If Advance Directives do not exist:
The staff will refer the resident or personal representative to the information provide in the Advance Directives packet.
If the resident or personal representative requests further instruction, he/she will be instructed by staff and referred to community resources such as an attorney, physician.
Findings:
Resident #8
Review of Resident #8's medical record revealed an admission date of 08/04/2023.
Review of Resident #8's medical record failed to reveal documentation that Resident #8 and/or Resident #8's representative's received information regarding advance directives.
During an interview on 07/15/2024 at 9:30 a.m. S18 Medical Records reported the facility did not have documentation that advance directive information had been provided for Resident #8.
Resident #17
Review of Resident #17's medical record revealed an admission date of 01/26/2016.
Review of Resident #17's medical record failed to reveal documentation that Resident #17 and/or Resident #17's representative's received information regarding advance directives.
During an interview on 07/16/2024 at 3:00 p.m. S18 Medical Records reported they were unable to provide documentation that advance directive information had been provided to Resident #17.
Resident #23
Review of Resident #23's medical record revealed an admission date of 05/13/2016.
Review of Resident #23's medical record failed to reveal documentation that Resident #23 and/or Resident #23's representative's received information regarding advance directives.
During an interview on 07/14/2024 at 2:00 p.m. S18 Medical Records reported the facility was unable to provide documentation that the advance directive information had been provided to Resident #23.
Resident #50
Review of Resident #50's medical record revealed an admission date of 03/13/2024.
Review of Resident #50's medical record failed to reveal documentation that Resident #50 and/or Resident #50's representative received information regarding advance directives.
During an interview on 07/15/2024 at 9:30 a.m. S18 Medical Records reported the facility did not have documentation that advance directive information had been provided for Resident #50.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to thoroughly investigate, document findings, and follow up within 3 working days per facility grievance policy for 1 (#51) out of 1 (#51) re...
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Based on record reviews and interviews the facility failed to thoroughly investigate, document findings, and follow up within 3 working days per facility grievance policy for 1 (#51) out of 1 (#51) resident reviewed for personal property.
Findings:
Review of facility's Filing Grievances/Complaints policy (undated) revealed in part:
Policy statement: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made.
Policy Interpretation and Implementation:
1. Any resident, his or her responsible party may file a grievance or complaint concerning medical care, behavior of other residents, staff members, theft of property, etc. without the fear of threat of reprisal in any form.
3. Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident.
5. Upon receipt of written grievance and/or complaint, the social services director will investigate the allegations and submit a written report of such findings to the administrator within 24 hours of receiving the grievance and/or complaint.
6. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, needs to be taken.
7. The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or designee, within 3 working days of the filing of the grievance or complaint with the facility.
Review of grievance filed on 06/12/2024 revealed grievance was communicated verbally to the DON (Director of Nursing). Further review revealed grievance form was completed by S23 Social Services.
Describe concern in detail: Resident # 51 states that when she left her room her things came up missing. drink flavored packs, chips, crackers, cheese. Resident #51 reported a week after being admitted to the facility she reported she had $198.00 missing. Resident #51 reported pants and socks were also missing.
Further review of grievance form revealed S23 Social Services was assigned responsibility for the investigation.
Findings of investigation: I spoke with Resident # 51's roommate to see if she heard or saw anything she stated she did not.
Review of grievance filed on 06/14/2024 revealed grievance was communicated verbally to S23 Social Services.
Further review revealed grievance form was completed by S23 Social Services.
Describe concern in detail: Resident # 51 states someone took a pack of depends, a protein shake and a juice
Further review of grievance form revealed S23 Social services was assigned responsibility for the investigation.
Findings of investigation: Spoke with Resident # 51 roommate to see if she knew anything. She stated she did not see anything.
During an interview on 07/14/2024 at 2:30 p.m. Resident # 51 reported several missing items that to a lady. Resident #51 was unable to recall the lady's name or department. Resident #51 reported missing items included: 2 rows of depends purchased by her family and brought to the facility, apple juice, grape juice, food items: chips, dip, tuna and a package of crackers. Resident #51 reported the lady wrote down the information to make a report and Resident #51 reported she has not received a follow up of the findings or what they were going to do about the missing items.
During an interview on 07/15/2024 at 3:35 p.m Resident #51 described the missing items were a red shirt with cars on it, sweat pants, socks, and $198.00 in cash she had in her pocket. Resident # 51 reported she can just say the money is missing, when she first came to the facility she was not thinking right and maybe did not put the money up right. Resident #51 reported when she woke up all the money in her pocket was gone.
During an interview on 07/15/2024 at 3:50 p.m. S23 Social Services reported Resident #51's missing items were documented on a grievance form, then the grievance form was given to the Administrator and DON (Director of Nursing) informing them about Resident #51's missing items. S23 Social Services confirmed only documentation of the grievance investigation was asking Resident #51's roommate had she seen or heard anything. S23 Social Services confirmed no other investigation was documented. S23 Social Services reported she thought the Administrator and/or the DON would get back to the resident.
During an interview on 07/16/2024 at 4:45 p.m. S1 Administrator reported a follow up was done with Resident #51 yesterday and a thorough investigation was not done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to ensure a criminal background check and sex offender registry check had been conducted prior to hire for 1 (S14 CNA[Certified Nursing Assista...
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Based on record review and interview the facility failed to ensure a criminal background check and sex offender registry check had been conducted prior to hire for 1 (S14 CNA[Certified Nursing Assistant]) of 5 (S12 CNA, S13 CNA, S14 CNA, S15 CNA, and S16 CNA) CNA personnel records reviewed.
Findings:
Review of undated policy on Abuse Prevention revealed:
Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.
Procedure:
A. Steps to prevent, detect and report:
Screening:
1. The facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals or misappropriation of property.
3. The facility will pre-screen all potential new employees, volunteers, and residents for a history of abusive behavior.
Review of S14 CNA's personnel record revealed a hire date of 06/25/2020. Further review of S14 CNA's personnel record failed to reveal a criminal background check and a sex offender registry check had been conducted prior to hire.
During an interview on 07/16/2024 at 1:47 p.m. S17 HR (Human Resources) reported a criminal background and sex offender registry check prior to S14 CNA's hire date of 06/25/2020 was not found and there should be one.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a comprehensive, person-centered care plan h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a comprehensive, person-centered care plan had been developed and implemented for 4 (#6, #23, #30 and #54) of 29 sampled residents. The facility failed to ensure:
1. Resident #6 was monitored for anticoagulant use and AV (Arteriovenous) shunt was monitored.
2. Resident #23 was care planned for oxygen
3. Resident #30 was care planned for oxygen, nebulizer treatment minutes were documented and abdominal binder was in use
4. Resident #54 was care planned for having a PICC (peripherally inserted central catheter) line.
Findings:
Resident #6
Review of Resident #6's medical record revealed an admit date of 06/17/2024 with diagnoses which included in part, Chronic Kidney Disease, Stage 4 and Type 2 Diabetes.
Review of Resident #6's medical record revealed the following physician's orders:
06/17/2024 Check AV shunt each shift; assess for bruit and thrill.
06/17/2024 Apixaban (anticoagulant) oral tablet 5 mg. (milligram); give 0.5 (half) tablet by mouth two times a day
06/17/2024 Anticoagulants - Check for bleeding & bruising every shift.
Review of Resident #6's July 2024 TAR (Treatment Administration Record) failed to reveal monitoring for bleeding and bruising and monitoring of AV shunt for bruit and thrill had been completed on the following dates/shifts:
07/01/2024 evening shift
07/02/2024 evening shift
07/03/2024 day shift and evening shift
07/04/2024 day shift and evening shift
07/05/2024 evening shift
07/08/2024 evening shift
07/09/2024 day shift and evening shift
07/10/2024 day shift
07/11/2024 day shift and evening shift
07/12/2024 evening shift
07/15/2024 evening and night shift
During an interview on 07/16/2024 at 10:30 a.m., S2 DON (Director of Nursing) reviewed Resident #6's July 2024 TAR and acknowledged monitoring for bleeding and bruising and monitoring of AV shunt had not been completed every shift as ordered and should have been.
Resident #23
Review of Resident #23's medical record revealed an admit date of 05/13/2016 with diagnoses which included in part, acute on chronic systolic congestive heart failure, atrial flutter, anxiety disorder, presence of cardiac pacemaker, essential hypertension, and seizures.
Review of Resident #23's MDS (Minimum Data Set) dated 05/22/2024 revealed Resident #23 was cognitively intact with a BIMS (brief interview for mental status) score of 15.
Observation on 07/14/2024 at 9:30 a.m. revealed an oxygen concentrator at foot of Resident #23's bed running with nasal cannula attached.
During an interview on 07/14/2024 at 9:30 a.m. Resident #23 confirmed he used the oxygen daily for shortness of breath.
Review of Resident #23's medical record failed to reveal an order for oxygen.
Review of Resident #23's comprehensive care plan failed to reveal a care plan for oxygen with appropriate approaches.
Review of Resident #23's interdisciplinary notes revealed Resident #23 arrived to the facility on [DATE] at 3:13 p.m.on 3 liters oxygen by nasal cannula.
During an interview on 07/16/2024 at 6:00 p.m. S2 DON reported Resident #23 was using oxygen daily because he was short of breath and should have had an order for oxygen use and care/treatment of oxygen supplies and did not.
Resident #30
Review of Resident #30's medical record revealed an admit date of 05/27/2022, with diagnoses which included in part, acute and chronic respiratory failure, brain stem stroke syndrome, and chronic atrial fibrillation.
Review of Resident #30's medical record revealed the following physician's orders:
12/07/2023 Abdominal binder. Patient to wear daily. Only remove for bath/soiling.
06/20/2023 Oxygen 2L(liters)/nasal cannula continuously every shift related to acute and chronic respiratory failure.
06/10/2024 Minutes of Nebulizer administration every 4 hours.
Review of Resident #30's comprehensive care plan failed to reveal Resident #30 was care planned for oxygen with appropriate interventions.
Review of Resident #30's medical record failed to reveal minutes of nebulizer treatments had been documented.
During an interview on 07/16/2024 at 1:30 p.m. S10 MDS Coordinator reviewed Resident #30's comprehensive care plan and confirmed resident #30 was not care planned for the use and care of oxygen and should have been.
Observation on 07/152024 at 4:00 p.m. with S7 LPN (Licensed Practical Nurse) failed to reveal Resident #30 had an abdominal binder in place.
During an interview on 07/15/2024 at 4:00 p.m. S7 LPN verified Resident #30 was not wearing an abdominal binder and should have been.
Resident #54
Review of undated policy for PICC Line or Midline Catheter Dressing Change revealed:
Policy: A dressing change will be done to prevent external infection of the peripheral or central venous catheter.
Responsible party:
Procedure:
1. Identify the resident and assess the resident's chart for any signs, symptoms of complications related to his/her vascular access device.
.
11. Secure the lumens down with tape strip.
12. Document dressing change per facility protocol with initial and date.
13. Reposition the resident to a comfortable position.
15. Document treatment per facility protocol.
16. Assess the dressing change in the first 24 hours for accumulation of blood or moisture beneath the dressing. Change every 7 days and as needed if dressing loose, damp, or soiled.
Review of Resident #54's medical revealed an admit date of 06/14/2024 with diagnoses that included in part, infection and inflammatory reaction due to other internal joint prosthesis and presence of right artificial shoulder joint.
Review of Resident #54's medical record revealed the following physician orders:
06/18/2024 IVs (intravenous): Evaluate site for leakage/bleeding/signs of infection every shift
06/18/2024 IVs: Flush PICC or Mid Line with 10ml (milliliters) of normal saline before and after each infusion.
07/13/2024 Change PICC Dressing q (every) Saturday
07/14/2024 Vancomycin HCl (hydrochloride) Intravenous Solution - Use 1.5 gram intravenously every 24 hours for infection 5pm.
Review of Resident #54's care plan failed to reveal Resident #54 was care planned for PICC line with interventions.
Observation on 07/14/2024 at 10:40 a.m. revealed Resident #54 had a PICC line in place on left inner upper arm with undated clear dressing that was peeling off and black at the edges with a wide piece of clear tap over the end of the dressing and top of port ends.
During an interview on 07/16/2024 at 4:55 p.m.S10 MDS Coordinator reviewed Resident #54's care plan and reported Resident #54 was not care planned for the use and care of a PICC line.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure 1 (#53) of 2 (#6, #53) residents reviewed for nutrition received care as ordered by the physician and as stated in the facility pol...
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Based on record reviews and interviews the facility failed to ensure 1 (#53) of 2 (#6, #53) residents reviewed for nutrition received care as ordered by the physician and as stated in the facility policy. Resident #53 did not have weekly weights as ordered and the registered dietician's recommendations were not implemented.
Findings:
Review of facility's policy of weights (undated) revealed in part:
Policy: All residents are weighed upon admission, readmission, and monthly thereafter to establish weight pattern and monitor for changes.
Responsibility:
Nursing assistants monitored by the licensed nurse.
Procedure:
1. Each resident will be weighed by the 10th of the month.
2. Those residents with significant weight changes will be re-weighed by the 15th of the month.
3. The Dietician and/ or charge nurse or designee will determine which residents are to be weighed more frequently than monthly
4. Weights will be entered electronically.
5. When all the resident's weights on the unit have been obtained, the Charge Nurse is to review the weights for accuracy.
6. Upon completion of inputting the weights, the licensed nurse and/ or dietician will review the weight change history to ensure that the information is accurate by comparing the weight list to the weight change history.
7. Weight loss or gain of 5% in one month and/ or 10% in 6 months must be reported to the Dietician and Physician.
Review of Resident # 53's medical diagnoses revealed unspecified severe protein calorie malnutrition (07/01/2024).
Review of Resident # 53's July 2024 Physician Orders revealed:
05/12/2024: Weigh weekly
05/09/2024: 2 gram Sodium diet, regular texture, regular/thin Liquids consistency; 1000 milliliter fluid restriction
05/12/2024: MedPass (house supplement) three times a day for severe protein calorie malnutrition; Give 60 ml (milliliters) by mouth three times a day.
Review of Resident # 53's admission MDS (Minimum Data Sets) dated 05/16/2024 revealed a BIMS (Brief Interview of Mental Status) 00 indicating severe cognitive impairment. Further review of admission MDS revealed Resident #53 height was 68 inches and weight of 174 pounds.
Review of Resident # 53's Care Plan revealed the potential for impaired nutritional status related to disease process and medication side effects with a diagnosis of malnutrition with approaches to explain and reinforce the importance of maintaining the diet ordered and encourage the resident to comply. Registered Dietician to evaluate and make diet change recommendations.
Review of Resident # 53's Nutrition Evaluation Initial Annual and Significant Change dated 07/03/2024 revealed recommendations to increase house supplement (Medpass) to 120 ml three times a day.
Review of #53's weights documented in Electronic Health Record revealed:
05/13/2024: 174 pounds
05/27/2024: 164 pounds
06/7/2024: 164 pounds
Review of facility's weight loss binder with S4 Corporate Nurse revealed a weight of 141 pounds on July 2024 indicating a 14.02 % weight loss.
During an interview on 07/16/2024 at 12:40 p.m. S4 Corporate Nurse confirmed weekly weights were not obtained as ordered by physician and entered electrically.
During an interview on 07/16/2024 at 12:40 p.m S2 DON reviewed Resident #53's July physician orders and confirmed Resident #53 physician order for house supplement was not increased to 120 ml as recommended by registered dietician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on record reviews, observations, and interviews the facility failed to provide appropriate treatment and services for 2 (Resident #30 and #257) of 3 (#24, #30 and #257) residents reviewed for tu...
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Based on record reviews, observations, and interviews the facility failed to provide appropriate treatment and services for 2 (Resident #30 and #257) of 3 (#24, #30 and #257) residents reviewed for tube feeding. The facility failed to ensure the tube feeding bottles were labeled properly.
Findings:
Review of facility's undated Tube Feeding policy revealed in part:
Definition: A Nasogastric, Gastrostomy or Jejunostomy tube provides a method of administering nutrients directly into the stomach/GI (Gastrointestinal) tract and is indicated for those residents who cannot consume adequate nutrients safely via the oral cavity
Procedure:
7. Label the feeding bag with the resident's name, formula ordered and date.
Resident #30
Review of Resident #30's medical record revealed an admission date of 11/09/2022. Diagnoses included in part, Gastrostomy, Dysphagia and Brainstem Stroke Syndrome.
Review of Resident #30's medical record revealed a Physician's order dated 07/04/2024, which read, Glucerna 1.5 at 60 ml (milliliters)/hr. (hour) x (times) 22 hours.
Observation on 07/14/2024 at 9:40 a.m. revealed Resident #30 with a tube feeding in progress. Review of Resident #30's feeding bottle label failed to reveal Resident #30's name, the time the feeding was started and the rate of infusion.
During an interview on 07/14/2024 at 9:50 a.m. S8 LPN (Licensed Practical Nurse) reported the feeding tube label should contain the resident's name, the date and time started, the rate and who started the feeding. S8 LPN confirmed Resident #30's feeding bottle was not labeled properly.
Resident #257
Review of Resident #257's medical record revealed an admission date of 07/09/2024 with diagnoses, which included in part, Cerebral Edema, Major Depressive Disorder, Type 2 Diabetes and Gastrostomy Status.
Review of Resident #257's medical record revealed a Physician's order dated 07/14/2024, which read in part, Glucerna 1.5 cal. (calorie) at 55ml/hr. every shift.
Observation on 07/14/2024 at 8:00 a.m. revealed a Glucerna 1.5 feeding bottle hanging at Resident #257's bedside. Further observation failed to reveal the feeding bottle had been labeled with Resident #257's name, the date and time feeding was initiated, or the nurse's initials.
During an interview on 07/14/2024 at 9:30 a.m. S8 LPN acknowledged Glucerna 1.5 feeding container had not been labeled with Resident #257's name, date and time the feeding was initiated, or the nurse's initials and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure residents who need respiratory care were prov...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for 3 (#23, #30, #46) of 3 (#23, #30, #46) residents with an order for oxygen and/or respiratory treatments. The facility failed to ensure:
(1) Oxygen tubing and humidification bottle were changed weekly for Resident #23 and Resident #30 and the oxygen tubing was stored properly for Resident #23.
(2) Nebulizer mask was stored properly for Resident #46.
Findings:
(1)
Review of the facility's undated Oxygen Therapy policy revealed in part:
Equipment:
1. Source of oxygen delivery system (oxygen concentrator)
2. Humidifier, if needed
3. Oxygen connecting tube
4. Deliver service (cannula, mask,)
Procedure:
1. Oxygen therapy is to be provided under the direction of a written physicians order.
8. Change tubing weekly.
9. Date tube when changed (weekly).
Resident #23
Review of Resident #23's medical record revealed an admit date of 05/13/2016 with diagnoses that include in part, severe morbid obesity, congestive heart failure, atrial flutter, cardiac pacemaker and seizures.
Review of Resident #23's MDS (Minimum Data Set) dated 05/22/2024 revealed Resident #23 was cognitively intact with a BIMS (brief interview for mental status) score of 15.
Observation on 07/14/2024 at 9:00 a.m. revealed Resident #23's oxygen concentrator was on at 2.5 l/m (liters/minute) with the nasal cannula wrapped around the concentrator handle, un-bagged, undated and the humidification bottle was undated.
During an interview on 07/14/2024 at 9:00 a.m. Resident #23 confirmed he used the oxygen daily and Resident #23 reported the tubing was not changed routinely.
During an interview on 07/14/2024 at 9:50 a.m. S8 LPN (Licensed Practical Nurse) confirmed Resident #23's oxygen tubing was un-bagged and not dated and the humidification bottle was not dated and both should have been changed weekly.
Resident #30:
Review of resident #30's medical record revealed an admit date of 05/27/2022 with diagnoses that include in part, chronic respiratory failure, brain stem stroke syndrome, and chronic atrial fibrillation.
Review of Resident #30's July 2024 physician orders revealed:
06/30/2024 Change O2 (oxygen) tubing, mask and/or nasal cannula weekly. May change sooner as needed, one time a day every Sunday.
10/15/2023 Change tubing, mask weekly may change sooner as needed.
06/20/2023 Oxygen 2L (liter) /NC (nasal cannula) continuously every shift related to acute and chronic respiratory failure.
Observation on 07/14/2024 at 9:40 a.m. revealed Resident #30's oxygen in use via concentrator at 2.5 l/m per nasal cannula. Further observation revealed the nasal cannula tubing was not dated and humidifier bottle was dated 06/09/2024.
During an interview on 07/14/2024 at 9:50 a.m. S8 LPN confirmed resident #30's oxygen tubing was not dated and should have been and the humidification bottle was out of date and should have been changed weekly.
Observation on 07/15/2024 at 11:30 a.m. revealed oxygen in use via concentrator at 2.5 l/m per nasal cannula. Further observation failed to reveal a date on the nasal cannula tubing and humidifier bottle dated 06/09/2024.
During an interview on 07/15/2024 at 11:40 a.m. S9 LPN confirmed Resident #30's oxygen tubing was not dated and should have been and the humidification bottle should have been changed weekly and was not.
(2)
Review of the facility's undated Small Volume Nebulizer Therapy Policy revealed in part:
Policy: Nebulizer therapy will be utilized to administer medication per physician's order.
Responsibility: All licensed nursing personnel/respiratory therapist
Equipment:
1. small volume nebulizer (tubing and T-piece mouthpiece and/or mask) labeled with resident's name.
5. plastic bag
Procedure:
14. replace small volume nebulizer approximately weekly or when visibly soiled. Change set-up weekly.
15. Store in a labeled plastic bag.
Review of Resident #46's medical record revealed diagnoses that included myocardial infarction, dyspnea, and fatigue.
Review of Resident #46's July 2024 physician orders revealed the following related to Nebulizer treatment:
05/31/2024: Budesonide Suspension 0.5 MG (milligram)/ 2 ML (milliliter); 1 application inhale orally every 12 hours for SOB (shortness of breath).
06/30/2024: Change nebulizer tubing and mask weekly. May change sooner as needed, every day shift every Sunday.
Observation on 07/14/2024 at 8:40 a.m. revealed Resident # 46's nebulizer was on the overbed table with the nebulizer mask not labeled and tubing stored on top of the nebulizer.
During an interview on 07/14/2024 at 9:45 a.m. S21 RN (Registered Nurse) confirmed Resident #46's nebulizer mask and tubing should have been labeled and stored in a plastic bag when not in use.
Surveyor: [NAME], [NAME]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure nursing and related services were provided to assure resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure nursing and related services were provided to assure resident safety and maintenance of highest practicable physical, mental, and psychosocial well-being for 1 (#54) of 29 sampled residents. The facility failed to ensure Resident #54's PICC (peripherally inserted central catheter) line dressing changes had been conducted weekly.
Findings:
Review of policy for PICC Line or Midline Catheter Dressing Change revealed:
Policy: A dressing change will be done to prevent external infection of the peripheral or central venous catheter.
Responsible party:
.
Procedure:
1. Identify the resident and assess the resident's chart for any signs, symptoms of complications related to his/her vascular access device.
12. Document dressing change per facility protocol with initial and date.
15. Document treatment per facility protocol.
16. Assess the dressing change in the first 24 hours for accumulation of blood or moisture beneath the dressing. Change every 7 days and as needed if dressing loose, damp, or soiled.
Review of Resident #54's medical record revealed Resident #54 was admitted to the facility on [DATE] and had diagnoses that included, in part, infection and inflammatory reaction due to other internal joint prosthesis, muscle wasting and atrophy, right shoulder, and presence of right artificial shoulder joint.
Review of 06/20/2024 admission MDS (Minimum Data Set) revealed Resident #54 had a BIMs (Brief Interview Mental Status) score of 15 which indicated Resident #54 was cognitively intact.
Review of Resident #54's physician orders revealed:
07/13/2024 Change PICC Dressing every Saturday
07/14/2024 Vancomycin HCl (hydrochloride) Intravenous Solution - Use 1.5 gram intravenously every 24 hours for infection 5 pm
Review of 06/18/2024 S20 NP (Nurse Practitioner) progress note revealed, in part, S/P (status post) right shoulder arthroplasty revision. History of post-op site infection. Currently being empirically managed with IV (intravenous) antibiotics X 6 weeks.
Observation on 07/14/2024 at 10:40 a.m. revealed Resident #54 had a PICC line in place on left inner upper arm with an undated clear dressing that was peeling off and black around all edges with a wide piece of clear tape over the end of the dressing and top of port ends.
During an interview on 07/14/2024 at 10:40 a.m. Resident #54 reported he had been on IV (intravenous) Vancomycin antibiotics. Resident #54 further reported the dressing on the IV line had been there since he was in the hospital and had never been changed since he was admitted to the facility.
Review of Resident #54's June 2024 and July 2024 MAR (medication administration record) failed to reveal Resident #54's PICC line dressing change had been conducted.
Review of Resident #54's Progress Notes also failed to reveal Resident #54's PICC line dressing change had been conducted.
During an interview on 07/14/2024 at 10:50 a.m. S21 RN (Registered Nurse) confirmed Resident #54's PICC line dressing was dirty and needed to be changed.
During an interview on 07/16/2024 at 4:31 p.m. S2 DON (Director of Nursing) reviewed Resident #54's medical record and reported there was no evidence that Resident #54's PICC line dressing had been changed since he was admitted to the facility. S2 DON further reported Resident #54's PICC line dressing should be changed at least weekly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure a licensed pharmacist had conducted a review of residents' d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure a licensed pharmacist had conducted a review of residents' drug regimen at least once a month for 5 (#1, #5, #17, #30 and #42) of 5 (#1, #5, #17, #30 and #42) residents reviewed for unnecessary medications.
Findings:
Review of undated policy for Consultant Pharmacist Services revealed in part:
Policy: Consultant Pharmacist services are provided to residents, as required by federal guidelines.
Responsibility:
Executive Director, Consultant Pharmacist
Procedure: .
The pharmacy agrees to provide consultant pharmacist services in accordance with local, state, and federal laws, regulations, and guidelines. They will also abide by facility policies and procedures, and professional standards of practice.
The facility will retain Medication Regimen Review reports and documentation of actions taken according to facility policy and/or state and federal guidelines.
The consultant pharmacist will ensure that the following services are performed:
1. Medication regimen review will be conducted monthly, utilizing state/federal guidelines, as well as professional standards of care. The consultant pharmacist generates a report for each resident's medical record. In addition, a summary report indicating that all residents' medication regimen reviews have been conducted, with their findings is to be provided to the Director of Nursing, Executive Director and Medical Director. The report is to contain the resident's name, relevant drug and any irregularities.
Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] and was receiving medication therapy.
Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] and was receiving medication therapy.
Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE] and was receiving medication therapy.
Review of Resident #30's medical record revealed Resident #30 was admitted to the facility on [DATE] and was receiving medication therapy.
Review of Resident #42's medical record revealed Resident #42 was admitted to the facility on [DATE] and was receiving medication therapy.
Review of Pharmacy Binder failed to reveal a monthly medication review had been conducted for March, April, and May 2024.
During an interview on 07/15/2024 at 2:20 p.m., S3 ADON (Assistant Director of Nursing) reported a pharmacy change had occurred on 03/01/2024 and that pharmacy had not done monthly medication reviews for March, April, or May 2024.
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 observation and interview, the facility failed to ensure dietary services were provided in a sanitary environment for the 56 residents receiving a meal tray from the kitchen as reported by S5...
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Based on observation and interview, the facility failed to ensure dietary services were provided in a sanitary environment for the 56 residents receiving a meal tray from the kitchen as reported by S5 Dietary Manager. The facility failed to ensure opened food items were labeled and dated; failed to ensure the sugar scoop was not stored in the sugar bin; failed to ensure a soda bottle was not stored in the ice machine; and failed to ensure the refrigerator and freezer were monitored at the proper temperature to prevent potential food borne illness.
Findings:
Observation on 07/14/2024 at 8:00 a.m. revealed 5 undated opened spice bottles, a scoop stored in the sugar container, and a staff member's soda bottle was stored inside the ice machine. Temperature monitoring for the walk-in refrigerator and freezer had not been completed since 07/11/2024. Monitoring for the three-compartment sink had not been completed since 07/11/2024. Temperature checks for food served had not been completed since breakfast on 07/12/2024.
During an interview on 07/14/2024 at 8:30 a.m. S5 Dietary Manager confirmed the temperature monitoring for the refrigerator, freezer, three-compartment sink and food had not been completed and should have been. S5 Dietary Manager acknowledged improper labeling of the spices, scoop storage in the sugar container and the employee's soda bottle in the ice machine were unacceptable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to conduct (QAA) Quality Assessment and Assurance meeting was held at least quarterly.
Findings:
Review of facility's QAA binder with S1 Adm...
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Based on record review and interview, the facility failed to conduct (QAA) Quality Assessment and Assurance meeting was held at least quarterly.
Findings:
Review of facility's QAA binder with S1 Administrator failed to reveal any documentation of QAA meetings since last annual survey on 08/23/2023.
During an interview on 07/16/2024 at 9:19 a.m S1 Administrator confirmed the facility's QAA binder did not contain any documentation of quarterly meetings since the last annual survey on 08/23/2023.
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 record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent t...
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Based on record reviews, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for 4 (#6, #17, #24, and #30) of 29 sampled residents.
Findings:
Review of the facility's Enhanced Barrier Precautions undated policy revealed in part:
Definition: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of (Multidrug Resistant Organisms) MDROs in Nursing Homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. (for example) resident with wounds or indwelling medical devices).
2. EBP only require use of gown/gloves when performing high contact resident activities:
a. dressing
b. bathing/showering
c. transfer (in room, shower/tub rooms, and therapy gyms)
d. AM (morning)/PM (evening) care
e. changing linens
f. changing briefs or assisting with toileting
g. Device care or use: central, urinary catheter, feeding tube, tracheostomy, or ventilator
h. Wound care: any skin opening requiring a dressing
Equipment:
1. Door sign that read Enhanced Barrier Precautions or Visitors Must See Nurse Before Entering.
2. Supply of gowns, gloves and plastic bags.
Resident #6
Review of Resident #6's medical record revealed and admission date of 06/17/2024 with diagnoses, which included in part, Chronic Kidney Disease, Stage 4, and Type 2 Diabetes.
Review of Resident #6's medical record revealed a Physician's order dated 06/17/2024 which read in part, Hemodialysis- assess site for bruising, bleeding, symptoms of infection; Check AV (Arteriovenous) shunt each shift.
Observation on 07/14/24 at 4:30 p.m. failed to reveal signage of EBP on the door of Resident #6's room or a PPE (Personal Protective Equipment) cart available with supplies.
During an interview on 07/14/2024 at 4:30 p.m., S3 ADON (Assistant Director of Nursing) acknowledged Resident #6 should have been placed on EBPs. S3 ADON acknowledged EBP signage was not in place and PPE equipment was not available for staff and should be.
Resident 17
Review of Resident #17's medical record revealed and admission date of 01/26/2024 with diagnoses, which included in part, Multiple Sclerosis, Acute Kidney Failure, and Major Depressive Disorder.
Review of Resident #17's medical record revealed a Physician's order dated 06/29/2024, which read in part, Wound care to left lateral ankle: cleanse with wound cleanser.
Observation on 07/14/2024 at 9:30 a.m. revealed a small (4x2 inch) EBP precautions information hanging under Resident #17's room number outside the room. No PPE's are noted outside the doorway for donning PPE's or contamination containers inside the room for doffing PPEs after care.
During an interview on 07/14/2024 at 10:00 a.m. S24 Infection Control reported she understood that any resident with a catheter, IV(intravenous), wound, or feeding tube needed to be on the EBP's. S24 Infection Control confirmed the EBP PPE's were not located outside the resident's rooms for donning prior to providing care and red boxes in the resident's rooms for doffing used PPEs prior to exiting a resident's room and should be.
Observation on 07/14/2024 at 10:45 a.m. revealed S25 CNA (Certified Nursing Assistant) shaving Resident #17's face during AM care. S25 CNA was wearing gloves but no other PPEs were in use.
During an interview on 07/15/2024 at 11:00 a.m., S25 CNA reported she was in-serviced on enhanced barrier precautions and when to use them, and should use them during patient care. S25 CNA confirmed she was shaving Resident #17 the day before and was not wearing a gown while providing AM care.
Resident 24
Review of Resident #24's medical record revealed an admission date of 09/13/2019 and re-entry on 12/19/2022. Diagnoses included in part, Cerebral Palsy, Gastrostomy Status, and Anxiety Disorder.
Review of Resident #24's medical record revealed a Physician's order dated 10/14/2022, which read, enteral feed every shift and tube feeding check for placement every shift.
Observation on 07/14/2024 at 9:30 a.m. revealed enteral feeding in progress via pump with Jevity at 65 cc/hr (cubic centimeters/hour) to peg site. Further observation failed to reveal EBP were in place for resident #24.
During an interview on 07/14/2024 at 10:00 a.m. S24 Infection Control reported she understood that any resident with a catheter, IV, wound, or feeding tube needed to be on the EBP's. S24 Infection Control confirmed the EBP PPE's were not located outside the resident's rooms for donning prior to providing care and red boxes in the resident's rooms for doffing used PPEs prior to exiting a resident's room and should have been.
Resident 30
Review of Resident #30's medical record revealed an admission date of 05/27/2024 and re-entry on 09/15/2023. Diagnoses included in part, Gastrostomy, Dysphagia and Brainstem Stroke Syndrome.
Review of Resident #30's medical record revealed a Physician's order dated 06/05/2023, which read in part, Enteral Feed every 6 hours.
Observation on 07/14/2024 at 9:45 a.m. failed to reveal EBP were in place for resident #30.
During an interview on 07/14/2024 at 10:00 a.m., S24 Infection Control verified EBP precautions were not in place for resident #30 and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on personnel record reviews and interview, the facility failed to ensure provision of at least 12 hours of in-service training per year that included dementia management, resident abuse preventi...
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Based on personnel record reviews and interview, the facility failed to ensure provision of at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired for 5 (S12 CNA [Certified Nursing Assistant], S13 CNA, S14 CNA, S15 CNA, and S16 CNA) of 5 CNA personnel records reviewed.
Findings:
Review of S12 CNA's personnel record revealed a hire date of 05/08/2018. Further review of S12 CNA's personnel record failed to reveal evidence that S12 CNA had completed 12 hours of annual training.
Review of S13 CNA's personnel record revealed a hire date of 09/21/2023. Further review of S13 CNA's personnel record failed to reveal evidence that S13 CNA had completed 12 hours of annual training.
Review of S14 CNA's personnel record revealed a hire date of 06/25/2020. Further review of S14 CNA's personnel record failed to reveal evidence that S14 CNA had completed 12 hours of annual training.
Review of S15 CNA's personnel record revealed a hire date of 06/25/2020. Further review of S15 CNA's personnel record failed to reveal evidence that S15 CNA had completed 12 hours of annual training.
Review of S16 CNA's personnel record revealed a hire date of 11/01/2021. Further review of S16 CNA's personnel file failed to reveal evidence that S16 CNA had completed 12 hours of annual training.
During an interview on 07/16/2024 at 2:29 p.m. S17 HR (Human Resources) reported she was unable to locate evidence that 12 hours of annual training had been completed for S12 CNA, S13 CNA, S14 CNA, S15 CNA, or S16 CNA.
May 2024
2 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Safe Environment
(Tag F0584)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to maintain a safe, clean, comfortable and homelike e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (Resident #1, #2, #3, and #4) of 4 (Resident #1, #2, #3, and #4) sampled residents.
The deficient practice resulted in an Immediate Jeopardy on 05/17/2024 when the facility's HVAC (Heating, Ventilation, and Air Conditioning) system, which regulated the temperature for the front section of the facility, failed. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #1 lying in bed with oxygen infusing per nasal cannula with a personal fan in use and her face appeared flushed. Further observation failed to reveal a pitcher of ice water. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #2 sitting upright in bed with red cheeks, appearing uncomfortable with personal fan blowing at highest speed at close proximity to her face. Observation on 05/22/2024 at 8:15 a.m. revealed Resident #3 sitting upright in bed covered with only a sheet, her face appeared flushed. Further observation revealed a small empty cup with straw on bedside table and failed to reveal a water pitcher or a bedside fan. Observation on 05/22/2024 at 2:00 p.m. revealed Resident #4 awake in bed with only a bed sheet for coverage and a personal fan blowing at close proximity. On 05/17/2024 S1FacilityOwner was notified by S2Former Maintenance Director of the broken HVAC system and the immediate need for replacement. Over the weekend of 05/18/2024 - 05/19/2024, residents and staff voiced complaints of warmer temperatures in the building. The facility failed to assess residents for heat related issues or monitor room temperatures to maintain the environment at a comfortable level.
This deficient practice had the likelihood to cause more than minimal harm to the 32 residents housed on the front section of the facility, according to the Resident Census List dated 05/22/2024.
S3DON (Director of Nursing) and S4Regional Clinical Consultant were notified of the Immediate Jeopardy on 05/23/2024 at 5:00 p.m.
The Immediate Jeopardy was removed on 05/24/2024 at 1:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit.
Findings:
Review of the facility's Summer Heat Precautions policy (not dated) revealed in part:
Policy: During periods of high humidity and high temperatures, special precautions are to be taken.
Responsibility: All staff, monitored by the Director of Nursing and Executive Director
Procedure:
1. Identify residents who are at high-risk for heat stroke or exhaustion:
Those with circulation or respiration problems; cognitively impaired; certain medications such as diuretics, anti-hypertensives, sedatives, hypnotics and anti-cholinergics (i.e. antihistamines); dependent in mobility
2. Symptoms and signs of heat stroke and heat exhaustion .
3. Protect against temperature elevations within the facility by closing window blinds and shades and turning off unnecessary heat-producing devices.
4. Encourage fluid intake/offer water and other fluids.
5. Dress in non-constrictive, loose, light clothing.
Review of the facility's Major Utilities Failure policy with a review date of 08/21/2023 revealed in part:
Policy: Prompt action will be initiated by trained personnel in the event of a major utility failure to ensure a safe and healthful environment.
Procedure:
The Director of Environmental Services/Designee will:
Determine the cause of the utility failure;
Whether the utility can be made operational;
Contact the Emergency Service Contractor/Provider for immediate response for the following:
HVAC failure .
Notify Executive Director and other appropriate staff on the emergency call list.
Review of the facility's Clinical Power Outage Response policy with a revision date of 07/21/2023 revealed in part:
Contact medical staff in advance if possible, for planning of care as certain medical conditions suggest increased awareness and or monitoring such as acute COPD (chronic obstructive pulmonary disease), Diabetes .
Ensure an adequate amount of ice is available in the building.
Assign staff members to offer additional fluids to residents.
Evaluate residents every four hours and prn for normal body temperature, profuse perspiration, cool, clammy skin, tiredness, weakness, headache, cramps, n/v (nausea and vomiting), dizziness, fainting.
Additional interventions include but are not limited to the following:
Encourage hydration with frequent fluids made available and are offered.
Keep shades, blinds, or curtains closed during the hottest part of the day and open windows at night.
Consider the use of a cool water sponge bath, and consider use of cool wet towels around the resident's neck, underarms and groin area.
Dim lights if deemed safe to decrease heat introduced into the environment.
Review of the facility's Maintenance Log Book failed to reveal room temperatures had been measured on 05/17/2024 and continually monitored for resident rooms on the front section.
Review of https://weatherspark.com/h/m/10178/2024/5/Historical-Weather-in-May-2024-in-[NAME]-City-Louisiana-United-States#Figures-GrowingSeason on-line temperature chartings for 05/18/2024 through 05/24/2024 for the surrounding area of the facility, with heat parameters of hot registered as 85-95 degrees, revealed in part:
05/18/2024 temperatures registered hot with a high of 91.4 degrees at 3:56 p.m.
05/19/2024 temperatures registered hot with a high of 93.2 degrees at 2:56 p.m.
05/20/2024 temperatures registered hot with a high of 91.4 degrees at 1:56 p.m.
05/21/2024 temperatures registered hot with a high of 91.4 degrees at 3:56 p.m.
05/22/2024 temperatures registered hot with a high of 89.6 degrees at 12:56 p.m.
05/23/2024 temperatures registered hot with a high of 86.0 degrees at 1:56 p.m.
05/24/2024 temperatures registered hot with a high of 91.4 degrees at 1:56 p.m.
Initial observations upon entrance to the facility on [DATE] at 7:30 a.m. revealed in part, one medium sized industrial fan was positioned at the entrance of the single hallway and was noted to be blowing air down the front section of the facility. A small floor fan was noted at the end of this hallway where the front section of the facility is met with a central nursing station, which divides the two sections of the facility. The front hallway lights were observed to be on. Maintenance was not in the building to assess room temperatures and no thermometer gun available upon entrance.
Resident #1
Resident #1 was initially admitted to the facility on [DATE] with re-entry on 11/20/2023. Diagnoses, included in part, metabolic encephalopathy, COPD, Type 2 Diabetes, and morbid obesity. Resident #1 resided in the front section of the facility.
Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 03/25/2024 revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating intact cognition. Resident #1 required extensive assist by two staff for bed mobility.
Review of Resident #1's current Physician's orders revealed an order dated 05/16/2023 which read, O2 (oxygen) at 2.5l (liters) per nc (nasal cannula) per minute; continuous.
Observation on 05/22/2024 at 8:05 a.m. revealed Resident #1 lying in bed with O2 infusing per nc and a personal fan in use. Resident #1's face appeared flushed. Further observation failed to reveal a pitcher of ice water.
During an interview on 05/22/2024 at 8:05 a.m., Resident #1 reported the air conditioning had been out for weeks and she and her family had both reported it. Resident #1 reported she was uncomfortable and hot. Resident #1 reported by 4:00 p.m., her room is so hot, she can hardly breathe. Resident #1 reported the facility had not provided any provisions related to the air conditioning outage and a family member had purchased her a fan. Resident #1 reported the facility does not pass out ice and water unless we ask for it. Resident #1 reported the facility had not been making special rounds or checking the room temperature.
Observation on 05/22/2024 at 12:30 p.m. revealed Resident #1 awake and lying in bed wearing only a gown with her legs uncovered and fully exposed. Further observation revealed Resident #1 was red in the face and appeared uncomfortable.
During an interview on 05/22/2024 at 12:30 p.m., Resident #1 reported she had just woken up from a nap and her back and gown were wet from sweating. Resident #1 reported she had turned her fan up to the highest level but could not cool down.
During an interview on 05/23/2024 at 2:45 p.m., Resident #1 stated, It is still hot in here.
Resident #2
Resident #2 was admitted to the facility on [DATE] with diagnoses, which included in part, anoxic brain damage, major depressive disorder and morbid obesity. Resident #2 resided in the front section of the facility.
Review of Resident #2's Quarterly MDS dated [DATE] revealed in part, Resident #2 had a BIMS score of 12 out of 15 indicating moderately impaired cognition.
Observation on 05/22/2024 at 8:05 a.m. revealed Resident #2 sitting upright in bed with personal fan blowing at highest speed at close proximity to her face. Resident #2's cheeks were red and Resident #2 appeared uncomfortable.
During an interview on 05/22/2024 at 8:05 a.m., Resident #2 reported the air conditioning had been out for weeks but her room started getting warmer over the past weekend of 05/18/2024. Resident #2 reported by mid-day her room gets extremely hot. Resident #2 reported rounds had not been made and provisions had not been offered by staff, specific to the air conditioning outage. Resident #2 reported the facility had not offered fans but she was lucky to have her own personal fan. Resident #2 further reported staff only provides water when asked and she has her own water cup she fills up. Resident #2 reported S2Former Maintenance Director informed her only one compressor was working when she inquired as to why her room was so hot.
During an interview on 05/22/2024 at 4:30 p.m., Resident #2 was eating dinner in dining room and stated, Well, yeah it was hot in here this weekend.
Resident #3
Resident #3 was initially admitted to the facility on [DATE] with re-entry on 12/28/2020. Diagnoses, included in part, unspecified dementia, essential primary hypertension and chronic kidney disease. Resident #3 resided in the front section of the facility.
Review of Resident #3's Quarterly MDS dated [DATE] revealed in part, Resident #3 had a BIMS score of 00 out of 15 indicating Resident #3 was unable to participate in interview. Resident #3 required extensive assist with two staff for bed mobility.
Observation on 05/22/2024 at 8:15 a.m. revealed Resident #3 sitting upright in bed eating breakfast, covered with only a sheet. Resident #3's face appeared flushed and further observation failed to reveal a bedside fan. Further observation revealed a small empty cup with straw on bedside table and failed to reveal a water pitcher.
Resident #3 was unable to participate in interview.
Resident #4
Resident #4 was initially admitted to the facility on [DATE] with diagnoses, which included in part, Type 2 Diabetes, functional quadriplegia and morbid obesity. Resident #4 resided in the front section of the facility.
Review of Resident #4's MDS dated [DATE] revealed in part, Resident #4 had a BIMS score of 12 out of 15 indicating moderately impaired cognition. Resident #4 required extensive assist by one staff for bed mobility.
Observation on 05/22/2024 at 2:00 p.m. revealed Resident #4 awake in bed with only a bed sheet for coverage and a personal fan blowing at close proximity.
During an interview on 05/22/2024 at 2:00 p.m., Resident #4 reported her room was hot and she could not use a blanket until the air conditioning was repaired. Resident #4 reported she noticed her room getting warmer over the past weekend of 05/18/2024 and by mid-day, the room was barely tolerable. Resident #4 reported staff did not check on her over the weekend regarding heat related issues or monitor room temperatures.
During an interview on 05/22/2024 at 4:30 p.m., Resident #4 reported her sister was bringing curtains for her room to block the sunlight and heat from coming in.
During an interview on 05/22/2024 at 7:30 a.m., S5LPN (Licensed Practical Nurse) reported the facility has been having trouble with the air conditioner and that is why the fans are blowing in the hallway. S5LPN acknowledged the temperature felt warmer than usual in the facility.
During an interview on 05/22/2024 at 7:35 a.m., S6LPN reported the air conditioner has not been working for a couple of days.
During an interview on 05/22/2024 at 7:40 a.m., S7LPN reported facility's air conditioner has not been working for about 3 days.
During an interview on 05/22/2024 at 7:45 a.m., S8Cook, reported the air has not been working since last Thursday, 05/16/2024 and maintenance had to keep coming back for repairs. S8Cook further reported the kitchen and dining room were extremely hot over the weekend of 05/18/2024.
During an interview on 05/22/2024 at 8:30 a.m., S10CNA (Certified Nursing Assistant) reported she worked yesterday and it was hot and got hotter into the night.
During an interview on 05/22/2024 at 9:00 a.m., S3DON reported she was notified on Friday, 05/17/2024, by S2Former Maintenance Director that the facility was down to one unit and the single unit was not working properly because it kept freezing up. S3DON reported S2Former Maintenance Director had gotten the single unit back working around 4:30 p.m. on 05/17/2024, but reported he was unsure how long it would be able to regulate the temperature for the front section. S3DON reported she did not return to the facility until Sunday, 05/19/2024 around 1:15 p.m. and Resident #1 told her it was hot in the facility. S3DON reported two or three other residents voiced it was warm along with some of the staff. S3DON reported she returned to work on Monday, 05/20/2024 and at 7:40 a.m. S2Former Maintenance Director informed her the air conditioning unit was acting up again. S3DON reported on Monday, 05/20/2024 around 2:30 p.m., residents on the front hall began complaining of the heat. S3DON reported S2Former Maintenance Director notified S1Facility Owner on Friday, 05/17/2024 at approximately 1:40 p.m. and again on 05/20/2024 of the HVAC system failure. S3DON reported S2Former Maintenance Director had not come in over the weekend to check on the HVAC system to her knowledge. S3DON acknowledged fans had not been provided to residents who resided on the front section of the facility.
During an interview on 05/22/2024 at 12:15 p.m., S11Maintenance for sister facility reported he was first informed of the air conditioning issue on 05/21/2024 when he was asked to come over and assist S2Former Maintenance Director with the repair. S11Maintenance reported two 10-ton condensers are required and run in sync to cool and maintain the temperature in the front half of the building. S11Maintenance reported unit 1 had burned up wires, a bad contactor and the transformer kept overheating. S11Maintenance reported unit 2 was not working at all. S11Maintenance further reported he borrowed parts from unit 2 to use on unit 1 and was able to get unit 1 running. S11Maintenance stated he put a band-aid on the HVAC system and acknowledged the single unit would not provide the cooling capacity needed to regulate the temperature on the front half of the facility. S11Maintenance reported he had spoken to the S1Facility Owner this morning, 05/22/2024 and S1Facility Owner had me (S11Maintenance) go and purchase portable air conditioning units to install in the front section of the facility to help supplement the one unit. S11Maintence reported he was not sure how long this supplemental air would last. S11Maintenance further reported as far as he knew, fans had not been provided to the residents who reside on the front section of the facility. S11Maintenance acknowledged he had not monitored resident room temperatures since he entered the facility on 05/21/2024 to assist with repair. S11Maintenance confirmed he did not have a temperature gun to assess resident room temperatures and would have to go down to the sister facility and get a temperature gun in order to do so.
During an interview on 05/22/2024 at 1:00 p.m., S4Regional Clinical Consultant reported she was made aware the air conditioning unit was not working on Tuesday, 05/22/2024.
Observation of Dining Room on 05/22/2024 at 2:00 p.m. with S11Maintenance revealed a large open area on the right corner section of the ceiling. Further observation revealed the crawl space was exposed and hot air, temped at 126 degrees Fahrenheit by S11Maintenace, was blowing into the Dining Room.
During an interview on 05/22/2024 at 2:20 p.m., S9Medical Records, reported the issues with the air conditioner had been going on for a while, but it was not until Monday, 05/20/2024 that she realized it was a problem.
During an interview on 05/22/2024 at 3:45 p.m., S4Regional Clinical Consultant confirmed the outage of the HVAC system had not been reported to the State Agency per the LA Administrative Code (LAC) for Emergency Preparedness. S4Regional Clinical Consultant acknowledged one unit would not adequately cool the front of the facility. S4Regional Clinical Consultant confirmed she could not produce any documentation of resident room temperature monitoring or frequent resident assessments.
During an interview on 05/23/2024 at 8:20 a.m. R1Owner of _____ Refrigeration acknowledged the invoice he provided to the facility was an estimated cost of replacing the HVAC system which required two 10-ton units to regulate the temperature adequately. R1Owner confirmed there was no current date for installation due to the S1Facility Owner seeking financing for the units.
During an interview on 05/23/2024 at 9:35 a.m., S1Facility Owner reported the facility has had air conditioning issues for the last week or two with the system continually going out and being repaired. S1Facility Owner acknowledged one of the two 10-ton units stopped working completely on 05/17/2024 and he was informed of this by S2Former Maintenance Director. S1Facility Owner further acknowledged temperature regulation was dependent upon just one 10-ton unit to cool the front section of the facility since 05/17/2024 and it required two 10-ton units. S1Facility Owner confirmed he had not yet purchased a new HVAC system.
During an interview on 05/23/2024 at 10:20 a.m., S12LPN reported she had worked on Friday, 05/17/2024 and noticed the facility was getting warm around morning medication pass. S12LPN further reported at least two residents voiced the same. S12LPN further reported she informed S3DON on 05/17/2024 the air was not working. S12LPN reported she worked Saturday, 05/18/2024 and Sunday, 05/19/2024 and the building remained warm. S12LPN acknowledged she was not given instructions specific to the frequency of resident safety checks or room temperature monitoring to be completed.
During an interview on 05/23/2024 at 10:40 a.m., S3DON confirmed on 05/17/2024 being made aware the one air conditioning unit left to regulate the temperature was not working consistently and was frequently going in and out, freezing. S3DON acknowledged frequent checks on residents or monitoring of the facility temperatures had not been initiated and should have been.
During an interview on 05/23/2024 at 11:00 a.m., S2Former Maintenance Director confirmed the building had only one working unit for at least the past two months. S2Former Maintenance Director acknowledged the building required two 10-ton units that have to be operational for the front half of the building to be cooled. S2Former Maintenance Director reported S1Facility Owner instructed him to take parts from one unit and place it on the other unit to make one operational unit. S2Former Maintenance Director confirmed multiple conversations with S1Facility Owner informing him the building needed a new HVAC system. S2Former Maintenance Director reported the one unit stopped working adequately on 05/17/2024 and
S1Facility Owner was made aware early that afternoon. S2Former Maintenance Director confirmed checking resident room temperatures on Saturday, 05/18/2024 and Sunday, 05/19/2024 with temperatures in the 79 to 80 degree range but could not produce any documentation.
During an interview on 05/23/2024 at 5:15 p.m., S13LPN reported she worked both evening and night shifts on Saturday, 05/18/2024 and Sunday, 05/19/2024 and the temperature in the facility was warm and awful. S13LPN reported the only thing the facility had been provided were the two fans for the hallway. S13LPN reported she had not observed maintenance take any room temperatures over the weekend.
During an interview on 05/24/2024 at 9:10 a.m., S14Housekeeping reported she worked Monday, 05/20/2024 and she could not wait to go home because it was very warm in the facility and once she started mopping and sweeping, she got hot and sweaty.
During an interview on 05/24/2024 at 8:20 a.m., S4Regional Clinical Consultant acknowledged the facility failed to monitor and document room temperatures and frequent resident assessments in order to maintain a safe and comfortable environment and should have.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected multiple residents
Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable...
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Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 4 (#1, #2, #3, and #4) of 4 residents (#1, #2, #3, and #4) sampled residents. The facility failed to ensure a system was in place to assess residents for heat related issues and monitor room temperatures to maintain environment at a comfortable level when the HVAC (Heating, Ventilation, and Air Conditioning) system failed.
The deficient practice resulted in an Immediate Jeopardy on 05/17/2024 when the facility's HVAC system, which regulated the temperature for the front section of the facility, failed. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #1 lying in bed with oxygen infusing per nasal cannula with a personal fan in use and her face appeared flushed. Further observation failed to reveal a pitcher of ice water. Observation on 05/22/2024 at 8:05 a.m. revealed Resident #2 sitting upright in bed with red cheeks, appearing uncomfortable with personal fan blowing at highest speed at close proximity to her face. Observation on 05/22/2024 at 8:15 a.m. revealed Resident #3 sitting upright in bed covered with only a sheet, her face appeared flushed. Further observation revealed a small empty cup with straw on bedside table and failed to reveal a water pitcher or a bedside fan. Observation on 05/22/2024 at 2:00 p.m. revealed Resident #4 awake in bed with only a bed sheet for coverage and a personal fan blowing at close proximity. On 05/17/2024 S1FacilityOwner was notified by S2Former Maintenance Director of the broken HVAC system and the immediate need for replacement. Over the weekend of 05/18/2024 - 05/19/2024, residents and staff voiced complaints of warmer temperatures in the building. The facility failed to assess residents for heat related issues or monitor room temperatures to maintain the environment at a comfortable level.
This deficient practice had the likelihood to cause more than minimal harm to the 32 residents housed on the front section of the facility, according to the Resident Census List dated 05/22/2024.
S3DON (Director of Nursing) and S4Regional Clinical Consultant were notified of the Immediate Jeopardy on 05/23/2024 at 5:00 p.m.
The Immediate Jeopardy was removed on 05/24/2024 at 1:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit.
Findings, Cross Reference F584:
During an interview on 05/22/2024 at 12:15 p.m., S11Maintenance for sister facility reported he was first informed of the air conditioning issue on 05/21/2024 when he was asked to come over and assist S2Former Maintenance Director with the repair. S11Maintenance reported two 10-ton condensers are required and run in sync to cool and maintain the temperature in the front half of the building. S11Maintenance reported unit 1 had burned up wires, a bad contactor and the transformer kept overheating. S11Maintenance reported unit 2 was not working at all. S11Maintenance further reported he borrowed parts from unit 2 to use on unit 1 and was able to get unit 1 running. S11Maintenance stated he put a band-aid on the HVAC system and acknowledged the single unit would not provide the cooling capacity needed to regulate the temperature on the front half of the facility. S11Maintenance acknowledged he had not monitored resident room temperatures since he entered the facility on 05/21/2024 to assist with repair. S11Maintenance confirmed he did not have a temperature gun to assess resident room temperatures and would have to go down to the sister facility and get a temperature gun in order to do so.
During an interview on 05/22/2024 at 3:45 p.m., S4Regional Clinical Consultant confirmed the outage of the HVAC system had not been reported to the State Agency per the LA Administrative Code (LAC) for Emergency Preparedness. S4Regional Clinical Consultant acknowledged one unit would not adequately cool the front of the facility. S4Regional Clinical Consultant confirmed she could not produce any documentation of resident room temperature monitoring or frequent resident assessments.
During an interview on 05/23/2024 at 9:35 a.m., S1Facility Owner reported the facility has had air conditioning issues for the last week or two with the system continually going out and being repaired. S1Facility Owner acknowledged one of the two 10-ton units stopped working completely on 05/17/2024 and he was informed of this by S2Former Maintenance Director. S1Facility Owner further acknowledged temperature regulation was dependent upon just one 10-ton unit to cool the front section of the facility since 05/17/2024 and it required two 10-ton units. S1Facility Owner confirmed he had not yet purchased a new HVAC system.
During an interview on 05/23/2024 at 10:40 a.m., S3DON confirmed on 05/17/2024 being made aware the one air conditioning unit left to regulate the temperature was not working consistently and was frequently going in and out, freezing. S3DON acknowledged frequent checks on residents or monitoring of the facility temperatures had not been initiated and should have been.
During an interview on 05/24/2024 at 8:20 a.m., S4Regional Clinical Consultant acknowledged the facility failed to monitor and document room temperatures and frequent resident assessments in order to maintain a safe and comfortable environment and should have.
Aug 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit resident assessment for 1 (#51) out of 1 (#51) resident as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit resident assessment for 1 (#51) out of 1 (#51) resident assessment reviewed. The facility failed to transmit Resident #51's Discharge Minimum Data Set (MDS) within 14 days after completion of resident assessment.
Findings:
Review of Resident #51's Medical Records revealed admit date of 03/24/2023 and discharge date of 04/07/2023.
Review of Resident #51's Discharge MDS assessment dated [DATE] revealed status as in progress.
During an interview on 08/23/2023 at 2:05 p.m. S3 MDS Nurse acknowledged the Discharge MDS Assessment was not transmitted and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and interviews the facility failed to complete an annual performance evaluation for 1 (S12 CNA {Certified Nurse Assistant}) out of 5 (S12 CNA, S13 CNA, S14 CNA, S15 CNA, & S16 C...
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Based on record review and interviews the facility failed to complete an annual performance evaluation for 1 (S12 CNA {Certified Nurse Assistant}) out of 5 (S12 CNA, S13 CNA, S14 CNA, S15 CNA, & S16 CNA) CNA personnel records reviewed.
Findings:
Review of S12's CNA personnel record revealed a hire date of 6/25/2020.
Review of S12's CNA personnel record failed to reveal an annual performance review for the year of 2022.
During an interview on 8/23/2023 at 3:00 p.m. S10 Human Resources confirmed S12 CNA was an active employee and an annual performance evaluation was not done for S12 CNA for the year 2022.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a DON (Director of Nursing) attended a quarterly QAA (Quality Assessment and Assurance) Committee meeting for the facility's first an...
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Based on record review and interview the facility failed to ensure a DON (Director of Nursing) attended a quarterly QAA (Quality Assessment and Assurance) Committee meeting for the facility's first and second quarter of the year 2023.
Findings:
Record review of the facility's QAA committee meetings failed to reveal a DON signature on the sign in sheet for the facility's first and second quarter of the year 2023.
During an interview on 08/23/2023 at 9:43 a.m. S1 Administrator reviewed the QAA meetings sign in sheet from January 2023 through June 2023. S1 Administrator verified a signature was not completed by the DON for the first and second quarter of 2023 QAA Committee meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to maintain a sanitary, orderly and comfortable environment,
1. The facility failed to ensure Resident #23's feeding pump pole and floor were ...
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Based on observations and interviews the facility failed to maintain a sanitary, orderly and comfortable environment,
1. The facility failed to ensure Resident #23's feeding pump pole and floor were cleaned.
2. The facility failed to ensure Resident #30 and Resident #52's fans were cleaned.
Findings:
1. Resident #23:
Observation on 08/21/2023 at 9:00 a.m. revealed a dried egg shell colored substance on the floor between Resident #23's bed and feeding pump pole.
Observation on 08/22/2023 at 2:33 p.m. with S2 DON (Director of Nursing) revealed a dried egg shell colored substance on the floor between Resident #23's bed and feeding pump pole.
During an interview on 08/22/2023 at 2:33 p.m. S2 DON acknowledged the dried egg shell colored substance on the floor between Resident #23's bed and feeding pump pole. S2 DON reported Resident 23's floor and feeding pump pole should be cleaned of the substance.
2. Resident #30:
Observation on 08/21/2023 at 10:00 a.m. revealed Resident #30 had 2 fans in her room, a white stand up fan without a front cover with gray fuzzy particles covering the blades and back of the fan, and a small black fan on Resident #30's overbed table covered with gray fuzzy particles on the front and back.
Observation on 08/22/2023 at 2:35 p.m with S6 LPN and S9 Maintenance revealed Resident #30's white stand up fan without a front cover contained gray fuzzy particles covering the blades and back of the fan, and a small black fan covered with gray fuzzy particles on Resident #30's overbed table.
During an interview on 08/22/2023 at 2:35 p.m. with S6 LPN and S9 Maintenance, S6 LPN acknowledged the gray fuzzy particles covering Resident#30's fans and reported the fans need to be cleaned. S9 Maintenance further indicated Resident #30's white stand up fan that did not have a front covering should not be in use.
Resident #52:
Observation on 08/21/2023 at 10:30 a.m. revealed a small black fan sitting in a chair in Resident #52's room with gray fuzzy particles.
Observation on 08/22/2023 at 2:40 p.m. with S6 LPN and S2 DON revealed a small black fan sitting in a chair in Resident #52's room with gray fuzzy particles covering the front and back.
During an interview on 08/22/2023 at 2:40 p.m. S6 LPN and S2 DON acknowledged the gray fuzzy particles on Resident #52's fan and reported the fan needed to be cleaned.
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 record reviews, observation and interviews the facility failed to ensure the comprehensive care plan had been completed/implemented for 3 Residents (#23, #25, #28) of 34 sampled residents rev...
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Based on record reviews, observation and interviews the facility failed to ensure the comprehensive care plan had been completed/implemented for 3 Residents (#23, #25, #28) of 34 sampled residents reviewed.
1. The facility failed to develop a comprehensive care plan for residents #25 and #28.
2. The facility failed to implement the care plan related to wound care for resident #23.
Findings:
Resident #23:
Review of Resident #23's Medical Diagnoses revealed the following diagnoses in part: cerebral palsy, dysphagia following cerebral infarction and gastrostomy.
Review of Resident # 23's August 2023 Physician Orders revealed an order dated 5/24/2023: Perform daily peg tube care: Cleanse with wound cleanser. Pat dry. Cover with dressing. Change daily and PRN (as needed) soiled.
Observation on 08/23/2023 at 8:30 a.m. with S6 LPN (Licensed Practical Nurse) revealed Resident #23 split gauze dressing to peg site had dark reddish/ black colored drainage dated 8/20/2023. S6 LPN reported Resident #23's peg site should be cleaned and dressing change should be done daily by wound care nurse.
During an interview on 08/23/2023 at 10:00 a.m. S5 LPN/WCN (Wound Care Nurse) reported she has been working the floor for the last 2 days and was not able to perform wound care.
Resident #25:
Review of Resident #25's clinical record revealed an admit date of 07/10/2023 with the following diagnosis in part: Diabetes, end stage renal disease, dependence of renal dialysis, and unspecified protein-calorie malnutrition.
Review of Resident #25's admission MDS (Minimum Data Set) Assessment revealed a completion date of 07/19/2023.
Review of Resident #25's clinical record failed to reveal a Comprehensive Care Plan had been completed.
During an interview on 08/23/2023 at 9:55 a.m. S3 MDS Nurse reported a Comprehensive Care Plan was not completed for Resident #25.
Resident #28:
Review of Resident #28's Medical Records revealed an admit date of 07/12/2023 with the following diagnoses, in part: morbid (severe) obesity due to excess calories, body mass index (BMI) 70 or greater/adult, prediabetes, other forms of acute ischemic heart disease, cellulitis/unspecified, muscle weakness (generalized), anemia unspecified, essential (primary hypertension, repeated falls, unspecified osteoarthritis/unspecified site, and cellulitis of right lower limb.
Review of Resident #28's MDS Assessment revealed a completion date of 07/19/2023.
Review of Resident #28's Baseline Care Plan revealed completion date of 07/13/2023.
Further review failed to reveal a comprehensive care plan was completed.
During an interview on 08/23/23 at 9:10 a.m. S3 MDS Nurse acknowledged a comprehensive care plan was not completed for Resident #28.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure 1 (#28) out of 1 (#28) resident reviewed for pressure ulcers received care consistent with professional standards of practice to p...
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Based on record reviews and interviews, the facility failed to ensure 1 (#28) out of 1 (#28) resident reviewed for pressure ulcers received care consistent with professional standards of practice to prevent pressure ulcers. The facility failed to complete weekly skin evaluations, re-evaluate wound/skin treatment, and provide wound care daily as ordered for Resident #28.
Findings:
Review of Facility's Skin Evaluation Policies and Procedures (revision date 04/01/2017) revealed:
Policy: A licensed nurse will complete a total body evaluation on each resident weekly, and prior to a hospital or other facility transfer/discharge, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure injury, lesions, abrasions, reddened areas and skin problems.
Procedure: 1. Licensed nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. 3 For pressure areas complete the Pressure Injury Record.
Review of Facility's Skin and Wound Best Practice (10/01/2021) revealed Skin Observation: Weekly skin evaluations completed by licensed nurse. Re-evaluate wound/skin treatment within two weeks of start date and every 2 weeks thereafter. Skin impairments documented on weekly wound report.
Review of Resident #28 Medical Records revealed an admit date of 07/12/2023 with the following diagnoses, in part: morbid (severe) obesity due to excess calories, prediabetes, other forms of acute ischemic heart disease, cellulitis/unspecified, muscle weakness (generalized), anemia unspecified, essential (primary hypertension, repeated falls, unspecified osteoarthritis/unspecified site, and cellulitis of right lower limb.
Review of Resident #28's Baseline Care Plan dated 07/13/2023 revealed- prevent any skin breakdown or injury, heal/improve current skin issues, and follow facility skin protocol.
Review of Resident #28's Braden Scale for Predicting Pressure Sore Risk dated 07/13/2023 revealed a score of 14 indicating a moderate risk.
Review of Resident #28's August Physician's Order revealed:
An order dated 08/23/2023 - wound care: clean stage 3 pressure ulcer to sacrum with wound cleanser, pat dry, with clean dry gauze, apply alginate dressing, cover with gentle border daily until healed
An order dated 07/18/2023 - clean wound on right buttock with wound cleanser and gauze, pat dry with clean dry gauze, add alginate dressing, cover with gentle boarder until healed one time a day
An order dated 07/12/2023 - weekly skin sweeps
Review of Resident #28's July and August MAR/TAR (Medication Administration Record/Treatment Administration Record) failed to reveal wound care was performed on the following days: July 25, 29, 30th and August 5, 7, 10, 13, and 20th. Further review failed to reveal weekly skin sweeps were completed as ordered.
Review of Resident #28's Weekly Skin Integrity Reviews dated 07/14/2023 revealed current skin condition - left lower leg (rear) there appears a place . and top of scalp has shingles spread across her forehead and right eye; skin intact - NO; she has wound care and eye care. Further review failed to reveal weekly skin reviews completed following 07/14/2023 review.
Review of Resident #28's Wound Evaluations dated 07/15/2023 revealed - wound location - right lower leg, folds; type of wound - surgical; thickening/stage 3; slough/granulation; measurements 6 x 6 x 1; tunneling NO; exudate light, serous, clear; no odor; change dressing right lower leg after cleaning wound .apply xeroform dress daily. Wound Evalution dated 08/01/2023 revelaed - date first observed - wound location - right buttock; type of wound - pressure; stage 3; measurements 5 x 1.5 x 1; tunneling yes, exudate - moderate serous clear; odor no; wound bed - slough; surrounding skin - maceration/excoriation; wound edges unattached; treatment - wound cleanser, pat dry, apply calcium alginate, cover with gentle boarder.
During an interview on 08/23/2023 at 11:55 a.m. S2 Director of Nursing reported wound evaluations and weekly skin sweeps were not completed and should have been. S2 DON acknowledged the only wound evaluation completed occurred on 08/01/2023 and the only skin integrity review completed occurred on 07/15/2023 following admission.
During an interview on 08/23/2023 at 9:15 a.m. S8 Nurse Practitioner reported she was aware of Resident #28's original skin issue to the right buttock but had not been informed of the wound getting worse and tunneling.
During an interview on 08/23/2023 at 1:50 p.m. S5 LPN/WCN (licensed practice nurse/wound care nurse) reported a certified nursing assistant notified her about the wound on Resident #28's right buttock worsening and a wound evaluation was completed on 08/01/2023. S5 LPN/WCN further acknowledged this was the only wound evaluation completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure there was a sufficient number of skilled licensed nurses, n...
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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 there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide documentation of the minimum required staffing hours for 11 of 24 weekend days.
Findings:
Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1-March 31) revealed the submitted weekend staffing data was excessively low.
Staffing pattern forms for 2 weeks prior to the annual survey and 2nd quarter (January through March 2023) weekend staffing was included in the entrance conference packet that was given to the S2 DON (Director of Nursing) on 08/21/2023 at 7:30 a.m.
Staffing patterns forms were completed and signed by S1 Administrator dated 08/21/2023. Review of 2nd quarter (January-March 2023) weekend staffing pattern revealed unusually high staffing hours and was returned to S10 (Human Resources) on 08/21/2023 at 2:30 p.m.
Surveyor requested revised staffing patterns were requested on 08/22/2023 at 1:00 p.m. and S10 Human Resources and S17 Corporate Nurse reported they were still working on weekend staffing numbers.
S17 Corporate Nurse presented surveyor with 2 week annual survey staffing pattern on 08/23/2023 at 12:00 p.m. and reported she will begin to work on the 2nd quarter staffing pattern.
S17 Corporate Nurse presented surveyor with January 2023 weekend staffing pattern on 08/23/2023 at 1:30 p.m.
Surveyor requested the remaining 2nd quarter staffing pattern forms on 08/23/2023 at 3:00 p.m.
S17 Corporate Nurse presented the surveyor with February 2023 and March 2023 weekend staffing pattern report for weekends from FY (Fiscal Year) Quarter 2 2023 revealed unusually high weekend staffing for the following dates: 02/19/2023, 02/25/2023, 02/26/2023, 03/04/2023, 03/05/2023, 03/11/2023, 03/12/2023, 03/18/2023, 03/19/2023, 03/25/2023, and 03/26/2023.
During an interview on 08/23/2023 at 3:00 p.m. S17 Corporate Nurse reported she was in the process of completing February 19, 2023 weekend hours and have not started on March 2023. S17 Corporate Nurse reported time sheets and daily staffing sign in sheets were being reviewed to complete the 2nd quarter staffing pattern forms.
During an interview on 08/23/23 at 3:49 p.m. S17 Corporate Nurse reported she did not know who submits the PBJ (payroll based journal) report. S17 Corporate Nurse thought S1 Administrator or S10 HR submitted the PBJ report.
During an interview on 08/23/23 at 3:54 p.m. S17 Corporate Nurse reported S18 Corporate Director Healthcare Analytics and Reporting actually is the one that sends out the PBJ report but does not know how S18 Corporate Director Healthcare Analytics and Reporting gets information from facility to report. S17 Corporate Nurse reported she was not aware the facility had any issues with staffing and if the facility had issues with staffing they did not notify her.
During an interview on 08/23/2023 at 4:00 p.m. S1 Administrator and S17 Corporate Nurse reported S19 Regional (Vice President) had been contacted for further guidance to determine the issue with the PBJ report and was told to contact S18 Corporate Director Healthcare Analytics and Reporting.
S1 Administrator reported the company had computer issues with a data breach on December 22, 2022 that effected everything, computer systems, charting, time keeping and the facility had to tracked the hours during this time. S1 Administrator and S10 Human Resources reported the computer issues and data breach lasted for about 6 weeks. S1 Administrator also reported the facility had power outages with the bad storms in [DATE].
During an interview on 08/23/2023 at 4:15 p.m. S1 Administrator and S17 Corporate nurse reported they have attempted to contact S18 Corporate Director of Analytics and Reporting by email and text message and had not received a response.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure 20 out of 20 glucometers used in the facility were maintained in safe operating condition. S4 ADON (Assistant Director of Nurses) p...
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Based on record reviews and interviews the facility failed to ensure 20 out of 20 glucometers used in the facility were maintained in safe operating condition. S4 ADON (Assistant Director of Nurses) provided a list of 16 residents (#14, #32, #19, #22, #1, #13, #29, #306, #11, #3, #16, #5, #54, #307, #41, #32) residing in the facility with orders for glucose monitoring. There were 56 residents in the facility according to the facility Resident Census and Conditions of Residents report dated 08/21/2023.
Findings:
During an interview on 08/23/2023 at 11:10 a.m. S4 ADON reported the facility's two medication carts had a general glucometer for the cart and a glucometer for each resident with orders for glucose monitoring labeled for the resident kept in a separate plastic storage container on their hall's medication cart. S4 ADON indicated glucometer control monitoring was done nightly and documented on the glucometer quality control records.
During observation on 08/23/2023 at 11:10 a.m. with S4 ADON revealed the front hall medication cart contained 2 general glucometers and glucometers in separate plastic storage containers labeled for 11 residents (#13, #29, #306, #11, #3, #16, #5, #54, #307, #41, #32). Further observation at that time with S4 ADON revealed the back hall medication cart contained 2 general glucometers and glucometers in separate plastic storage containers labeled for 5 residents (#14, #32, #19, #22, #1). S4 ADON confirmed there were a total of 20 glucometers.
Review of the facility's glucometer quality control records failed to reveal documentation of any glucometer control monitoring for August 2023.
During interview on 08/23/2023 at 11:40 a.m. S2 DON reported there had not been any residents sent to the emergency room or admitted to the hospital for blood sugar related issues in the past month.
During interview on 08/23/2023 at 12:20 p.m. S4 ADON confirmed there were 16 residents (#14, #32, #19, #22, #1, #13, #29, #306, #11, #3, #16, #5, #54, #307, #41, #32) who had orders for regular glucose monitoring. S4 ADON confirmed there was a total of 20 glucometers for use on the facility's two medication carts, two general cart glucometers and 16 designated specifically for each resident who had orders for glucose monitoring. S4 ADON reviewed the facility's glucometer quality control records and acknowledged there was not documentation of any glucometer control monitoring for the 20 glucometers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to ensure resident's call light system was functioning properly for 1 resident (#19) out of 5 (#19, #23, #28, #30, #52) residents reviewed for ...
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Based on observations and interviews the facility failed to ensure resident's call light system was functioning properly for 1 resident (#19) out of 5 (#19, #23, #28, #30, #52) residents reviewed for environment.
Findings:
Observation on 08/21/2023 at 09:00 a.m. during the initial pool process Resident #19 could be heard calling out for help.
During an interview on 08/21/2023 at 09:00 a.m. Resident #19 reported call light had not worked for a while and must holler out loud when she needed staff assistance. Resident #19 reported roommate's call light functions and roommate will call out for help when if needed. Resident #19 reported last week her roommate was attempting to adjust the temperature in the room and her roommate's wheelchair became stuck between the bed and air conditioner. Resident #19 reported having to holler out for staff to come in the room to assist her roommate.
Observation on 8/22/2023 at 2:20 pm with S6 LPN (Licensed Practical Nurse) and S11 CNA (Certified Nurse Assistant) present surveyor activated Resident #19 call light.
During an interview on 8/22/2023 at 2:20 p.m. S6 LPN confirmed call light was activated and light was on in Resident #19's room. S11 CNA reported call light was not blinking outside of Resident's room or sounding at the nurses' station when activated by surveyor. S6 LPN and S11 CNA reported Resident #19 hollers out for staff when she needs help.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $73,487 in fines. Review inspection reports carefully.
- • 61 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $73,487 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (6/100). Below average facility with significant concerns.
Bottom line: Trust Score of 6/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Heritage Manor Health & Rehab's CMS Rating?
CMS assigns HERITAGE MANOR HEALTH & REHAB an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Heritage Manor Health & Rehab Staffed?
CMS rates HERITAGE MANOR HEALTH & REHAB's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 55%, compared to the Louisiana average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Heritage Manor Health & Rehab?
State health inspectors documented 61 deficiencies at HERITAGE MANOR HEALTH & REHAB during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 59 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Heritage Manor Health & Rehab?
HERITAGE MANOR HEALTH & REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 64 certified beds and approximately 56 residents (about 88% occupancy), it is a smaller facility located in BOSSIER CITY, Louisiana.
How Does Heritage Manor Health & Rehab Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, HERITAGE MANOR HEALTH & REHAB's overall rating (1 stars) is below the state average of 2.4, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Heritage Manor Health & Rehab?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Heritage Manor Health & Rehab Safe?
Based on CMS inspection data, HERITAGE MANOR HEALTH & REHAB has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Heritage Manor Health & Rehab Stick Around?
HERITAGE MANOR HEALTH & REHAB has a staff turnover rate of 55%, which is 9 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 Heritage Manor Health & Rehab Ever Fined?
HERITAGE MANOR HEALTH & REHAB has been fined $73,487 across 1 penalty action. This is above the Louisiana average of $33,814. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Heritage Manor Health & Rehab on Any Federal Watch List?
HERITAGE MANOR HEALTH & REHAB is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.