Evangeline Oaks Guest House
For profit - Corporation
190 Beds
Independent
Data: November 2025
Trust Grade
30/100
#197 of 264 in LA
Photo by AGG
Photo by AGG
Photo by Barbara Guidry
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Evangeline Oaks Guest House has received a Trust Grade of F, indicating significant concerns and poor overall performance. Ranking #197 out of 264 facilities in Louisiana places it in the bottom half, and at #9 out of 10 in Lafayette County, there is only one local option that is better. The facility is experiencing a worsening trend, with issues increasing from 20 in 2024 to 25 in 2025. Staffing is a major concern, as it has a low rating of 1 out of 5 stars and a high turnover rate of 75%, significantly above the state average of 47%. While there have been no fines recorded, the facility has less RN coverage than 85% of the state's facilities, which may impact the quality of care. Specific incidents noted by inspectors include the failure to maintain accurate staffing information, which was outdated and misleading, and the improper preparation of pureed and chopped meals that could lead to nutritional issues for residents. Overall, while the absence of fines is a positive, the facility has multiple weaknesses that families should carefully consider.
- Trust Score
- F
- In Louisiana
- #197/264
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 75% turnover. Very high, 27 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 9 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 62 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 26%
No red flags
20 → 25 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 25 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: 75%
29pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is very high (75%)
27 points above Louisiana average of 48%
The Ugly 62 deficiencies on record
Aug 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 that a resident's physician and responsible party were imme...
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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 that a resident's physician and responsible party were immediately notified when the resident was injured for 1 (Resident #2) of 10 (#1-#9 and #R1) sampled residents. Findings:Review of the facility's policy with a review date of 01/01/2024 titled, Accidents and Incidents - Investigating and Reporting read in part, Policy Interpretation and Implementation, 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included in the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom.Review of Resident #2's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, end stage renal disease, dependence on renal dialysis, type 2 diabetes and atrial fibrillation. Review of the facility's Incident Report dated 06/21/2025 revealed Resident #2 had an incident described as a fall during staff assist on 06/21/2025 at 7:00 a.m. Further review of the facility's incident report revealed the wrong physician and wrong responsible party were notified on 06/21/2025.On 08/25/2025 at 7:27 a.m., a phone interview was conducted with S4LPN (Licensed Practical Nurse). She stated that on the morning of 06/21/2025, she recalled the fall incident involving Resident #2 and the facility's van driver. S4LPN confirmed she did not immediately notify the resident's responsible party because she believed she had 72 hours to notify the resident's family and physician. On 08/27/2025 at 4:30 p.m., an interview was conducted with S1DON (Director of Nursing) and S2ADM (Administrator). Both confirmed they were familiar with the staff assisted fall involving Resident #2 and the facility van on 06/21/2025. Both verified S4LPN failed to notify the correct physician and the resident's responsible party.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews and record reviews, the facility failed to file a grievance for 1 (Resident #2) out of 10 (#1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews and record reviews, the facility failed to file a grievance for 1 (Resident #2) out of 10 (#1-#9 and #R1) sampled residents.Findings:Review of the facility's policy and procedure titled, Grievances/Complaints, Filing, with a revised date of April 2017 revealed, in part: Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care not furnished.Grievances and/or complaints may be submitted orally or in writing.Upon receipt of a grievance and/or complaint, the Grievance officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.Review of Resident #2's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses, but were not limited to, end stage renal disease, dependence on renal dialysis, type 2 diabetes and atrial fibrillation. On 08/27/2025 at 9:52 a.m., a phone interview was conducted with Resident #2's appointed representative. She reported Resident #2 called her and told her he fell while in his wheelchair on the lift of the van prior to leaving the facility for his scheduled dialysis on Saturday morning 06/21/2025. Resident #2's representative stated she was really, really upset because the facility hadn't notified her until the night of 06/21/2025. She stated she went to the facility on Monday morning, 06/23/2025 and spoke to S1DON (Director of Nursing) in person about her concerns.Review of the facility's grievance log from June 2025 until August 25, 2025 failed to include a grievance filed for Resident #2.On 08/27/2025 at 3:40 p.m., an interview was conducted with S1DON. She confirmed she did speak with Resident #2's appointed representative in person on Monday 06/23/2025. S1DON verified Resident #2's representative was upset that she was not notified of the accident involving Resident #2 and the van lift prior to the resident's scheduled dialysis on Saturday 06/21/2025. S1DON denied filing a grievance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews and record reviews, the facility failed to ensure staff provide care and services that meet p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews and record reviews, the facility failed to ensure staff provide care and services that meet professional standards of quality as evidenced by failing to perform chest compressions immediately to a resident requiring cardiopulmonary resuscitation (CPR) for 1 (#5) resident out of 10 (#1-#9 and #R1) sampled residents.Findings:Review of Resident #5's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction (Stroke), weakness, jaw pain, hyperlipidemia, type 2 diabetes mellitus without complications and hypertension. Review of Resident #5's June 2025 physician's orders revealed an order date of 09/25/2024 for full code status.Review of the facility's policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation, with a revised date of April 2016, revealed in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), for victims of sudden cardiac arrest.Preparation for CPR. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS training material.Emergency Procedure-Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: .d. Initiate the basic life support sequence (BLS) of events. 2. The BLS sequence of event is referred to as C-A-B (chest compression, airway, breathing). 3. Chest compressions: a. following initial assessment, begin CPR with chest compressions.d. Minimize interruptions in chest compressions.6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest.Review of the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care revealed in part:.Increased focus on methods to ensure that high-quality cardiopulmonary resuscitation (CPR) is performed in all resuscitation attempts. According to an American Heart Association Journal (https://doi.org/10.1161/CIR.0000000000000916), AHA implemented updates to Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care in 2020, which incorporated the importance of minimizing interruptions in chest compressions and ensuring chest compressions provided are of adequate rate and depth. CPR is the single-most important intervention for a patient in cardiac arrest, and chest compressions should be provided promptly. Chest compressions are the most critical component of CPR, and a chest compression-only approach is appropriate if lay rescuers are untrained or unwilling to provide respirations.Review of Resident #5's nursing progress notes revealed an entry dated 06/02/2025 at 7:50 a.m. per S3LPN (Licensed Practical Nurse) read in part: Called into Resident's bedside by CNA (Certified Nursing Assistant) passing food tray. Resident located in bed, nonresponsive and nonreactive to verbal or tactile stimuli. No movements were present. Nonreactive pupil reflex. Grunting breath sounds present. No pulse present. Resident's chart clarified full code. Code Blue initiated. Began CPR at 7:57 a.m. Emergency Medical Services (EMS) arrived at 8:10 a.m. Resident expired on 06/02/2025 at 8:48 a.m.Review of EMS' Pre-Hospital Care Report Summary dated 06/02/2025 revealed the following:Call Received at 07:56:19, EMS Dispatched at 07:56:26, EMS en route at 07:56:31 and arrived on scene at 08:05:55. EMS made contact with Resident #5 at 08:08:55. Chief compliant (primary) was Cardiac Arrest and provider impression was Cardiac Arrest. EMS initiated Protocol 1: Asystole / PEA Protocol. EMS assessment revealed Resident #5 was apneic (breathing had stopped), skin was pale in color and was unresponsive which was not normal for the resident. On 08/26/2025 at 4:06 p.m., an interview was conducted with S7WC (Ward Clerk) who confirmed she was working on the morning of 06/02/2025. S7WC explained S6CNA asked S7WC to go with her because Resident #5 was not herself. S7WC reported Resident #5 was observed sitting up, kind of slouched in bed, not responding and her eyes were closed. S7WC stated she exited the resident's room and called 911. S7WC stated S1DON (Director of Nursing) started chest compressions when S1DON arrived to the facility around 8:00 a.m. on 06/02/2025.On 08/26/2025 at 4:12 p.m., an interview was conducted with S6CNA. S6CNA confirmed she was assigned to Resident #5 on the day shift on 06/02/2025. S6CNA explained she was picking up breakfast trays and she went into Resident #5‘s room and observed Resident #5 in her bed and her eyes were open but Resident #5 was not responding. Then S6CNA called S7WC and S3LPN to observe Resident #5. S3LPN then notified S1DON who was on her way to work. S1DON started CPR when she arrived to the facility on [DATE] around 8:00 a.m.On 08/26/2025 at 4:26 p.m., an interview was conducted with S3LPN. S3LPN confirmed she was assigned to Resident #5 on the day shift on 06/02/2025. She explained she was called to Resident #5's room by S6CNA because S6CNA reported Resident #5 was breathing weird and was not acting like herself. S3LPN stated when she went to Resident #5's room, she observed the resident kind of slouched in her bed. S3LPN attempted to arouse Resident #5, but the resident was not responsive. S3LPN reported that she did not start chest compressions immediately. S3LPN explained S7WC called 911 and S1DON started CPR when she arrived to the facility around 8:00 a.m. On 08/27/2025 at 1:42 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON explained S3LPN notified her via text message on 06/02/2025 at 7:52 a.m. that Resident #5 was unresponsive, had labored breathing, and pupils were not reactive. S1DON instructed S3LPN to call 911 and start CPR-chest compressions. S1DON further explained she arrived to the facility on [DATE] at 8:00 a.m. and immediately went to Resident #5's room and performed a sternal rub with no resident response. S1DON then hollered for S7WC to call 911 and then S1DON started chest compressions. S1DON verified S6CNA and S3LPN were CPR certified and should have started CPR immediately after discovering Resident #5 was unresponsive.
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 F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews and record reviews, the facility failed to ensure staff maintained current CPR certification ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interviews and record reviews, the facility failed to ensure staff maintained current CPR certification for 1 (S3LPN-Licensed Practical Nurse) of 3 (S3LPN, S5LPN and S6CNA-Certified Nursing Assistant) personnel records reviewed.Findings: Review of the facility's policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation, with a revised date of [DATE], revealed in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), for victims of sudden cardiac arrest.Preparation for CPR 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS training material. On [DATE] at 4:26 p.m., an interview was conducted with S3LPN who stated she had BLS certification.A review of S3LPN's personnel record revealed her BLS certification expired 05/2025 but was not renewed until [DATE].On [DATE] at 3:40 p.m., an interview and review of S3LPN's BLS certification records was conducted with S1DON (Director of Nursing). S1DON confirmed S3LPN's BLS certification had lapsed and should have been renewed in 05/2025, but was not.
Jul 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the provider failed to implement the plan of care by not following physician orders to obtain laboratory testing as ordered for 1 (#2) out of 3 (#1, #2, #3) sampl...
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Based on record review and interview, the provider failed to implement the plan of care by not following physician orders to obtain laboratory testing as ordered for 1 (#2) out of 3 (#1, #2, #3) sampled residents.Review of Resident #2's medical record revealed his most recent readmission to the facility was on 02/04/2025 with diagnoses which included: essential hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia, and hyperlipidemia. Review of Resident #2's order summary report revealed laboratory orders dated 02/25/2025 for the following: Lipid panel q (every) 6 months (June/December); and PSA (Prostate Specific Antigen) and urine for microalbumin yearly (June). Further review of Resident #2's medical record failed to reveal evidence a Lipid panel, PSA and urine for microalbumin were obtained during the month of June.On 07/29/2025 at 10:30 a.m., an interview and record review of physician orders and laboratory testing results was conducted with S1DON (Director of Nursing). She confirmed Resident #2 had orders to obtain a Lipid panel every 6 months (June/December), and a PSA and urine for microalbumin yearly (June). She reviewed the file for laboratory results and confirmed those tests were not obtained as ordered.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents that were unable to carry out activi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents that were unable to carry out activities of daily living received personal hygiene (incontinent care) per their care plan for 1 (#1) out of 3 (#1-#3) sampled residents. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypertension, and copd (chronic obstructive pulmonary disease). Review of the resident's annual MDS (Minimum Data Set) dated 06/11/2025 revealed the resident's BIMS (Brief Interview Mental Status) score was 13 for being cognitively intact. Further review of the annual MDS revealed the resident had limited ROM (Range of Motion) on one side; used a wheelchair for mobility device; was dependent for toileting and personal hygiene. The resident was dependent for mobility. The resident was assessed to be incontinent for bowel and bladder. Review of the resident's care plan revealed that it addressed alteration in elimination related to bowel and bladder incontinence and to check every 2 hours for dryness and assist with personal care. On 07/28/2025 at 9:30 a.m., the resident was observed sitting up in wheelchair in the dayroom for an activity. On 07/28/2025 at 10:45 a.m., the resident was observed participating in activities in the dayroom. On 07/28/2025 at 11:00 a.m., the resident was observed sitting up in her wheelchair in the dayroom after activities. S4CNA (Certified Nursing Assistant) was then observed bringing the resident to the dining room for lunch. There was no observation of staff bringing the resident back to her room for incontinent care prior to lunch. On 07/28/2025 at 12:15 p.m., S5CNA and S6CNA were observed transferring the resident from her wheelchair to the bed with the use of the lifter with 2 person assist. The resident's pants were observed to be soaking wet when resident was lowered down in bed. S5CNA and S6CNA both confirmed the resident's pants was soaking wet. S6CNA stated the resident should have been toileted every 2 hours to ensure the resident was not wet. S6CNA stated she cleaned and changed the resident around 6:30 a.m. or 7:00 a.m. and that she did not change the resident again until now after lunch, which was approximately over 5 hours ago. On 07/28/2025 at 4:15 p.m., an interview was conducted with S1DON (Director of Nurses). S1DON stated the residents should be checked or rounded on every 2 hours and as needed for incontinent episodes. S1DON stated that checking for incontinent episodes requires the CNAs to bring the resident back to their room in order to check for incontinent episodes. On 07/29/2025 at 8:15 a.m., an interview was conducted with S3CNAS (Certified Nursing Assistant Supervisor). S3CNAS stated the CNAs should be toileting Resident #1 every 2 hours and that means the resident should be brought to her room and put in bed with the use of the lifter and incontinent care be provided. S3CNAS confirmed S5CNA and S6CNA informed her that the resident was not brought to her room for incontinent care that morning and was brought after lunch and at that time the resident was soaking wet.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the resident was receiving continuous oxygen a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the resident was receiving continuous oxygen as ordered for 1 (#1) out of 3 (#1-#3) sampled residents.Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypertension, and copd (chronic obstructive pulmonary disease).Review of the resident's annual MDS (Minimum Data Set) dated 06/11/2025 revealed the resident's BIMS (Brief Interview Mental Status) score was 13 for being cognitively intact. Review of the resident's care plan revealed that it addressed the resident was at risk for edema and sob (shortness of breath) related to copd. Interventions included administer respiratory therapy treatments, assess for signs and symptoms of respiratory distress, and oxygen as ordered.Review of the resident's current physician's orders revealed an order for oxygen at 2L/NC (two liters nasal cannula) continuously to keep sats (oxygen saturation) greater than 92% for hypoxia. The order was started on 07/22/2025.Review of the resident's nurse's note dated 07/28/2025 at 11:00 a.m. revealed, Resident observed in dining room with no oxygen on per n/c as ordered.On 07/28/2025 at 9:30 a.m., the resident was observed sitting up in wheelchair in the dayroom for an activity. An oxygen tank was observed inside the oxygen tank holder that was attached to the back of the resident's wheelchair. The oxygen was not in use during this observation. On 07/28/2025 at 10:45 a.m., the resident was observed participating in activities in the dayroom. The resident was not using oxygen during this observation.On 07/28/2025 at 11:00 a.m., the resident was observed being brought to the dining room for lunch by S4CNA (Certified Nursing Assistant). The oxygen tank was observed inside the tank holder that was attached on the back of the resident's wheelchair. S4CNA was asked if the resident used oxygen. S4CNA responded that she did not know if the resident used oxygen. The resident was not using oxygen during this observation.On 07/28/2025 at 11:05 a.m., an observation and interview were conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed the oxygen tank was inside the tank holder on the back of the resident's wheelchair. S2LPN checked the oxygen tank and verified it was empty. On 07/28/2025 at 11:10 a.m., S2LPN reviewed the resident's physician's orders and confirmed the resident had orders for continuous oxygen at 2 liters per nasal cannula. S2LPN confirmed the resident was not receiving continuous oxygen as ordered.On 07/28/2025 at 4:15 p.m., an interview was conducted with S1DON (Director of Nursing) and she confirmed the resident should have had continuous oxygen in use per the physician's orders.
May 2025
11 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 the resident's Minimum Data Set (MDS) assessment accurately ...
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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 the resident's Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #45) out of 56 sampled residents by failing to ensure that Resident #45 was coded correctly for the use of a wander bracelet.
Findings:
Review of Resident #45's electronic medical record revealed that he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Bipolar Disorder, Unspecified, Wandering in Diseases Classified Elsewhere and Anxiety Disorder, Unspecified.
Review of Resident #45's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 08, indicating moderate cognitive impairment.
Further Review of Resident #45's most recent quarterly MDS dated [DATE] Section P - Restraints and Alarms, P0200 Alarms, E. Wander/elopement Alarm, revealed it was coded as 0, Not used.
Review of Resident #45's Order Audit Report revealed an order that read, Roam Alert Bracelet Check Every Shift. Roam Alert Bracelet is intact and working properly every day and night shift with a start date of 09/26/2024 and a discontinued/revision date of 04/25/2025.
On 05/06/2025 at 3:27 P.M., an interview and record review was conducted with S7MDS. She confirmed that Resident #45 was using a wander bracelet daily. S7MDS also confirmed that Resident #45's quarterly MDS dated [DATE] had been coded incorrectly for using a wander bracelet daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and/or implement a comprehensive person-centered plan 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 develop and/or implement a comprehensive person-centered plan of care and/or follow physician's orders for 2 (#34 and #42) residents as evidence by failing to:
1. Follow physician's orders for applying a carrot splint to the left hand for Resident #34
2. Update Resident #42's care plan to address a urinary tract infection.
Findings:
Resident #34
A review of Resident #34's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction affecting Left Non-Dominant Side and Essential Primary Hypertension.
A review of Resident #34's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/19/2025 revealed a BIMS (Brief Interview for Mental Status) of 11, indicating moderate cognitive impairment.
A review of Resident #34's May 2025 Order Summary Report revealed a physician's order, dated 11/04/2024 that read, in part, apply carrot splint to left hand every day x (for) 8 hours as tolerated every day shift.
A review of Resident #34's Care plan Report included a focus of Potential for Contractures related to history of CVA (Cerebrovascular Accident) and Left Hemiparesis, Left Hand Contracture. Interventions did not include the application of the carrot splint to left hand per physician's orders.
A review of Resident #34's nurse's notes dated 05/04/2025 to 05/06/2025 revealed no documentation of Resident #34's refusal to wear the carrot splint.
On 05/05/2025 at 11:10 A.M., an observation was made of Resident #34 with a contracture noted to his left hand. Resident #34 was not wearing a splint. A carrot splint was noted on Resident #34's bedside table. He reported that staff had not applied the splint in a long time.
On 05/05/2025 at 3:45 P.M., a second observation was made of Resident #34 not wearing the carrot splint. It was observed on Resident 34's bedside table.
On 05/06/2025 at 9:09 A.M., a third observation was made of Resident #34 not wearing the carrot splint.
On 05/06/2025 at 4:02 P.M., an observation, interview and record review was conducted with S6LPN (Licensed Practical Nurse). She stated that she was staff that worked with Resident #34 on 05/05/2025 on the day shift and confirmed she had not placed the carrot splint on Resident #34 on 05/05/2025. S6LPN also confirmed that Resident #34 was not wearing the carrot splint at this time and that he had not used it all day.
On 05/06/2025 at 4:19 P.M., an interview and record review was conducted with S2DON (Director of Nursing). She confirmed that Resident #34 had a physician's order for a carrot splint to left hand and that this intervention was not included on his care plan report. S2DON also confirmed the carrot splint had not been applied on 05/05/2025 and 05/06/2025 and should have.
Resident #42:
Findings:
A review of Resident #42's electronic record revealed the resident was admitted to the facility on [DATE], with diagnoses which included, but were not limited to chronic kidney disease, heart failure, and muscle weakness.
Review of the facility's emergency transfer log revealed Resident #42 was transferred to the hospital on [DATE] and returned on 02/17/2025. Reason for transfer was listed as acute UTI (urinary tract infection).
Review of the hospital discharge summary revealed Resident #42 was admitted on [DATE] with UTI. Further review revealed discharge instructions including Ciprofloxacin HCL (Hydrochloride) (an antibiotic), 500 mg (milligram) oral every 12 hours.
Review of Resident #42's comprehensive plan of care did not indicate a focus area or interventions to address the residents UTI.
On 05/06/2025 at 2:38 P.M., an interview and review of Resident #42's current care plan was conducted with S14MDS (Minimum Data Set). She confirmed that the resident was not care planned for UTI, and stated that the care plan should have been updated when the resident returned to the facility to address the urinary tract infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's comprehensive care plan was revised for 2 (#21...
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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 comprehensive care plan was revised for 2 (#21 and #47) out of 30 sampled residents. The facility failed to ensure that comprehensive care plan were updated:
1. to include accurate advance directive code status for Resident #21, and
2. to include the removal of floor mats for Resident #47.
Findings:
Resident #21
A review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction and Congestive Heart Disease.
A review of Resident #21's physician's orders revealed he was admitted to Hospice services and a change in advance directive to reflect DNR (Do Not Resuscitate) code status on 01/27/2025.
A review of Resident #21's clinical record documentation, Louisiana Physician Order for Scope of Treatment (LaPOST), revealed a DNR code status was initiated on 01/27/2025.
A review of Resident #21's comprehensive care plan revealed it was not revised to reflect the change in code status and revealed a code status of Full Code.
On 05/06/2025 at 2:43 P.M., an interview and record review were conducted with S7MDS (Minimum Data Set). She stated that Resident #21 was a resident who received hospice services and had a DNR code status started on 01/27/2025. A review of the resident's comprehensive care plan was conducted with MDS, and she confirmed that Resident #21's code status of Full Code was documented, and should have been revised to state DNR with appropriate interventions.
On 05/06/2025 at 2:48 P.M., an interview was conducted with S3DON (Director of Nursing). S2DON stated that resident's comprehensive care plan were to reflect their accurate code status.
Resident #47
Review of Resident #47's admission Record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, seizures, schizoaffective disorder and hypertension.
Review of Resident #47's Order Summary Report revealed an order dated 10/01/2024 that read in part, bed in low position with mats on the floor x 2 when in bed. Monitor every shift.
Review of Resident #47's comprehensive care plan dated 10/28/2024 read in part, Potential for falls r/t weakness, seizures, medication use. Further review revealed an intervention which read in part, will apply a floor mat to left side of floor, padding to be added to floor.
Review of Resident #47's MDS (Minimum Data Set) dated 04/03/2025 read in part, Section C: Cognitive Patterns, BIMS (Brief Interview for Mental Status) score was 13 which indicated the resident was cognitively intact.
Review of Resident #47's Grievance Form revealed a grievance was filed by resident's R.P. (Responsible Party) on 03/06/2025. The actions taken to resolve complaint read in part, mats will be removed from the sides of the bed.
On 05/06/2025 at 11:12 A.M., an observation was made of Resident #47's room. Resident was lying in bed. No fall mats were noted on floor on either side of bed.
On 05/06/2025 at 2:25 P.M., a second observation was made of Resident #47's room. Resident was lying in bed. No fall mats were noted on floor on either side of bed.
On 05/06/2025 at 2:25 P.M., an interview was conducted with S13LPN (Licensed Practical Nurse). S13LPN confirmed there were no fall mats on floor next to Resident #47's bed and there should have been.
On 05/06/25 at 2:57 P.M., an interview was conducted with S2DON (Director of Nursing). S2DON confirmed the floor mats were removed from Resident #47's room, but the physician's order for floor mats was still in place. S2DON stated Resident #47's R.P. filed a grievance and floor mats were removed to resolve the grievance. S2DON confirmed Resident #47's care plan and orders were not updated to reflect the removal of the floor mats and they should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who were unable to carry out act...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition for 1 (#42) of 4 (#21, #42, #48, and #87) residents investigated for ADLs.
Findings:
On 05/08/2025, a review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, with a last revised date of 01/05/2025, read in part, Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition .4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is declining care. Approaching the resident in a different way, at a different time, or having another staff member speak with the resident may be appropriate.
A review of Resident #42's electronic record revealed the resident was admitted to the facility on [DATE], with diagnoses which included, but were not limited to chronic kidney disease, heart failure, muscle weakness, and cognitive communication deficit.
Review of Resident #42's Significant Change Minimum Data Set (MDS) with an assessment reference date of 02/23/2025, revealed in section GG that the resident had impairment of one side of upper extremities and required supervision or touching assistance with eating.
Review of Resident #42's comprehensive plan of care revealed a focus area dated 12/18/2024 for self-care deficit, and a goal that the resident will have all ADL needs met every day with appropriate assistance. Further review revealed a focus area dated 03/30/2025 indicating potential for alteration in nutrition, and interventions including encourage resident to eat all meals and drink all fluids, assist with meals as needed.
On 05/06/2025 at 11:32 A.M., an observation was made of Resident #42 during lunch. The resident was lying in bed and her lunch tray was on top of her over-bed table which was pushed away from the bed. The meal was unopened.
An observation of lunch activities continued out in Hall O. It was observed at 11:53 A.M., S16CNA (Certified Nursing Assistant) walked to the end of the hall twice to place used trays on a cart parked at the end of the hall, but did not enter the resident's room.
On 05/06/2025 at 11:53 A.M., an interview and observation of Resident #42's meal tray was conducted with S17LPN. She confirmed all of the resident's lunch was still on her tray and stated that no one reported to her that Resident #42 had not eaten or refused her lunch.
On 05/06/2025 at 12:01 P.M., an interview was conducted with S16CNA. She stated the resident refused her tray and she left it at her bedside and did not go back in to feed her or encourage her to eat and stated she should have.
On 05/06/2025 at 12:04 P.M., an interview was conducted with S2DON. She stated that if the Resident refused her lunch when the CNA brought it in, the CNA should have reported it to the nurse and gone back in the room to encourage the resident to eat.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assure that residents received foods in the appropr...
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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 assure that residents received foods in the appropriate form to support the resident's plan of care, in accordance with their goals and preferences for 1 (#90) resident out of a final sample of 56 residents.
Findings:
Review of the facility's policy titled Therapeutic Diets with a last revised date of 01/01/2024, read in part: Policy Statement- Therapeutic Diets are prescribed by the Attending Physician to support the resident's treatment plan of care and in accordance with his or her goals and preferences.
Review of Resident #90's medical record revealed she was admitted to the facility on [DATE] with diagnoses including: dysphagia pharyngeosophageal phase, gastro-esophageal reflux disease, and esophagitis.
Review of section C - Cognitive Patterns, of Resident #90's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13, indicating she was cognitively intact.
Review of Resident #90's May 2025 physician's orders revealed the following order dated 04/22/2025: Regular diet, Soft texture, Regular consistency, as tolerated; may have soft breads and cakes, soft vegetables and soft deserts. NO rice, NO corn, PUREED MEAT AND EGGS.
On 05/05/2025 at 11:15 A.M., an observation was made of Resident #90 during lunch in the dining room. The resident's meal ticket was reviewed and read pureed meat. An observation was then made of the resident's meal. The resident's meat was not pureed, but was chopped/ground. Resident #90 stated that she could not eat the meat because it was not pureed.
On 05/05/2025 at 11:26 A.M., an interview was conducted with S6Cook and S7DS (Dietary Supervisor). S6Cook stated that the meat on the resident's meal tray was pureed meat, but when she added thickener it added texture. She confirmed that the texture was not smooth. S7DS observed the pureed meat and also stated that the texture was supposed to be smoother, and the meat appeared to be more chopped than pureed. She stated the meat should have been pureed longer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain the recertification of terminal illness for 1 (#21) out 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 obtain the recertification of terminal illness for 1 (#21) out of 1 (#21) sampled residents reviewed for hospice.
Findings:
A review of the facility's undated policy titled, Hospice Program, with a last review date of 01/05/2025, revealed, in part, Our facility has designated . to coordinate care provided to the resident by our facility staff and hospice staff. He or she is responsible for the following: . d. obtaining the following information from the hospice: 1. The most recent hospice plan of care 3. Physician certification and recertification of the terminal illness specific to each resident .
A review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but not limited to, Cerebral Infarction and Congestive Heart Disease.
A review of Resident #21's Significant Change Minimum Data Set, dated [DATE] revealed, in part, Section O: Special Treatments, revealed the resident was admitted to hospice.
A review of Resident #21's physician's orders revealed an order entry with a start date of 01/27/2025, read in part, Admit to, Contracted Hospice, dx (diagnosis) of CVA (Cerebral Vascular Accident).
A review of Resident #21's person-centered plan of care revealed, in part, a focus on receiving hospice care .
A review of Resident #21's hospice documents in the contracted hospice binder revealed, in part, that the most recent certification of terminal illness by the Contracted Hospice Agency's physician was signed on 01/22/2025 for the recertification period of 01/15/2025 through 04/14/2025.
On 05/06/2025 at 2:48 P.M., an interview and record review were conducted with S2DON (Director of Nursing). She stated all hospice documents were in the resident's contracted hospice binder. A review of Resident #21's hospice binder with S2DON revealed the last certification was dated 01/15/2025 through 04/14/2025. She confirmed there should have been an updated hospice recertification in Resident #21's contracted hospice binder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure appropriate hand hygiene was performed during wound care for 1 (#65) resident out of a final sample of 56 residents.
Findings:
Review of the facility's policy titled Handwashing/Hand Hygiene, with a last reviewed date of 01/05/2025, read in part: Use an alcohol based hand rub containing at least 62% alcohol; or alternatively soap and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc .k. after handling used dressings .8. Hand hygiene is the final step after removing and disposing of PPE (Personal Protective Equipment). 9. The use of gloves does not replace hand washing/hand hygiene.
Review of Resident #65's medical record revealed he was admitted to the facility on [DATE] with diagnoses including pressure induced deep tissue damage of unspecified site and type 2 diabetes mellitus.
On 05/06/2025 at 9:20 A.M., an observation was made of S5TN (Treatment Nurse) perform Resident # 65's wound care. S5TN removed the resident's soiled dressing to his left heel, removed her gloves, and applied clean gloves. She did not perform hand hygiene prior to putting on clean gloves. S5TN proceeded to clean the resident's left heel with wound cleanser and then used clean, dry gauze to pat dry the resident's heel. She did not change her gloves or perform hand hygiene prior to using the gauze to dry the resident's wound. S5TN proceeded to perform wound care on the resident's right heel. During wound care to the right heel, S5TN removed dry gauze that was being held on the resident's heel by the CNA (Certified Nursing Assistant). She placed the soiled gauze in her gloved hand, and removed that glove. She then put on a clean glove to her right hand. S5TN did not perform hand hygiene prior to putting on the clean glove. S5TN proceeded to apply mesalt to the resident's right heel, removed her gloves, put on clean gloves, and did not perform hand hygiene.
On 05/06/2025 at 9:56 A.M., an interview was conducted with S5TN. She confirmed she did not realize that she missed several opportunities for hand hygiene during wound care.
On 05/06/2025 at 3:00 P.M., an interview was conducted with S3IC (Infection Control Nurse). She confirmed that S5TN was trained on hand hygiene during wound care and should have performed hand hygiene after removing soiled gloves and prior to putting on clean gloves.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
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 have a system in place to ensure 1 resident's (#34) ...
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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 have a system in place to ensure 1 resident's (#34) funds was safeguarded against any misappropriation. The deficient practice had the potential to affect a census of 87.
Findings:
A review of Resident #34's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction affecting Left Non-Dominant Side and Essential Primary Hypertension.
A review of Resident #34's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/19/2025 revealed a BIMS (Brief Interview for Mental Status) of 11, indicating moderate cognitive impairment.
On 05/05/2025 at 9:57 A.M., an interview was conducted with Resident #34. He stated that he was missing $40 about a month ago that was given to him by a friend. He stated that he had given the money to a CNA (Certified Nursing Assistant).
On 05/06/2025 at 1:29 P.M., an interview was conducted with S6LPN (Licensed Practical Nurse) and S12CNA (Certified Nursing Assistant). S12CNA stated that Resident #34 had money that he had given to the staff about two weeks ago and that it was locked in the narcotic box. S6LPN verified this and stated that Resident #34 had an envelope in the narcotic box with his name on it. She stated that it was locked up, so that Resident #34 would not lose or misplace it. S6LPN opened the narcotic box and there was an envelope with Resident #34's name on it with $40 inside. S6LPN stated that she was not sure of what the process was when funds were given to staff from residents.
On 05/08/2025 at 9:30 A.M., an interview was conducted with S2DON (Director of Nursing). She stated that there was currently no process in place when money was received from residents on weekends and after hours that she is aware.
On 05/08/2025 at 9:45 A.M., an interview was conducted with S11AC (Administration Clerical) who confirmed that she was responsible for residents' trusts funds. She confirmed that there was no process in place to temporarily safeguard residents' funds that may have been received from residents on the weekend or after hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interviews, the facility failed to provide a safe, clean, and homelike environment as evidenced by failing to ensure shower drains in Room A were free from excessive hair.
Fin...
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Based on observation and interviews, the facility failed to provide a safe, clean, and homelike environment as evidenced by failing to ensure shower drains in Room A were free from excessive hair.
Findings:
Review of the facility's policy titled Homelike Environment, with a last reviewed date of 01/05/2025, read in part: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment.
On 05/06/2025 at 12:40 P.M., an observation was made of Room A. The shower drains were observed in each shower. There was hair clogged in the shower drains and sitting on top of the drains.
On 05/06/2025 at 12:47 P.M., an observation and interview was conducted with S2DON (Director of Nursing). S2DON observed the hair in the shower drains, and stated that the CNAs (Certified Nursing Assistants) were responsible for cleaning the shower room, whirlpool, and showers in between resident showers.
On 05/06/2025 at 2:43 P.M., S2DON confirmed that the CNAs should have been cleaning the hair out of the shower drains between resident showers.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observations and interview, the facility failed to ensure staffing information that was posted daily was accurate and current. The facility's census was 87.
Findings:
On 05/06/2025 at 8:35 A....
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Based on observations and interview, the facility failed to ensure staffing information that was posted daily was accurate and current. The facility's census was 87.
Findings:
On 05/06/2025 at 8:35 A.M., an observation of the daily posted staffing information revealed a date of 05/05/2025 with a census of 90 residents.
On 05/08/2025 at 8:15 A.M., a second observation of the daily posted staffing information revealed a date of 05/05/2025 with a census of 90 residents.
On 05/08/2025 at 10:50 A.M., an interview was conducted with S11AC (Administration Clerical). She confirmed that the staffing information posted daily included information from the day before. The staffing information with a date of 05/05/2025 including staffing information and census from 05/04/2025. She stated the information had always been posted with the previous day's information, and not the current date.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected most or all residents
Based on observations, record review, and interview, the facility failed to ensure recipes for pureed, chopped, and bite-sized meals were used during meal preparation. This failure had the potential t...
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Based on observations, record review, and interview, the facility failed to ensure recipes for pureed, chopped, and bite-sized meals were used during meal preparation. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for 15 (#4, 10, 14, 27, 30, 33, 42, 48, 60, 67, 70, 73, 74, 87, 90) residents who received pureed meals, 12 (Residents #1, 19, 34, 37, 49, 51, 54, 56, 64, 72, 76, 77 ) who received finely chopped and 10 (Residents #2, 8, 11, 21, 23, 24, 43, 52, 78, 80 ) who received bite sized.
Findings:
Review of the facility's Lunch menu for 05/05/2025 revealed, in part: black eyed peas & sausage, steamed rice, and greens.
On 05/05/2025 at 10:12 A.M., an observation was made of S9Cook preparing puree greens with an electric food processor. S9Cook was observed pouring an unmeasured amount of thickener into the mixture of greens, mixed the thickener with the greens, then poured an additional unmeasured amount of thickener in to the mixture of greens, mixed the greens and thickener, then poured an additional unmeasured amount of thickener powder from the container to the greens mixture. There was no recipe being used.
On 05/05/2025 at 10:17 A.M., a second observation was made of S9Cook preparing the alternate of puree Salisbury steak. S9Cook was observed removing a total of 13 cooked Salisbury steaks from a baking sheet and into the electric food processor with an unmeasured amount of gravy for liquid. S9Cook was observed adding an unmeasured amount of thickener powder to the Salisbury steak mixture. When asked how many servings she was preparing, S9Cook stated, think like 13. There was no recipe being used.
On 05/05/2025 at 10:27 A.M., an observation was made of S9Cook removing an unmeasured amount of cooked steamed rice and adding it to the electric food processor. There was no recipe being used.
On 05/05/2025 at 11:45 A.M., an interview was conducted with S8DS (Dietary Supervisor) who stated recipes should be used when preparing puree meals. S8DS grabbed the recipe binder from the dry storage room and stated S9Cook should have used the recipes to prepare the pureed greens, Salisbury steak, and pureed rice.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1.
Ensure the resident's respiratory equipment was s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1.
Ensure the resident's respiratory equipment was stored properly for 1 (Resident #2) and
2.
Indicate when to use BIPAP(Bilevel Positive Airway Pressure) for 1 (Resident #2)
out of a 3 residents (Resident #1, #2, and #3) sampled for respiratory care.
Findings:
A review of the facility's policy titled Respiratory: Pulmonary Conditions, with a last review date of 01/20/2025 read in part: Storage- 1. All nasal cannulas are to be stored in sealed and dated storage bags when not in use.
Review of Resident #2's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Chronic Obstructed Pulmonary Disease, Heart Failure, Unspecified Dementia, Morbid Obesity, and Obstructive Sleep Apnea.
Review of Resident #2's Significant Change MDS (Minimum Data Set) assessment date of 01/28/2025 revealed the Resident had a BIMS (Brief Interview of Medical Status) of 8, indicating that the resident's cognition was moderately impaired. Further review of Section GG Chair/bed-to chair transfer was coded as 2, indicating that the resident required substantial/maximal assistance.
Review of Resident #2's current physician's orders read in part: Oxygen 2 liters per nasal cannula continuously resident may remove as he tolerates, Keep respiratory equipment in a plastic bag when not in use every shift, and BIPAP set at 14/9 CM (Centimeters) every shift.
Further review of Resident #2's current physician orders failed to include a frequency for the application of BIPAP.
On 04/28/2025 at 10:18 a.m., an observation of Resident #2 and his room was made. Resident #2 was in bed sleeping with his wheelchair noted away from the bed. Resident #2 was observed not wearing a BIPAP mask. An oxygen nasal cannula was observed connected to a portable oxygen tank, hanging freely from his wheelchair, not in a storage bag.
On 04/28/2025 at 10:26 am, an interview and observation with S1CNA (Certified Nursing Assistant) was conducted. S1CNA confirmed that the oxygen nasal cannula hanging on Resident #2's wheelchair should have been in a plastic storage bag and was not. She stated that staff were responsible for placing the oxygen nasal cannula, not in use, into a storage bag after the resident was transferred to the bed and a separate nasal cannula connected to a portable concentrator was applied.
On 04/28/2025 at 10:29 a.m., an interview and observation was conducted with S2LPN (Licensed Practical Nurse). S2LPN confirmed that Resident #2's oxygen nasal cannula should have been stored in a plastic bag and was not. S2LPN stated that Resident #2 has not transferred himself without staff from his wheelchair to his bed and only wears his BIPAP at night.
On 04/28/2025 at 3:39 p.m., an interview was conducted with S3IP (Infection Preventionist). S3IP confirmed that oxygen nasal cannulas when not in use, should be placed in a storage bag.
On 04/28/2025 at 3:50 p.m., an interview was conducted with S4DON (Director of Nursing). S4DON stated that Resident #2 should have BIPAP applied anytime he was sleeping, including naps. S4DON confirmed that Resident #2's physician order for BIPAP did not indicate when the BIPAP was to be used and should have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were accurately documented and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were accurately documented and maintained in accordance with professional standards of practice for one (# 1 ) resident out of 3 (#1, #2, #3) sampled residents.
Findings:
Review of the facility's policy titled Guidelines for Charting and Documentation , with a last reviewed date of January 2025, read in part .the purpose of charting and documentation is to provide: 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident .General Rules for Charting and Documentation .2. Be concise, accurate, and complete .6. Document assessments, interventions, treatments, outcomes, etc.
Review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, shortness of breath, and obstructive sleep apnea.
Review of Resident #1's physician's orders revealed an order dated 10/01/2024 that read: CPAP/BIPAP (Continuous Positive Airway Pressure / Bi level Positive Airway Pressure) mask and tubing , clean daily with warm soapy water, rinse with warm water and allow to air dry.
Review of Resident #1's April 2025 (MAR Medication Administration Record) revealed the following : CPAP/BIPAP mask and tubing , clean daily with warm soapy water, rinse with warm water and allow to air dry. The task was marked with the nurse's initials, indicating the task was completed on 04/28/2025.
On 04/28/2025 at 10:00 a.m., an observation was made of Resident #1's CPAP mask. There was brown residue and beard hairs on the inside of the mask.
On 04/28/2025 at 12:10 p.m., a second observation was made of Resident #1's CPAP mask. [NAME] residue and beard hair remained in the resident's CPAP mask.
On 04/28/2025 at 12:12 p.m., an interview was conducted with S5LPN (Licensed Practical Nurse). S5LPN stated that Resident #1's CPAP mask was to be cleaned daily with soap and water. S5LPN stated that this was documented once per shift, and she had not cleaned the mask yet. When asked about her documenting that the CPAP mask was cleaned today, she stated that she had not yet cleaned it, but she did document it. She stated that she was allowed to document that tasks were complete even though she had not completed the task.
On 04/28/2025 at 3:19 p.m., an interview was conducted with S4DON (Director of Nursing). She stated that nurses were not allowed to document that they completed a task prior to completing the task.
Mar 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident who is unable to carry out activitie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming by failing to trim a resident's fingernails for 1 (#2) out 7 (#1-#7) sampled residents.
Findings:
Review of the facility policy and procedure entitled Fingernails/Toenails, Care of last reviewed August 2024 revealed that the purpose of this procedure are to clean the nail bed, to keep nails trimmed . The general guidelines included 1. Nail care included cleaning as needed and regular trimming .
Review of Resident #2's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Huntington disease, mood affective disorder, depression, and anxiety disorder.
Review of the resident's quarterly MDS (minimum data set) dated 02/12/2025 revealed the resident's BIMS (brief interview mental status) score was 6, meaning the resident was severely impaired for cognition. The resident was coded as being dependent with maximum assistance for all adls (activities of daily living).
Review of the resident's active physician's orders revealed an order to trim nails as needed (prn). The start date for the order was 10/01/2024.
On 03/05/2025 at 7:55 AM, the resident was observed in his room lying down in bed. S4CNA (Certified Nursing Assistant) was observed in the hall and entered the resident's room. The surveyor asked the CNA for assistance to check the resident's hands. The CNA uncovered the resident's hands. The resident's fingernails were observed to be long and unclean. The resident's fingernails on both hands were observed with multiple dark brown colored substance under the fingernails. The CNA confirmed the resident's fingernails were long and dirty and needed to be trimmed and cleaned.
On 03/05/2025 at 8:15 AM, an observation was made of the resident with S2QA (Quality Assurance) Nurse. She confirmed the resident's fingernails were long and had dark brown colored substances under the fingernails. She confirmed the resident's fingernails needed to be trimmed and cleaned.
On 03/06/2025 at 10:55 AM, an interview was conducted with S1DON (Director of Nursing). She confirmed that if the resident's fingernails were long and had a build-up of a dark brown substance under the nails, the resident's nails should have been trimmed and cleaned.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observations and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 96.
Findings:
On 03/03/2025 at 10:00 AM, an ob...
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Based on observations and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 96.
Findings:
On 03/03/2025 at 10:00 AM, an observation was made of the nurse staffing data posted on a whiteboard upon entry into the facility. The nurse staffing data revealed dates of 02/11/2025 and 02/12/2025.
On 03/03/2025 at 10:45 AM, an observation and interview was conducted with S1DON (Director of Nursing). S1DON confirmed that the nurse staffing data was posted on a whiteboard upon entry into the facility. She also confirmed the dates were 02/11/2025 and 02/12/2025. S1DON confirmed the nurse staffing data should have been updated daily and was not.
Feb 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 that a resident's physician and responsible party were imme...
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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 that a resident's physician and responsible party were immediately notified when the resident was injured for 1 (Resident #5) of 5 (#1, #2, #3, #4, #5) residents reviewed.
Findings:
On 02/12/2025, a review of the facility's policy with a review date of 01/01/2024 titled, Accidents and Incidents - Investigating and Reporting read in part, Policy Interpretation and Implementation, 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included in the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom.
Review of Resident #5's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, anxiety disorder, fibromyalgia and osteoarthritis, unspecified.
Review of Resident #5's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/11/2024 revealed she had a BIMS (Brief Interview for Mental Status) of 14, indicating she was cognitively intact.
Review of the facility's Incident Report dated 01/04/2025 revealed Resident #5 had an incident and was hit in the head with her room door by staff on 01/04/2025 at 11:25 AM. Further review of the facility's incident report revealed the physician and responsible party was notified on 01/06/2025.
Review of Resident #5's medical record did not reveal the physician and responsible party were notified of the incident that occurred on 01/04/2025 until 01/06/2025.
On 02/11/2025 at 3:45 PM, an interview was conducted with Resident #5. She stated that she did recall the incident when she was hit in the head with the door by a nurse. Resident #5 stated that she was at her door bent over when the nurse walked in and the door hit her on the head which caused her to also hit her head on the wall.
On 02/12/2025 at 10:55 AM, an interview was conducted with S3LPN (Licensed Practical Nurse). She stated that on 01/06/2025 Resident #5 was complaining of a headache and wanted to be sent to the emergency room for evaluation because she had been hit in the head with the door when a nurse had entered her room on yesterday. She stated that she called Resident #5's nurse practitioner and responsible party and neither were aware of the incident.
On 02/12/2025 at 1:46 PM, a phone interview was conducted with S4ALPN (Agency Licensed Practical Nurse). She stated that she did not notify the physician or responsible of Resident #5's incident because she was unware that Resident #5's head was hit.
On 02/12/2025 at 3:15 PM, an interview was conducted with S1DON (Director of Nursing). She stated that according to the incident report dated 01/04/2025, Resident #5 was hit in the head with the door by staff. S1DON stated that the responsible party and physician were not notified until 01/06/2025 and should have been notified on 01/04/2025 when the incident occurred.
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 F0773
(Tag F0773)
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 write a telephone order and obtain a wound culture in a timely man...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to write a telephone order and obtain a wound culture in a timely manner as ordered by a physician for 1 (#2) out of 5 (#1, #2, #3, #4, #5) sampled residents.
Findings:
Review of Resident #2 record revealed she was admitted to the facility on [DATE] with diagnosis not limited to, stage 4 pressure ulcer of sacral region, stage 4 pressure ulcer of left elbow, pain, pressure ulcer of her left elbow, sepsis, cachexia, hemiplegia and hemiparesis of left side, and server protein calorie malnutrition.
Record review of Resident #2's nurse notes written and dated by S2Treatment Nurse,
10/02/2024 read in part, Upon performing wound care, this nurse noted malodorous odor with moderate amount of serosanguinous drainage from left hip stage III (3) pressure ulcer. Moderate amount of bright green exudate from right upper back stage IV (4) pressure ulcer .This nurse called .wound care clinic .new order per doctor to collect wound culture to left hip and collect wound culture to right upper back .
10/04/2024 Wound culture specimen was picked up per hospital technician.
Record review of wound culture from the hospital read in part, Wound Culture, collected 10/04/2024 at 1:20 PM, received at 6:18 PM on 10/04/2024.
On 02/12/2025 at 10:15 AM, an interview with S2Treatment Nurse confirmed she was Resident #2's treatment nurse on 10/02/2024. She stated on 10/02/2024 while she was treating Resident #2's wounds, there was a very strong odor from her multiple wounds. S2Treatment Nurse stated she called the Wound Care Clinic and received orders from the physician to culture the wounds and send them to the lab on that day (10/02/2024).
On 02/12/2025 at 2:05 PM, Record review of Resident #2's Nurses Notes and Lab results with S1DON (Director Of Nursing) confirmed the nurses notes on 10/02/2024 revealed S2Treatment Nurse received an order from the wound care physician to collect wound cultures and send them to the lab on 10/02/2024. She reviewed Resident #2's labs and confirmed the Resident wound cultures were collected and received at the lab on 10/04/2024 (two days later). S1DON reviewed Resident #2's paper chart and electronic records and could not find the Telephone Order S2Treatment Nurse was to have written for the wound cultures on 10/02/2024. At this time S1DON stated S2Treatment Nurse did not write a telephone order and they did not send the wound cultures to the lab in a timely manner as ordered by the physician.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by failing to ensure there was documentation of an incident that occurred for 1 (Resident #5) of 2 (Resident #3 and #5) residents reviewed for incidents.
Findings:
On 02/12/2025, a review of the facility's policy with a revised date of 04/2012 titled Guidelines for Charting and Documentation read in part. Purpose, 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care. General Rules for Charting and Documentation, 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. Nursing Summaries and/or Assessments, 16. Unusual Occurrence/Significant Events.
Resident #5
Review of Resident #5's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, anxiety disorder, fibromyalgia and osteoarthritis, unspecified.
Review of Resident #5's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/11/2024 revealed she had a BIMS (Brief Interview for Mental Status) of 14, indicating she was cognitively intact.
Review of the facility's Incident Report dated 01/04/2025 revealed Resident #5 had an incident and was hit in the head with her room door by staff.
Review of Resident #5's nurse's notes dated 01/04/2025 did not reveal any incident had occurred.
On 02/11/2025 at 3:45 PM, an interview was conducted with Resident #5. She stated that she did recall the incident when she was hit in the head with the door by a nurse. Resident #5 stated that she was at her door bent over when the nurse walked in and the door hit her on the head which caused her to also hit her head on the wall.
On 02/12/2025 at 1:46 PM, a phone interview was conducted with S4ALPN (Agency Licensed Practical Nurse). She stated that she did recall the incident, but was not able to recall the date. S4ALPN stated that she opened Resident #5's door and Resident #5 was at the door with her food tray and the door hit the food tray. She stated that she was not aware that Resident #5's head was hit.
On 02/12/2024 at 3:15 PM, an interview and record review was conducted with S1DON (Director of Nursing). She stated recalled the incident involving Resident #5. A review of Resident #5's nurse's notes dated 01/04/2025 did not reveal any documentation that the resident was hit on the head with the door. S1DON stated the nurse should have documented the incident in the nurse's notes.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that Resident #1's back door frame and north wall were in good repair for 1 (Resident #1) out of 3(#1, #2, and #3) residents sampled.
Findings:
On 06/24/2024 a review of the facility's policy titled, Homelike Environment with a review date of 01/01/2024 read in part, Residents are provided with a safe, clean, comfortable and homelike environment .
Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unspecified Dementia and Essential Hypertension.
Review of Resident #1 MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/27/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 10, indicating his cognition was moderately intact.
On 06/24/2024 at 11:11 a.m., an observation and interview was conducted with Resident #1. He stated that the facility should fix the rotten wood on the back door frame. An observation of the back door frame revealed a section of rotten wood located on the bottom left hand side of the door frame about one foot in height. An observation was made of the Resident #1's north wall on the left side of his bed, where two breaks in the sheetrock was observed.
On 06/24/2024 at 11:15 a.m., an interview and observation of Resident #1's room was conducted with S1MNT (Maintenance Supervisor). S1MNT opened Resident #1's back door and kicked the lower portion of the left side of the door frame. The wood from the door framed crumbled. S1MNT stated that Resident #1's door frame should not have been in that condition. S1MNT also confirmed that the north wall on the left side of the Resident #1's bed should not have been in that condition.
On 06/24/2024 at 11:17 a.m., an interview and observation of Resident #1's room was made with S2ADM(Administrator). S2ADM confirmed that the Resident #1's back door frame should not have been in that condition. S2ADM confirmed that the Resident #1's north wall on the left side of the Resident #1's bed should not have been in that condition.
May 2024
14 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to treat each resident with respect and dignity in a ...
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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 treat each resident with respect and dignity in a manner that promoted maintenance or enhancement of his or her quality of life by failing to address the resident by her name for 1 (#11) of 2 (#11, #74 ) sampled residents reviewed for dignity.
Findings:
Review of the facilities document Quality of Life - Dignity read in part .1. Residents are treated with dignity and respect at all times .7. Staff speak respectfully to resident at all times, including addressing by his or her name of choice and not labeling.
Resident #11
Review of the medical record for Resident #11 revealed the resident was admitted on [DATE] with diagnoses including Bipolar disorder, Chronic kidney disease, stage 4, and Type 2 diabetes mellitus.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 06, indicating severe cognitive impairment.
Review of the resident's care plan dated 03/04/2024 read in part .approach resident warmly and positively and in a calm manner.
On 05/21/2024 at 8:30 a.m., while making observation rounds on Hall A, Resident #11 was heard asking S8CNA (Certified Nursing Assistant) for some ice. 8CNA stated I'm busy girl.
On 05/21/2024 at 8:31 a.m., an interview was conducted with the Resident #11 who confirmed that when she asked S8CNA for some ice, she stated I'm busy girl. Resident #11 stated that she did not like to be called girl. She added that she was a grown woman and she was [AGE] years old. She stated that she would like for the staff to call her by her name.
On 05/21/2024 at 8:45 a.m., an interview was conducted with S8CNA who denied speaking to the resident in a disrespectful way.
On 05/22/2024 at 7:30 a.m., an interview was conducted with S2DON who stated the facility's goal was to make the residents feel valued and care for. She added that residents should be treated with dignity and respect at all times. She confirmed that the resident should not have been addressed as girl.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on review of the resident council minute meetings and interviews, the facility failed to organize resident group meetings in the facility monthly. This deficient practice had the potential to af...
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Based on review of the resident council minute meetings and interviews, the facility failed to organize resident group meetings in the facility monthly. This deficient practice had the potential to affect 95 residents residing in the facility.
Findings:
Review of the facility Resident Council Meeting Binder revealed on January 2024 and February 2024 Resident Council Meetings were held. Further review of the binder failed to provide further meetings for March 2024 or April 2024.
On 05/21/2024 at 9:30 a.m. an interview was conducted with the Resident #56, who was the Resident Council President, and three other residents (Resident #6, #10, #301) who attended the meeting for resident council review. They verbalized that the facility had not been conducting resident council meetings monthly.
On 05/21/2024 at 10:15 a.m., an interview was conducted with S10AD (Activity Director) who stated she had been conducting monthly meetings. S10AD was not able to provide documentation that resident council meetings were being conducted monthly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a homelike environment for 1 (#13) out of 3 (#13, #37, #62) r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a homelike environment for 1 (#13) out of 3 (#13, #37, #62) residents investigated for environment, out of a total sample of 34 residents.
Findings:
On 05/22/2024 a review of the facility's policy titled, Homelike Environment with a review date of 01/01/2024 read in part, Residents are provided with a safe, clean, comfortable and homelike environment .
Resident #13 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Chronic Pain and Acquired Absence of Right Leg Above Knee.
Review of Resident #13's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/13/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 15, indicating his cognition was intact.
On 05/20/2024 at 10:15 a.m., an observation and interview was conducted with Resident #13. The ceiling across from the resident's bed was cracked, peeling, and hanging. The resident stated the ceiling had been like that since his admission to the facility.
On 05/20/2024 at 2:23 p.m., an interview and observation of the resident's ceiling was conducted with S18MNT (Maintenance). He confirmed the ceiling in the resident's room was in disrepair. S18MNT stated that he was not aware of ceilings being checked in the facility.
On 05/22/2024 at 8:35 a.m., an interview and review of the facility's maintenance log was conducted with S19MNTSup (Maintenance supervisor). He stated that he checked only the call lights and beds on maintenance rounds, but had never checked anything else in the facility. Review of the maintenance log revealed that only beds and call lights were being checked.
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** Resident #89
Review of Resident #89's EMR (Electronic Medical Record) revealed an admission date of 12/06/2023 with diagnoses th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #89
Review of Resident #89's EMR (Electronic Medical Record) revealed an admission date of 12/06/2023 with diagnoses that included Alzheimer's Disease, Congested Heart Failure, Non-traumatic Subdural Hemorrhage, Pain, Muscle Weakness.
Review of the Resident #89's MAR (Medication Administration Record) for May 2024 revealed lap tray in place. Monitor Q (every) shift. Release every 2 hours.
Review of the Resident #89 active physician orders dated 02/22/2024 revealed lap tray in place. Monitor Q (every) shift.
Review of the Resident #89's Care Plan revealed; Potential for functional decline related to use of a restraint. Lap tray in place for poor trunk control.
Review of the Resident #89's Pre-Restraint Use Evaluation dated 02/22/2024 revealed After further review by the Interdisciplinary Team, the following recommendations were made: Resident with poor trunk control while sitting in wheelchair .Per hospice direction (RP (responsible party) consented), will attempt lap tray .Will monitor for safety and tolerance.
Review of the Resident #89's Quarterly MDS (Minimum Data Set) dated 05/15/2024 revealed under Section P-Restraints, the resident was not coded for the use of any restraints.
On 05/21/2024 at 8:36 a.m., an observation was made of Resident #89 sitting at feeder table in wheelchair with lap tray in place.
On 05/21/2024 at 8:36 a.m., an observation was made of Resident #89 sitting in at nurse's station in GeriChair with lap tray in place.
On 05/21/2024 at 8:36 a.m., an observation was made of Resident #89 eating at feeder table in wheelchair with lap tray in place.
On 05/22/2024 at 1:20 p.m., an interview was conducted with S5MDSC (Minimal Data Set Coordinator). S5MDSC confirmed Resident #89 had a lap tray restraint in place for poor trunk control. She reviewed the Quarterly MDS dated [DATE] Section P-Restraints, and confirmed the resident was not coded for use of any restraints and should have been.
Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the status of 2 (#63) and (#89) out of 34 sampled residents by failing to ensure that:
1. Resident #63 was coded correctly for medications received; and
2. Resident #89 was coded correctly for use of a restraint.
Findings:
Resident #63
Review of Resident #63's quarterly MDS assessment with an ARD (Assessment Reference Date) of 04/17/2024 revealed the resident was admitted to facility on 01/06/2023 and was coded as having received an injectable medication for one day.
Review of the resident's April 2024 eMAR (electronic Medication Administration Record) revealed there was no injectable medication administered for the entire month of April 2024.
On 05/22/2024 at 3:19 p.m., an interview and review of Resident #63's quarterly MDS assessment dated [DATE] was conducted with S15MDSC (Minimum Data Set Coordinator). She was unable to recall which injectable medication the resident had received. S15MDSC reviewed the resident's April 2024 eMAR to verify. S15MDSC verified there was no evidence that the resident received an injection and confirmed the quarterly assessment with an ARD of 04/17/2024 was not accurate.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #82
Review of Resident #82's EMR (Electronic Medical Record) revealed she was admitted to the facility on [DATE] with d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #82
Review of Resident #82's EMR (Electronic Medical Record) revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's Disease with late onset, Repeated falls, Laceration without foreign body, Hyperlipidemia, Delirium, Hypertension, Aphasia, Anxiety, Osteoarthritis, Depression, Osteoporosis, and Psychosis.
Review of Resident #82's physician's orders revealed an order entry with a start date of 04/29/2024 read: Padding on right and left side of bedframe for safety, monitor intact every shift.
Review of Resident #82's May 2024 MAR (Medication Administration Record) revealed the following order dated 04/29/2024: Padding on right and left side of bedframe for safety, monitor intact every shift.
On 05/20/2024 at 9:00 a.m., an observation was made of Resident #82's room. Padding was on the floor and not attached on the right or left side of bedframe.
On 05/20/2024 at 11:30 a.m., a second observation was made of Resident #82's room. Padding was on the floor and not attached on the right or left side of bedframe.
On 05/21/2024 at 10:00 a.m., an interview and observation of Resident #82's room was conducted with S17LPN (Licensed Practical Nurse). S17LPN confirmed that the padding was not intact or attached on the right and left side of bedframe and should have been monitored every shift.
Based on observations, interviews and record reviews, the facility failed to implement a person-centered care plan by failing to:
1. Ensure staff repositioned Resident #198 every 2 hours and provided a notebook and pen so she could make her needs known; and
2. Monitor padding on Resident #82's bedframe.
Findings:
Resident #198
Review of facility document titled Repositioning dated 01/01/2024 read in part: General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.
Resident #198 was admitted to the facility on [DATE] with a diagnoses including Acute kidney failure, Adult failure to thrive, Pneumonia, Cerebrovascular accident, and Major depressive disorder.
Review of the resident's care plan with a start date of 05/16/2024 revealed that she was at risk for skin impairment related to Gastro tube. Intervention - turned and repositioned every two hours while in bed. Difficulty making self-understood related to altered speech pattern due to Cerebrovascular accident. Intervention - provide notebook and pen as alternate means of communication, and provide communication board if needed.
On 05/20/2024 at 9:00 a.m., Resident #198 was observed in bed lying on her right side. Resident was awake and alert, gesturing with her hands. No communication board or notebook and pen were observed at the bedside. A second observation was conducted at 11:35 p.m. and the resident observed in bed lying on right side.
On 05/20/2024 at 12:43 p.m., another observation was conducted, and Resident #198 was observed on her left side. A second observation was conducted at 3:00 p.m., the resident was observed on her left side.
On 05/20/2024 at 12:28 p.m., an observation and immediate interview was conducted with S7LPN (Licensed Practical Nurse) who confirmed that the resident should have been turned on her left side. Further observation did not reveal a notebook and pen or communication board.
On 05/21/2024 at 2:28 p.m., an observation was conducted in the Resident #198's room with S9LPN an S8CNA (Certified Nursing Assistant). The resident was observed moving her arms and hands about, and moving her lips as if she was trying to speak. S9LPN stated I don't know what you want. I can't understand you. No communication board or notebook and pen were observed in resident's room. S9LPN stated she was not aware that the resident was supposed to have a notebook and pen or communication board.
On 05/21/2024 at 2:31 p.m., an interview was conducted with S12SS (Social Services) stated that she used a notebook and pen when she communicate with Resident #198. She stated that she bring her own paper and pen, and confirmed that the Resident should have had a communication board or notebook and pen in her room so that could make her needs known. S12SS stated that she was responsible for ensuring that the resident had a way to communicate with the staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that a resident and/or a resident's RP (Responsible Party) w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that a resident and/or a resident's RP (Responsible Party) was invited to the resident's care planning meeting for 1 (#70) out of a total sample of 34 residents. This deficient practice had the potential to affect a census of 95.
Findings:
On 05/22/2024, a review of the facility's policy titled Care Planning-Interdisciplinary Team with a review date of 01/01/2024, read in part: Policy Statement. The Interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation .3. The resident and Resident Representative are encouraged to participate in the development of and revisions to the resident's care plan. 8. If it is determined that participation of the resident or representative is not practicable for the development of the care plan, an explanation is documented in the medical record.
Resident # 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hydronephrosis with Renal and Ureteral Calculous Obstruction, Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms.
A review of Resident #70's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/24/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 14, suggesting his cognition was intact.
On 05/20/2024 at 9:52 a.m., an interview was conducted with resident #70. The resident stated that his catheter had been in over a year. He stated that he had been asking the nurses why he still needed it, but the nurses hadn't been telling him anything.
On 05/22/2024 at 11:30 a.m., an interview was conducted with Resident #70. The resident stated he had never been invited to a care plan meeting. He further stated that if he was invited he would have attended.
05/22/2024 at 11:54 a.m., an interview and review of resident's care plan review sign in sheet was conducted with S15MDSC (Minimum Data Set Coordinator). She stated they do not usually send an invitation to the residents for the care plan meeting, but they sent one to the RP. She stated that the CNAs (Certified Nursing Aides) usually tell the residents about the meetings, and if they refused to attend, a note is made in the note section of the meeting sign in sheet. A review of the sign in sheet for Resident #70 revealed only staff members signed in and the resident or RP were not listed. Further review revealed the note section on the sign in sheet was blank.
05/22/2024 at 2:37 p.m., an interview was conducted with Resident #70's RP. She stated that she had never received a letter from the facility inviting her to the care plan meeting to discuss the resident's care. She further stated she would have attended if she was invited.
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 F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure activities were provided based on the care pl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure activities were provided based on the care plan for 1 (#198) of 1 residents investigated for activities out of a final sample of 34 residents.
Findings:
Review of Resident #198's record revealed she was admitted to the facility on [DATE] with diagnoses including: Major Depressive Disorder, Pneumonia, Cerebrovascular accident, and Adult failure to thrive.
Review of Resident #198's plan of care revealed in part activities of choice - will encourage resident to participate in at least one activity per week. Intervention - find out resident's activity preferences; assist to activities as needed.
On 05/22/2024 at 9:49 a.m., review of the activity director's binder for room visits did not reveal that Resident #198 had been seen or engaged in activates since her return from the hospital on [DATE].
On 05/20/2024 at 9:00 a.m., an observation was conducted in Resident #198's room. Resident #198 was observed awake and alert. No television or radio was on at that time. After exiting the resident's room, an observation of the facility chapel revealed a group of residents participating in reciting the rosary.
On 05/22/2024 at 9:40 a.m., a second observation was made in the facility chapel revealed a group of residents reciting the rosary while other residents were observed watching TV in the television room. Resident #198 was observed in her room.
On 05/22/2024 at 10:00 a.m., an interview was conducted with S12SS (Social Services) who confirmed that Resident #198 had not participated in activities since her return from the hospital. S12SS stated that staff had not been getting her up. She added that prior to the resident going into the hospital, the resident was always up and out of her room.
On 05/22/2024 at 11:58 a.m., an interview was conducted with S10AD (Activity Director) who stated she was not aware of the resident's return from the hospital until the next day (05/16/2024) and confirmed they were not ensuring resident participated in activates.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide appropriate treatment and care for 1(#70) of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide appropriate treatment and care for 1(#70) of 3 (#30, #41, and #70) residents investigated for Urinary Catheter or UTI (Urinary Tract Infection) out of 34 sampled residents.
Findings:
On 05/22/2024, a review of the facility's policy titled Catheter Care, Urinary with a review date of 01/01/2024 read in part, Purpose. The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Preparation 1. Review the resident's care plan to assess for any special needs of the resident.
Resident # 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hydronephrosis with Renal and Ureteral Calculous Obstruction, Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms.
A review of Resident #70's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/24/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 14, suggesting his cognition was intact.
A review of Resident #70's plan of care revealed a potential for UTI related to the presence of indwelling catheter. Further review revealed an intervention to tape catheter to thigh.
On 05/21/2024 at 8:36 a.m., an observation was made of Resident #70 in his bed. His catheter bag was hung on the bed rail below his waist. The resident did not have tape or a leg strap securing the tubing to his thigh.
On 05/22/2024 at 12:12 p.m., a second observation was made of the resident in his room. The resident was sitting up in his chair with his catheter collection bag in a privacy bag hung on the chair below his waist. The resident's catheter was not taped to his thigh.
On 05/22/2024 at 12:20 p.m., an observation of Resident #70's catheter and interview was conducted with S14LPN (Licensed Practical Nurse). She confirmed that the resident's catheter was not taped to secure it to his leg.
On 05/22/2024 at 12:27 a.m., an interview was conducted with S15MDS. She stated that all nurses have access to the care plan and are responsible for checking it to make sure that all interventions are implemented.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent, by failing to administer medications at the right time...
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Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent, by failing to administer medications at the right time for 2 (#51, #90) of 5 (#11, #51, #74, #83, #90, ) residents observed during morning medication pass. There were 32 opportunities with 2 errors observed during medication pass with a calculated error rate of 6.25%. This deficient practice had the potential to affect a census of 95 residents.
Findings:
On 05/20/2024, a review of the facility's policy titled Medication Administration Schedule with a revision date of 01/01/2024, read in part: Policy Interpretation and Implementation: 3. Scheduled medications are administered within two (2) hours before or after their prescribed time.
A review of the facility's medication pass schedule revealed Med Pass Times: .BID (twice a day): 8 a.m., and 8 p.m.
On 05/20/2024 beginning at 9:50 a.m., an observation was made of S7LPN (Licensed Practical Nurse) during morning medication pass on Hall A. As she was preparing the resident's medications, the EMARs (Electronic Medical records) revealed the following residents' names highlighted in red which indicated the medications were being administered late:
Resident #51:
A review of current physician's orders revealed an order for Rivastigmine 6 mg (milligrams) two times a day at 8 am and 8 pm.
A review of the medication audit report revealed on 05/20/2024, Rivastigmine 6 mg was administered by S7LPN at 10:20 a.m.
Resident #90
A review of current physician's orders revealed an order for Gabapentin 100 mg. Give 1 tablet by mouth two times a day.
A review of the medication audit report revealed that on 05/20/2024, Gabapentin 100 mg was administered by S7LPN at 10:27 a.m.
On 05/13/2024 at 10:06 a.m., an interview was conducted with S7LPN who confirmed that the medications were being administered late.
There were 32 opportunities with 2 errors observed during medication pass with a calculated error rate of 6.25%.
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
Staffing Data
(Tag F0851)
Could have caused harm · This affected 1 resident
Based on data review and interviews, the facility failed to ensure accurate payroll data information was submitted for direct care staffing as required. The facility's census was 95.
Findings:
Review ...
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Based on data review and interviews, the facility failed to ensure accurate payroll data information was submitted for direct care staffing as required. The facility's census was 95.
Findings:
Review of the facility's Payroll Base Journal (PBJ) Staffing Data Report 1705D Fiscal Year Quarter 1 2024 (October 1, 2023 - December 31, 2023) revealed the facility failed to submit staffing data that verified 8 consecutive hours of Registered Nurse (RN) coverage during the weekend days on 10/14/2023, 10/15/2023, 10/28/2023, 10/29/2023, 11/11/2023, 11/12/2023, 11/25/2023, 11/26/2023, 12/09/2023,12/10/2023, and 12/23/2023 during the quarter.
On 05/20/24 at 10:10 a.m., an interview was conducted with S18CAdm (Consultant Administrator), S1ADM (Administrator) and S19OM (Office Manager) stated that PBJ staffing data reporting had been completed and submitted by the office manager with verification it was received by Centers for Medicare and Medicaid Services (CMS).
On 05/20/2024 at 2:00 p.m., S19OM (Office Manager) stated that she tried to communicate with CMS to correct the missing Registered Nurse hours through a phone call, but had no documentation or evidence CMS had been contacted. She then provided the RN clock-in data used by the facility for review of the days in question on the PBJ report in the first quarter that revealed a Registered Nurse was not in the facility at least 8 hours on each of the flagged weekend days. As we reviewed the information, S19OM stated she thought there must have been an error with the RN's PBJ number as to why there was a transmission error. S19OM stated she couldn't specifically identify the problem, but acknowledged the PBJ Staffing [NAME] Report 1705D marked the RN coverage data as an infraction on the weekend dates as identified which confirmed the facility failed to submit staffing data to CMS as required.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by staff failing to remove PPE (Personal Protective Equipment) prior to exiting Resident #12's room who was on contact isolation precautions.
Findings:
Review of the facility policy and procedure Isolation-Categories of Transmission-Based Precautions read in part: Contact Precautions .1. contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces .7. staff and visitors wear gloves (clean, non sterile) when entering the room. A. while caring for a resident, staff will change gloves after having contact with infective material. b. gloves are removed and hand hygiene performed before leaving he room .8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.
Review of Resident # 12's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses in part .Schizoaffective disorder, Bipolar disorder, Chronic obstructive pulmonary disease.
Review of Resident #12's current physician's orders revealed an order dated 05/16/2024 that read in part: Contact Isolation precautions for duration of antibiotic due to diagnoses of Extended-spectrum beta-lactamase (ESBL) in urine.
On 05/21/2024 at 11:46 a.m., an observation was conducted on the exterior door of Resident #12's room which read in part. to enter room, a glown, gloves and mask must be worn prior to entering room.
On 05/21/2024 at 11:45 a.m. an observation was conducted outside the room of Resident #12, which revealed that S11HSK (Housekeeper) was observed entering the contact isolation room with gloves, gown, mask and a mop. A few minutes later, S11HSK was observed outside of Resident #12's room wearing soiled gloves and a soiled gown, rinsing her mop head before reentering the contact isolation room.
On 05/21/2024 at 11:46 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse) who confirmed that used, soiled PPE should be properly removed prior to exiting a contact isolation room. At this time, S9LPN observed S11HSK attempting to exit the contact isolation room again wearing PPE before she was stopped by S9LPN. S11HSK had exited halfway outside of the contact isolation room with soiled gloves and soiled gown.
On 05/21/2024 at 11:47 a.m., an interview was conducted with S11HSK who asked, I have to change each time I go in and out? S9LPN stated yes.
On 05/21/2024 at 11:50 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Control Preventionists) who confirmed that S11HSK should not have exited a contact isolation room with soiled gown and gloves.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #83
Resident #83 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute E...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #83
Resident #83 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity and Major Depressive Disorder.
A review of Resident #83's current plan of care revealed a potential for contractures r/t (related to): fingers on both hands drawn in toward palm. Further review revealed self-care deficit/routine care needs with an intervention to respond to call light promptly and keep call bell within reach.
On 05/21/2024 at 7:53 a.m., an observation was made of Resident #83 in her bed. The resident stated that she has been hollering for help for a long time and nobody has come in. A call bell with a push button was attached to the resident's bed railing. Further observation revealed the resident's hands were contracted and clenched in a fist. The resident stated she is unable to use the call bell to call for help.
On 05/21/2024 07:57 an interview was conducted with S20CNA (Certified Nursing Assistant) as she walked into the room to feed the resident her breakfast. S20CNA stated that she had to feed the resident her meals because she is unable to feed herself. She also confirmed the resident was unable to use the press button to call for help.
On 05/21/2024 at 8:07 a.m., an observation of Resident #83 and interview was conducted with S2DONIP (Director of Nursing, Infection Preventionist). S2DONIP observed the resident's hands and her call button and asked the resident if she could press the button. The resident stated she could not. S2DONIP confirmed that Resident #83 was unable to use the call bell and agreed that the push button call bell was inappropriate for her.
Based on observation, interviews and record review, the facility failed to provide a call system to allow residents to call staff for assistance for 3 (#37, #62, #83) of 3 residents investigated for call devices, by failing to:
1. Place the call bell within reach of Residents #37 and 62; and
2. Provide a usable call bell for Resident #83.
Findings:
On 05/22/2024, a review of the facility's policy titled, Call System, Resident with review date of 01/01/2024 read in part: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized station Policy Interpretation and Implementation .1. Each resident is provided with a means to call staff directly for assistance from his/her bed .4. If a resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided .
Resident #37
Resident #37 was admitted on [DATE] with diagnoses that included, Type 2 diabetes mellitus, Chronic kidney disease, Atherosclerotic heart disease, and Weakness.
Review of Resident #37's care plan dated 12/05/2023 read in part .potential for fall related to Hypertension, Diabetes, and Cardiac history. Intervention - keep call bell in reach when in room.
On 05/20/2024 at 8:46 a.m., an observation of Resident #37 in her room revealed, she was awake and alert. The resident was attempting to pour water into her cup that was sitting on her bedside table. The resident accidently spilled water on her bedside table, and was unable to locate or reach her call bell.
On 05/20/2024 at 9:26 a.m., an observation and immediate interview was conducted with S7LPN (Licensed Practical Nurse) who stated that the call bell was not supposed to be clamped to the curtain. S7LPN confirmed that the call bell was not within reach of the resident.
Resident #62
Resident 62 was admitted on [DATE] with diagnoses that included End stage renal disease, Type 2 diabetes mellitus, and Peripheral vascular disease.
Review of Resident #62's care plan dated 02/27/2024 read in part .self-care deficit routine care needs. Interventions - respond to call light promptly. Keep call bell within reach.
On 05/20/2024 at 2:25 p.m., an observation was conducted in Resident #90's room. The resident was observed sitting in her wheelchair. Further observation revealed the resident's call bell in the middle of her bed, but not within reach of the resident. Resident #90 stated that she was hungry, and that she had been in dialysis all day. The resident was asked if she called staff for assistance in obtaining a meal tray. The resident stated that she could not reach the call bell.
On 05/20/2024 at 2:30 p.m., an interview was conducted with S8CNA (Certified Nursing Assistant) who confirmed that the call bell was not within reach of the resident, and it 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 review of policy and procedure, observations, and interviews, the facility failed to store food in accordance with professional standards by failing to follow appropriate food handling practi...
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Based on review of policy and procedure, observations, and interviews, the facility failed to store food in accordance with professional standards by failing to follow appropriate food handling practices as evidenced by:
1. Expired foods observed in the kitchen's walk in cooler and dry storage area;
2. Opened food items not labeled with the date and time; and
3. Absent temperature logs for the kitchen's reach in cooler, walk in cooler, and walk in freezer for the week of 03/24/2024-03/30/2024.
This deficient practice had the potential to affect the 93 residents who consumed food from the kitchen.
Findings:
On 05/20/2024, a review of the facility's policy titled, Refrigerators and Freezers, with a review date of 01/01/2024, revealed in part, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expirations guidelines. 7. Expiration dates on unopened food will be observed and use by dates are indicated once food is opened .8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates .
On 05/20/2024, a review of the facility's policy titled, Food Receiving and Storage, with a review date of 01/01/2024, revealed in part, Foods shall be received and stored in a manner that complies with safe food handling practices. 7.All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements.
On 05/20/2024 at 8:40 a.m., a tour of the facility's kitchen was conducted with S16DS (Dietary Supervisor), who stated she was responsible for the day to day management of the kitchen.
On 05/20/2024 at 9:00 a.m., an observation of the walk-in cooler was conducted with S16DS and revealed the following: 6 unopened containers of yogurt with an expiration date of 05/15/2024; and 3 unopened containers of orange jello with an expiration date of 04/23/2024.
Further observation of the cooler revealed the following items were opened but were not labeled with the date and time that they were opened:
1. (1) large container or ranch dressing
2. (2) large containers of sliced jalapenos
3. (1) large container of sliced pickles
4. (1) large container of mayonnaise
5. (1) large container of sour cream
6. (1) large container of honey mustard
7. (1) bottle of lemon juice
8. (1) bottle of yellow mustard; and
9. (1) gallon of milk
At this time, S16DS confirmed the food items were expired and should have been removed from the walk in cooler then discarded. She also confirmed the food items listed above were opened, not labeled with the date and time that they were opened, but should have been.
On 05/20/2024 at 9:08 a.m., an observation of the counter top was conducted with S16DS which revealed two squeeze bottles of grape jelly. Both bottles were opened, but were not labeled with the date and time that they were opened. S16DS confirmed the bottles of grape jelly were opened, but not labeled with the date and time that they were opened and should have been.
On 05/20/2024 at 9:20 a.m., an observation of the dry storage room was conducted with S16DS and revealed the following:
1. (1) plastic gallon bag with an opened bag of pasta dated 04/24/2024
2. (1) plastic gallon bag with an opened bag of chocolate cake mix dated 04/22/2024
3. (1) plastic gallon bag with an opened bag of bread crumbs dated 04/25/2024
4. (1) plastic gallon bag with an opened bag of taco seasoning dated 04/29/2024; and
5. (1) plastic opened container of peanut butter dated 04/24/2024
At this time, S16DS confirmed the food items were expired and should have been discarded.
On 05/20/2024 at 10:12 a.m., an interview and review of the temperature log binder for the kitchen coolers and freezer was conducted with S16DS who stated temperatures for the reach in cooler, walk-in cooler and walk-in freezer were to be checked and logged daily. S16DS confirmed temperatures were not taken for the week of 03/24/2024 - 03/30/2024 and should have been.
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 F0576
(Tag F0576)
Could have caused harm · This affected most or all residents
Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 95 residents residing in the facility.
Findings:
Review of ...
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Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 95 residents residing in the facility.
Findings:
Review of the facility's policy titled, Mail and Electronic Communication revealed the following:
Policy Interpretation and Implementation: 4. Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box. 5. The resident's out-going mail will be picked up by postal carriers and/or delivered to the postal service within twenty-four (24) hours of deposit of such mail with the facility, except when there is no regularly scheduled postal delivery and pick-up service. (no pickup/delivery on Saturdays, Sundays and holidays).
Review of a document dated 05/21/2024 read in part .this is to attest that the facility does not receive mail from the post office on Saturdays or Sundays, and signed per S1ADM (Administrator).
On 05/21/2024 at 9:35 a.m., during the resident council meeting, Resident #301 voiced concerns of not receiving mail on Saturdays. Resident #301 stated residents did not receive mail on Saturdays because S13BO (Business Office) did not work on the weekends.
On 05/21/2024 at 10:25 a.m., an interview was conducted with S13BO. She stated the office was closed on weekends and weekend staff did not have a key to the office to retrieve the mail. She stated S10AD (Activity Director) distributed the weekend mail to residents on Mondays.
On 05/21/2024 at 10:35 a.m., an interview was conducted with S2DON (Director of Nursing) who stated that she was not aware how the mailed delivery worked on Saturdays since the office was closed on the weekends.
On 05/21/2024 at 10:59 a.m., the local post office was called. The postal employee stated someone called and asked that the mail for the nursing home's address not be delivered on the weekends. The postal employee was not able to confirm how long this had been in effect or who put this hold on the weekend mail.
Apr 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure the resident was treated with respect and d...
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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 ensure the resident was treated with respect and dignity as evidenced by the facility failing to keep urinary catheter bag contained and private for 1 (Resident #4) of 4 (#1, #2, #3, #4) sampled residents.
Findings:
Review of facility's Quality of Life - Dignity policy with the revision date of October 4, 2022 revealed in part:
Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.
Policy Interpretation and Implementation:
1. Residents shall be treated with dignity and respect at all times.
2. Treated with dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.
11. Demeaning practices and standards of care the compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by:
a. Helping the resident to keep urinary catheter bags contained and private.
Resident #4 was admitted on [DATE] with diagnoses, which include in part: Schizophrenia, Hydronephrosis with renal and ureteral calculous obstruction, and Benign prostatic hyperplasia.
Review of Resident #4's current Physician orders for April 2024 dated revealed in part:
07/18/2022 Change 16 French indwelling foley catheter every month.
On 04/15/2024 at 11:10 a.m., an observation was made of Resident #4 sitting in his wheelchair eating lunch in the facility dining room. During this observation, the resident's urinary catheter bag was not contained for privacy.
During an interview on 04/15/2024 at 11:10 a.m., S3LPN/CNASUP (Licensed Practical Nurse/Certified Nursing Assistant Supervisor) acknowledged Resident #4's catheter bag was uncovered and should have been in a privacy bag.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on record review, observations, and interviews, the facility failed to ensure a medication cart was locked and the medication cart keys were not left on top of cart when left unattended and/or o...
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Based on record review, observations, and interviews, the facility failed to ensure a medication cart was locked and the medication cart keys were not left on top of cart when left unattended and/or out of view during medication administration.
Findings:
Review of facility's Storage of Medications policy revealed, in part:
5. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.
Observation on 04/16/2024 at 2:14 p.m., revealed S8LPN (Licensed Practical Nurse) left her medication cart unlocked, and unattended while she sat at the nurses station talking on the telephone and with other staff.
Further observation on 04/16/2024 at 2:15 p.m., revealed S8LPN left the medication cart keys on top of the unlocked and unattended medication cart.
On 04/16/2024 at 2:15 p.m., an observation and immediate interview was conducted with S3LPN/CNASUP (Licensed Practical Nurse/Certified Nursing Assistant Supervisor) who observed the unlocked medication cart, S3LPN/CNASUP confirmed that the cart should not have been left unlocked and unattended.
In an interview on 04/16/2024 at 2:16 p.m., S8LPN confirmed she left her medication cart unlocked and unattended with the keys on top of the medication cart.
In an interview on 04/16/2024 at 2:30 p.m., S2DON (Director of Nursing) stated the medication cart should be locked at all times when the nurse was not administering medications. S2DON stated the keys should not have been left on top of an unattended medication cart.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on policy review, observations, and interviews, the facility failed to properly process potentially contaminated resident clothing and linens in order produce sanitary laundry and prevent the de...
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Based on policy review, observations, and interviews, the facility failed to properly process potentially contaminated resident clothing and linens in order produce sanitary laundry and prevent the development and transmission of communicable diseases by failing to ensure detergent was being dispensed during wash cycles. There were 98 residents in the facility.
Findings:
On 04/15/2024, a review of facility document titled Departmental (Environmental Services) - Laundry and Linen read in part General Guidelines: Washing Linen and other Soiled Items: 1. Use any detergent designated for laundry processing and follow manufacturer's instructions. There was no date listed on the policy.
On 04/15/2024, a review of facility document titled Laundry and Bedding, Soiled read in part: Onsite Laundry Processing: 1. Use any detergent designated for laundry processing .4. Laundry equipment (e.g., washing machines, dryers) is used and maintained according to the manufacturer's Instructions for Use (IFU) to prevent microbial contamination of the system. There was no date listed on the policy.
On 04/15/2024 at 11:45 a.m., an observation was conducted in the laundry room with S4HSKSUP (Housekeeping Supervisor). Observation of the washing machine revealed three washing machines. Two were in operation and clothing was observed inside the machines. The third machine was not operable. Further observation of the two operational machines revealed that the middle washing machine failed to have the detergent dispenser hose connected to the posterior of the machine.
On 04/15/2024 at 11:55 a.m., an observation and immediate interview was conducted with S4HSPSUP who stated that the machine was operating correctly. Upon further observation, she confirmed that the detergent dispenser hose was not connected to the machine, and that it should have been connected for proper washing.
On 04/15/2024 at 12:10 p.m., an interview was conducted with S9LS (Laundry Staff) who stated that she had observed the detergent dispenser hose on the ground since Sunday (04/14/2024), and she used the machine to wash resident's linen that day. S9LS stated that when she arrived at work on 04/15/2024 at 5:00 a.m., she observed the detergent dispenser hose still on the ground. S9LS confirmed that she had used the washer on 04/15/204 and had completed six or seven loads of laundry since she had reported to work. S9LS stated that she was not aware that the hose needed to be connected to the posterior of the washing machine for the detergent to be dispensed.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on record review, observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment.
The facility failed to ensure:
1.
Room A had a tan blanket, pillo...
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Based on record review, observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment.
The facility failed to ensure:
1.
Room A had a tan blanket, pillow, blue gloves, an adult brief, green clothing hanger, and two turn cushions on the floor.
2.
Room B and C had a white substance at the base of the faucets, and room C faucet was leaking.
3.
Room D had a blue surgical mask and paper on the floor.
4.
Room E had paper towel, a brown cigarette bud, brown colored stains on the fall mats, a purple pillow on the floor, and a large brown stain in the corner of the room on the floor.
5.
Room F had three dresser drawers with a green and white substance on the exterior of the drawers.
6.
Room G had a towel on the floor inside the shower.
Findings:
Review of the facility document which states Maintenance Problem dated 02/24/2024 - 04/16/2024 did not reveal that Rooms B and C faucets were in disrepair.
Rooms A
Observations of Room A on 04/15/2024 at 10:20 a.m., revealed a pillow, tan blanket, blue gloves, two positioning pillow, an adult brief, and green clothing hanger on the floor.
Room B
Observation of Room B on 04/15/2024 at 10:25 a.m., revealed a bathroom faucet with a moderate amount of a white colored substance, and the faucet was leaking warm to touch water.
Room C
Observation of Room C on 04/15/2024 at 10:30 a.m., revealed a bathroom faucet with a white substance at the base of the faucet ending from the left and right side. Further observation revealed blue gloves, a clear plastic empty medication cup, and paper on the room floor.
Room D
Observation of Room D on 04/15/2024 at 10:35 a.m., revealed a blue mask, and paper on the floor.
Room E
Observation of Room E on 04/15/2024 at 10:45 a.m., revealed paper towel, a brown cigarette bud, a purple pillow on the floor. Further observation revealed two large brown stains on the floor in the coroner of the room.
Room F
Observation of Room F on 04/15/2024 at 10:47 a.m., revealed three dresser drawers with a green and white colored substance on the exterior of the drawers.
Room G
Observation of Room G on 04/15/2024 at 10:50 a.m., revealed a soiled towel on the floor in the shower.
On 04/15/2024 at 12:20 p.m., an observation and immediate interview was conducted with S4HSKSUP (Housekeeping Supervisor) who confirmed that the rooms should not have paper, clothing, and soiled gloves on the floor. She stated that the faucets that have the white substance on them, and the one that is leaking should have been reported and replaced. She added that the dresser needs to be replaced in Room F.
On 04/15/2024 at 3:15 p.m., another observation was conducted in Room A which revealed a purple pillow on the floor.
On 04/16/2024 at 9:00 a.m., another observation was conducted in Room G which revealed a soiled towel on the floor in the shower.
On 04/16/2024 at 12:35 p.m., an observation and immediate interview was conducted with S3LPN/CNASUP who also confirmed that the rooms should not have soiled gloves, clothing, pillows or any other trash on the floors. She stated that the faucets in Rooms B and C should have been reported to maintenance and replaced.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 each resident receives adequate supervision and assistance t...
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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 each resident receives adequate supervision and assistance to prevent accidents during a transfer for 1 (#3) out of 3 (#1, #2, #3) sampled residents.
Findings:
Resident #3.
The resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Hyperlipidemia, Atrial Fibrillation, Atherosclerotic Heart Disease, and Dementia.
Review of the resident's yearly MDS (Minimum Data Set) dated 10/18/2023 revealed the resident's BIMS (Brief Interview for Mental Status) score was 3, which meant the resident was severely impaired for cognition. Further review of the resident's MDS revealed the resident was coded extensive assistance with 2 plus person physical assist for transfers.
Review of the resident's care plan with start date 10/25/2023 revealed the resident was care planned for 2 person physical assist for transfers.
Review of the resident's nurse's note dated 12/13/2023 at 6:21 p.m. revealed, CNA (Certified Nursing Assistant) states that while she was transferring the resident, she presented calmly then became rigid and agitated while transferring from the chair to the bed. Resident then proceeds to [NAME] arm and swings it. Her left arm hit the bedside table .
Review of the resident's nurse's note dated 12/13/2023 at 6:31 p.m. revealed, Resident noted to have bruising to the left forearm. It was reported that she moved her arm during transfer bumping arm .
Review of the Incident Investigation report dated 12/13/2023 revealed, While CNA was transferring resident from chair to bed, resident did swing her left arm, hitting the bedside table sustaining a hematoma (bruise) to her left hand .
On 1/4/2024 at 12:55 p.m., an interview was conducted with S5CNA. She stated the resident was a one person assist for transfers. S5CNA stated the resident was calm and during the transfer the resident became rigid and agitated. The CNA stated that during the transfer from the chair to the bed, the resident started swinging her arms and her left hand hit the bedside table.
On 1/4/2024 at 1:00 p.m., an interview was conducted with S2MDS Coord (Minimum Data Set Coordinator). She stated that based on the documentation by the CNAs the resident was assessed for requiring 2 person assist for transfers.
On 1/4/2024 at 1:10 p.m., an interview was conducted with S6CNA and with S7CNA. The CNAs stated the resident was a 2 person assist for transfers.
On 1/4/2024 at 1:15 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). She stated the resident was 2 person assist for transfers.
On 1/4/2024 at 1:20 p.m., an interview was conducted with S4CNA Supervisor. She stated the resident was a 2 person assist for transfers.
On 1/4/2024 at 1:45 p.m., an interview was conducted with S1DON (Director of Nurses). She reviewed the resident's incident report and confirmed the resident was transferred with 1 person assist when the resident hit her left hand on the bedside table and sustained a fist sized hematoma to that hand. S1DON reviewed the assessments in the resident's clinical record and confirmed that based on the assessment conducted on 10/18/23 and the care plan, the resident should have been a 2 person assist for all transfers.
Jun 2023
16 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
Notification of Changes
(Tag F0580)
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 notify the responsible party of an injury of unknown origin for 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 notify the responsible party of an injury of unknown origin for 1 (#38) of 45 sampled residents.
Findings:
Review of the facility's policy titled, Reporting of Accidents/Incidents read in part, .Charge Nurse must include in the Report of Incident/Accident form: The date/time the injured person's family was notified.
Resident #38 was admitted to the facility on [DATE] with current diagnoses of, Dementia, Anxiety, and Major Depression. Her cognition was severely impaired. Resident's responsible party was her daughter.
Review of Resident #38's Incident Report dated 05/15/2023 at 3:30 a.m., read, .Called to room by CNA resident on floor .has skin tear above Lt (left) eyebrow, one on corner of same eye brow. Also has scratch to Lt. (left) Cheek .
Review of Resident #38's nurses notes, dated 05/15/2023 at 11:03 a.m., revealed .9:30 a.m., this nurse was notified by ward Clerk that resident's daughter had a concern about a mark on her (Resident#38's) face. Upon inspecting the Resident this nurse noted a red discoloration and what appeared to be a skin tear to the residents left eye. Upon Further investigation this nurse was informed by S17Assistant CNA Supervisor that Resident #38 had fallen at 3:30 a.m. Upon this nurse (S4LPN) arrival for a.m. shift resident was already up in chair. This nurse cleaned area and applied bandage to skin tear. Physician was notified and Resident RP (Responsible party) was present and aware at this time (Note signed by S4LPN).
On 06/20/2023 at 12:18 p.m., S4LPN confirmed she came to work 05/15/2023 day shift and was told that on 05/15/2023 at 3:30 a.m., Resident #38 rolled out of bed injuring herself, leaving a skin tear to her left eye. She stated the daughter came visit the resident at 9:30 a.m., and notified her that the resident had scratches on her left eye. S4LPN stated she went and assessed the scratches to the left side of her face. She stated the scratch was from Resident #38's fall during the night shift at 3:30 a.m. She stated the Responsible party was not notified of this injury.
On 06/21/2023 at 11:29 a.m., S2DON (Director of Nursing) stated Resident #38's Responsible Party (Daughter) talked to her about a month ago because she was not notified that her mother fell on 5/15/2023 at 3:30 a.m., and she was not notified of the resident's injuries. S2DON stated the staff are to notify the responsible party for any injuries. She stated Resident #38's Responsible Party (Daughter) wants to be notified even if it happened in the middle of the night. She stated on 5/15/2023 the night nurse should have called the Responsible party to notify her of the resident's fall and injuries.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to report an injury of unknown origin: hematoma above Resident #38's e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to report an injury of unknown origin: hematoma above Resident #38's eye; and the allegation from the daughter that someone hit the resident to the State Survey Agency immediately or no later than 2 hours after the allegation is made for 1 (#38) of 45 sampled residents.
Findings:
Review of the facility's policy titled, Abuse Reporting read in part, .All reports of resident abuse (Including injuries of unknown origins) .are reported to state and federal agencies . Injury of unknown source must be reported immediately . to the administrator and to other officials according to state law . Immediately is defined as within 2 hours of an allegation involving abuse
Resident #38 was admitted to the facility on [DATE] with current diagnoses of Dementia, Anxiety, Major and Depression. Her cognition was severely impaired. Resident's responsible party was her daughter.
Record review of Resident #38's Incident Report dated 04/15/2023 at 8:52 a.m., read in part, Called to television room per family member (daughter) while visiting resident. Reported small abrasion noted to left side of head. Purplish in color about 3 mm (millimeters) in size. Unknown how resident received bruise. Appears to be an old bruise. Resident unable to tell how it happened .
Review of the letter, dated 04/17/2023, from Resident #38's daughter to S1ADM and Former DON, read . When I visited my mom on Saturday, I immediately noticed a large hematoma on the top (left front side) my mom's head. It is approximately 2.5 (inches) x 3 in size and swollen . I had visited my mom on Thursday morning but had not noticed anything unusual . What happened to my mom? Did someone hit her? .
On 06/21/2023 at 1:11 p.m., S1ADM (Administrator) confirmed Resident #38 had an injury of unknown origin the Responsible Party (daughter) found on 04/15/2023. He stated the former DON (Director of Nursing) was unable to determine how the resident had gotten this injury. S1ADM stated he did not report this injury of unknown origin to the state as required by the facility's policy.
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
Investigate Abuse
(Tag F0610)
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 have evidence of a thorough investigation of the allegation that s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to have evidence of a thorough investigation of the allegation that someone hit Resident #38 for 1 (#38) resident out of a total of 45 sampled residents.
Findings:
Record review of the facility's policy titled, Abuse Investigating read in part, All reports of resident abuse (Including injuries of unknown origins) .are thoroughly investigated .The Administrator initiates the investigation assigning to an individual trained in investigating .Witness statements are obtained in writing, signed and dated .upon completion of the investigation the findings of the investigation . are provided to the administrator.
Resident #38 was admitted to the facility on [DATE] with current diagnoses of Dementia, Anxiety and Major Depressive Disorder. Her cognition was severely impaired. Resident's contact information revealed her responsible party was her daughter.
Review of Resident #38's Incident Report dated 04/15/2023 at 8:52 a.m., read in part, Called to television room per family member (daughter) while visiting resident. Reported small abrasion noted to left side of head. Purplish in color about 3 mm (millimeters) in size. Unknown how resident received bruise. Appears to be an old bruise. Resident unable to tell how it happened .
Review of the letter, dated 04/17/2023, from Resident #38's daughter to S1ADM and Former DON, read . When I visited my mom on Saturday, I immediately noticed a large hematoma on the top (left front side) my mom's head. It is approximately 2.5 (inches) x 3 in size and swollen . I had visited my mom on Thursday morning but had not noticed anything unusual . What happened to my mom? Did someone hit her? .
Evidence of the investigation of the injury of unknown origin and the allegation of abuse by the resident's daughter was requested from S1ADM and S2DON. The incident report describing the injury was provided. No witness statements or review of camera footage was included in the report, and there was no documentation that the investigation findings were reported to the administrator.
On 06/21/2023 at 1:11 p.m., S1ADM (Administrator) confirmed Resident #38 had an injury of unknown origin, and the daughter filed a letter asking what happened and did someone hit her mom. S1ADM stated the injury was first discovered during the Resident's Responsible Party's (daughter) visit to the facility on [DATE]. He stated the former DON (Director of Nursing) was assigned to investigate Resident #38's Injury of Unknown Origin. S1ADM stated that he did not have evidence of a thorough investigation, and the current DON, S2DON, did not have any documentation that she had investigated Resident #38's injury of unknown origin as required by the facility's policy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interview, the provider failed to ensure that a resident's MDS (Minimum Data Set) assessment was a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interview, the provider failed to ensure that a resident's MDS (Minimum Data Set) assessment was accurately coded to reflect the Resident's upper extremity impairment on one side for 1 (#3) of 45 sampled residents whose records were reviewed.
Findings:
Review of Resident #3's health record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Cerebral Palsy and Congenital Deformity of Left Foot.
Review of Resident #3's quarterly MDS assessment dated [DATE] revealed the resident has a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition for daily decision making. Under Section G: Functional Status, Resident #3 was coded as having no impairment in ROM (Range of Motion) limitation to his upper extremities.
An initial observation and interview was conducted with Resident #3 on 06/19/2023 at 9:30 a.m. Resident #3's left hand was observed in a contracted position and he stated he has Cerebral Palsy and was born with range of motion limitations to his left upper and left lower extremity.
On 06/21/2023 at 11:11 a.m., an interview was conducted with S23MDS (Licensed Practical Nurse/MDS) who confirmed she completed Section G of Resident #3's quarterly MDS assessment on 05/24/2023. S23MDS stated Resident #3 had an impairment that physically he was unable to use his left sided extremities and had a contracted left hand. S23MDS confirmed the assessment was not accurately coded to reflect Resident #3's impairment on one side of his upper extremity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure residents were informed of ongoing activities i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure residents were informed of ongoing activities in the facility for 1 (#84) out of 1 residents investigated for activities.
Findings:
Resident #84 was admitted to the facility on [DATE] with diagnoses that included, Generalized anxiety disorder, Chronic obstructive pulmonary disease, and Age related physical debility.
Review of Resident #84's MDS (Minimum Data Set) dated 05/17/2023 revealed her cognitive status was 15, out of 15, which indicated that the resident was cognitively intact. Under the Section F- Preferences for Customary Routine and Activities-Staff assessment of daily and activity preferences, the resident prefers to keep up with the news, do things with groups of people, do favorite activities, go outside when good weather, and participate in religious practices.
Review of Resident #84's Care plan dated 5/10/23 read in part: activities - will participate in at least 2 activities a week - provide activity calendar for room, find out residents preferred activities; assist to activities as needed.
On 06/19/23 at 10:16 a.m., an interview and observation was conducted with Resident #84, who stated she was admitted into the facility for therapy. She added that she to went to therapy daily, and when she finished with therapy for the day, she stayed in her room. When the resident was asked if she participated in facility activities? The resident stated that she was not aware that the facility had activities. An Observation of the resident's bathroom door revealed an activity calendar dated May 2023. The resident stated that she was not aware that the paper taped to her bathroom door was an activity calendar, and that no one told her about or invited her to any activities.
On 06/20/23 at 1:45 p.m., an observation was conducted in the facility dining room which revealed a group of residents who were playing bingo. Resident #84 was not present for this activity.
On 06/20/23 at 1:51 p.m., a follow up observation and interview was conducted with Resident #84, who was observed inside of her room, lying in the bed. The resident was asked if she liked to play bingo. She stated that she loved to play bingo and cards. She stated that no one invited her to play bingo.
On 06/20/23 at 4:06 p.m., an interview was conducted with S13AD (Activity Director) who was asked why the resident did not have an updated activity calendar inside of her room. She stated that they must have missed her room and forgot to update the activity calendar. When asked how many activities Resident #84 had participated in since her admission, S13AD stated that the resident had not attended any activities. When asked if she had invited the resident to any facility activities, S13AD stated that she had not invited the resident to any facility activities. S13AD confirmed that the resident should have an updated activity calendar inside of her room, and that she should have invited the resident to facility activities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure that a resident with limited range of motion ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure that a resident with limited range of motion receives the appropriate services or assistance to maintain mobility for 1(#68) of 2 (#47, #68) residents reviewed for position and mobility. did not experience reduction in range of motion from a sample of 45 Residents.
Findings:
Resident #68 was admitted to the facility on [DATE] with current diagnoses of Adult failure to thrive, Lack of coordination, Muscle Weakness, Abnormalities of gait, and Contractures to bilateral hips and knees. Resident had a BIMS (Brief Interview for Mental Status) score of 11 meaning his cognition was intact.
On 6/20/2023 at 9:00 a.m., observation and interview with Resident #68 revealed he was lying in bed with both of his knees severely contracted. At this time, Resident #68 stated he did not go to Rehab anymore and that he was not getting range of motion to his lower extremities.
Review of Resident #68's Physical Therapy Discharge summary dated [DATE] read in part, .Patient has made some gains with knee range of motion .
Review of Resident #68's care plan revealed under Schedules Care Task- there was no evidence the CNAs were performing range of motion to the resident's lower extremities.
On 06/20/2023 at 4:25 p.m., S16MDS Coordinator confirmed Resident #68 was not care planned to receive range of motion. She stated the resident was not on physical therapy's case load at this time. She confirmed that the resident was not receiving range of motion and not on the restorative program.
On 06/21/2023 at 8:24 a.m., S18 Restorative Nurse stated Resident #68 was not on her restorative case load. She stated he was discharged from therapy on 5/11/2023 but she had not received any orders from therapy to provide services. She stated S19 Rehab Director would give her orders to work with the resident.
On 06/21/2023 at 8:28 a.m., S19Rehab Coordinator confirmed Resident #68 was on physical therapies case load starting on 03/17/2023 and was discharged from their services on 05/11/2023. He stated the resident had contractures of his Hips and Knees. He stated when therapy finished with him he was supposed to be sent to restorative to provide range of motion so he would not loose what he had gained. At this time S19 Rehab Director stated he did not refer Resident #68 to S18 Restorative Nurse when he was discharged from their services on 5/11/2023. He stated he should have ordered for S18 Restorative Nurse to provide bilateral lower extremity range of motion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored when...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly stored when not in use for 1(#67) out of 1 residents investigated for respiratory care out of a total sample of 45 residents.
Findings:
Review of the facility's policy titled Oxygen Therapy read in part .place cannula in labeled plastic bag to cover when not in use.
Resident #67 was admitted to the facility on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease) and Atherosclerotic Heart Disease.
Review of Resident #67's plan of care read in part .Breathing pattern impaired r/t (related to) COPD and use of continuous oxygen via NC (nasal cannula) with an intervention for continuous oxygen as ordered.
Review of Resident #67's June 2023 Physician's Orders revealed an order that read: Oxygen 2 liters per nasal cannula continuously with an order date 02/24/2023. Further review of Resident #67's June 2023 Physician's Orders revealed an order that read: Keep respiratory equipment in a plastic bag when not in use with an order date of 02/24/2023.
On 06/19/2023 at 10:15 a.m., an observation was made of Resident #67's room. Resident #67's wheelchair was observed with an oxygen canister. There was a nasal cannula wrapped around the oxygen canister. The nasal cannula was not in a bag. The Resident stated that he used the wheelchair, oxygen canister, and nasal cannula when he was up in the wheelchair.
On 06/19/2023 at 11:22 a.m., a second observation was made of Resident #67's room. Resident #67 was observed sitting in his wheelchair in his room. Resident #67's oxygen concentrator was observed. The nasal cannula was on the floor. The resident stated that he was helped to the wheelchair by a staff member, and they removed his oxygen when putting him in the wheelchair.
On 06/19/2023 at 11:26 a.m. an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN stated that when nasal cannulas were not in use, they were supposed to be in a bag labeled with the date and time. An observation was then made in Resident #67's room with S4LPN. The resident's nasal cannula was observed on the floor. She proceeded to look for a bag in the Resident's room and could not find one. S4LPN confirmed that the nasal cannula was on the floor and should have been in a bag labeled with the date and time for storage.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 dialysis services were consistent with professional standard...
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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 dialysis services were consistent with professional standards by failing to ensure completed communication sheets were received from the dialysis center upon the resident's return for 1 (#60) of 1 residents investigated for dialysis services out of 3 total dialysis residents in the facility.
Findings:
Review of the facility's policy and procedure titled Dialysis read in part .will work with each dialysis center to provide the best possible treatment for each resident. Procedure .Dialysis Communication Slip.
Resident # 60 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Hypertension, and Type 2 Diabetes.
Review of Resident #60's June 2023 Physician's Orders revealed an order for Dialysis - Monday, Wednesday, Friday at .
Review of Resident #60's electronic medical record and hard chart revealed dialysis communication sheets had not been completed each time the Resident attended dialysis.
On 06/20/23 at 12:55 p.m., an interview was conducted with S2DON (Director of Nursing ) who stated dialysis communication sheets should be completed daily and the nurses were to ensure they were completed and placed in the hard chart when the resident returns from dialysis. A review of Resident #60's hard chart was reviewed with S2DON. S2DON confirmed that the dialysis communication sheets were not completed and in the chart for each day that the Resident went to dialysis and should have been.
On 06/20/2023 1:00 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN stated that she did not get a dialysis communication sheet for Resident #60 on Monday, 06/18/2023. S4LPN confirmed she did not ensure the dialysis communication sheets were completed and in the chart.
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 F0726
(Tag F0726)
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 nurse aides demonstrate competency by failing to report to th...
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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 nurse aides demonstrate competency by failing to report to the floor nurse that a resident had an injury to her forehead for 1 (#38) of 1 resident innvestigated for injury of unknown origin.
Findings:
Record review of the facilities policy titled, Reporting of Accidents/Incidents read in part, .a. Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as accident/incident is discovered or when information of such accident/incident is learned.
Resident #38 was admitted to the facility on [DATE] with current diagnoses of, Dementia, Anxiety, Major and Depression. Her cognition was severely impaired. Resident's responsible party was her daughter.
Record review of Resident #38's care plan revealed the CNA's (Certified Nursing Assistants)v were to provide personal hygiene, bathe resident daily and provide oral care. The nurses were to perform weekly body audits.
Record review of Resident #38's Incident Report dated 04/15/2023 at 8:52 a.m., read in part, .Called to television room per family member (daughter) while visiting resident. Reported small abrasion noted to left side of head. Purplish in color about 3 mm (millimeters) in size. Unknown how resident received bruise. Appears to be an old bruise.
On 6/14/2023 at 4:37 p.m., a telephone interview was conducted with responsible party (Daughter) she stated she saw her mother on Thursday 04/13/2023 at 8:15 a.m. and did not see any injuries to her mother. She stated she visited her mother on Saturday 4/15/2023 at 8:30 a.m., and noticed a hematoma to the top left on her hair line. She stated the hematoma was so big she doesn't know how anyone could not have observed the hematoma.
Record review of Resident #38's Weekly Nurse Skin assessment dated [DATE], 04/12/2023, 04/20/2023, 04/26/2023 confirmed no skin issues observed.
Record Review of Resident #38's Bed Bath Roster revealed the CNA were showering the resident or giving her a bed bath from 04/1/23-05/30/23.
Record review of Resident #38's Hygiene, Bathing and skin Check Roster revealed the CNA's were providing care on 04/12/23-04/16/23.
On 06/20/2023 at 12:27 p.m., S3TN (Treatment Nurse) confirmed that she did skin assessments on the residents weekly, the CNAs bathe the residents daily and provide grooming and oral hygiene daily. She stated this was how the facility monitors the residents skin for injuries. She stated if the CNA's find injury during care they are to report these findings to the nurse.
06/20/2023 at 12:40 p.m., S23CNA confirmed she bathes, [NAME] and provides oral hygiene to the residents daily. She stated if she finds any injuries she would notify the nurse.
06/21/2023 at 11:40 a.m., S12QA (Quality Assurance) Nurse stated on 04/15/2023 Resident #38's Responsible Party came into the facility and inquired about the hematoma she had found on the residents forehead. The hematoma was of unknown origin, we asked the staff but could not figure out how the resident got this hematoma. The CNAs bathe the residents daily, provide hygiene and the nurses do skin assessments weekly. They should have found the hematoma before the daughter.
On 06/21/2023 at 11:59 a.m., S20LPN (Licensed Practical Nurse) stated that on 4/15/2023, Resident #38's responsible party (Daughter) visited the resident and reported Resident #38 had a bruise in her left hairline. S20LPN stated she assessed the bruise and confirmed it was purplish in color that was about the size of a dime. She stated she didn't know how the resident got the bruise and the resident was unable to tell them due to her severe dementia. She stated none of the CNAs reported the bruise to her. She confirmed the CNA should have found this bruise while bathing or providing grooming and oral hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 2 (Cart A, B) of 2 (Cart A, B) medica...
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Based on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of the medication cart drawers for 2 (Cart A, B) of 2 (Cart A, B) medication carts observed. The facility had a census of 87 residents.
Findings:
Review of the facility's policy titled Storage of Medications read, in part,
Policy heading: The facility stores all drugs and biologicals in a safe, secure and orderly manner .
2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer meds between containers.
3. The nursing staff is responsible for maintaining med storage and prep areas in a clean, safe and sanitary manner.
On 06/20/2023 at 2:48 p.m., Cart A was inspected with S2DON (Director of Nursing) and S5LPN (Licensed Practical Nurse). 1 yellow capsule, and 1 round white pill were observed loose on the bottom of the second drawer. The pills were observed underneath resident medication blister packages. S2DON confirmed that these loose pills should not be in the bottom of the medication cart.
On 06/20/2023 at 3:00 p.m., Cart B was inspected with S2DON.1 yellow oblong pill, and 1 round pink pill were observed loose on the bottom of the third drawer. The pills were observed underneath resident medication blister packages. S2DON confirmed that these loose pills should not be in the bottom of the medication cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure that Resident #41 who was admitted to the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure that Resident #41 who was admitted to the facility with the diagnoses of Schizophrenia with auditory hallucinations had a Level II PASARR (Preadmission Screening and Resident Review) screening for 1 (#41) out of 1 resident investigated for PASARR.
Findings:
Resident #41 was admitted to the facility on [DATE] with the diagnoses that included Non-Alzheimer's dementia, and Schizophrenia.
Review of the physician orders dated 06/21/2017 revealed the resident was prescribed a medication for Schizophrenia which was Zyprexa 5 mg tablet daily.
Review of Care Plan dated 06/26/2017 of ongoing problem read in part Impaired thought processes related to short and long term memory loss diagnosis of Dementia, Schizophrenia. Interventions read in part Calmly talk with resident and offer reassurance prior to initiating cares as needed, keep resident environment free of clutter and safety hazards, approach resident warmly and positively and in calm manner, provide cues and orientation as needed, and always address resident by name.
Review of Minimum Data Set (MDS) dated [DATE] read in part: Active Diagnoses - Schizophrenia, Non-Alzheimer's dementia.
Review of a facility document titled Consent For Use Of Psychoactive Medication Therapy dated 06/14/2017 read in part: Specific condition to be treated - Schizophrenia. The beneficial effects expected from this medication: Reduced adverse behaviors.
Review of The Level 1 pre-screening dated 06/09/2017 was reviewed and revealed - Under Section III: Mental Illness the following was noted - 1. Has the applicant ever been diagnosed as having a serious mental illness? Include mental disorder that may lead to chronic disability. If yes to mental illness, please check the diagnosis below. Schizophrenia was checked and in auditory hallucinations was added in specification category.
On 06/21/2023 at 7:57 am, an interview was conducted with S14SSA (Social Services Assistant), who was responsible for the PASARR documentation for the residents in the facility, and she confirmed that the Level l PASARR was not completed for the resident. When asked why the Level II was not requested for the resident with the diagnoses of Schizophrenia with auditory hallucinations, she stated that the previous nurse did not follow up as she should have. S14SSA stated that she has known the resident personally for some time now, and that the resident does need to have a Level II PASARR evaluation completed.
On 06/21/2023 at 9:15 a.m., an observation was conducted while resident was receiving wound care. The resident was heard using profanities towards staff while they were attempting to assist her in turning.
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** Resident #22.
Resident #22 was admitted to the facility on [DATE] with diagnoses in part: Neuro Cognitive Disorder with Lewy Bod...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #22.
Resident #22 was admitted to the facility on [DATE] with diagnoses in part: Neuro Cognitive Disorder with Lewy Bodies, Unspecified Dementia, Impulse Disorder, Parkinson's Disease, Acute Embolism, and Thrombosis of Deep Vein.
Review of Resident #22's MDS (Minimum Data Set) assessment revealed he had a BIMS (Brief interview for Mental Status) score of 9, indicating that he had moderately impaired cognition.
Review of Resident #22's Plan of Care revealed the resident had impaired thought processes r/t (related to) Dementia and Parkinson's Disease, with a goal to be oriented daily to surroundings, and an intervention to ensure that resident had access to a clock or a watch at all times . Resident is at risk for bruising and bleeding r/t Xarelto .monitor for bruises and bleeding gum.
Review of Resident #22's eMar (electronic medication administration record) revealed no monitoring was conducted for bruises and bleeding gum.
On 06/20/2023 at 9:16 a.m., an observation was made of resident #22's room. The resident was in his room and had no access to a clock or watch. The resident stated he used to have a clock and a watch but he doesn't know where they are and he would like to have one.
On 06/20/2023 at 9:38 a.m., an interview and observation was conducted with S6LPN. S6LPN could not find a clock or watch in the resident's room. S6LPN reviewed the resident's care plan and confirmed that the resident should have access to a clock or watch at all times and did not.
On 06/20/2023 at 10:00 a.m., an observation and interview was conducted of Resident #22's room with S2DON. S2DON confirmed that there was no clock or watch in the resident's room. S2DON reviewed the resident's care plan and confirmed that he should have access to a clock or watch at all times and did not.
Resident #15.
Resident #15 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Obesity, and Heart Failure.
Review of Resident #15's plan of care revealed the Resident was at risk for bruising and bleeding related to Xarelto (Blood Thinner) and ASA (Aspirin) with an intervention to monitor for bruises, bleeding gums, and nosebleeds.
Review of Resident #15's June 2023 Physician's Orders revealed an order for Xarelto 20mg (milligrams) tablet. Give 1 tablet by mouth daily at bedtime.
Review of Resident #15's June 2023 eMAR (Electronic Medication Administration Record) failed to reveal evidence of monitoring for bleeding.
06/21/2023 at 12:43 p.m., an interview was conducted with S12QA (Quality Assurance). S12QA stated there was no monitoring for bleeding for residents that received blood thinners. She confirmed that monitoring for bleeding was an intervention in the care plans but it was not documented on the eMAR or anywhere else in the residents' charts.
Resident #63.
Resident #63 was admitted to the facility on [DATE] with diagnoses in part, Unspecified Atrial Fibrillation and Anemia.
Review of Resident #63's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 09 indicating moderately impaired cognition. Resident #63 was coded as having received the medication of an anticoagulant.
Review of Resident #63's Plan of Care dated 09/01/2022 revealed the resident was at risk for bruising/bleeding related to Coumadin use. Interventions read in part . monitor for bruises, bleeding gums, nose bleeds and inform medical doctor (MD), weekly skin assessments, lab per medical doctor orders, and report abnormal result to MD.
Review of Resident #63's June 2023 eMAR (electronic Medication Administration Record) revealed the resident had received Coumadin 2.5 mg (milligrams) tablet, 1 tablet by mouth every day from 06/01/2023 thru 06/14/2023 and was discontinued on 06/15/2023. Further review of the resident's eMAR revealed she had resumed Coumadin 2.5 mg starting on 06/20/2023. There was no evidence of Resident #63 being monitored for bruises, bleeding gums or nose bleeds.
Review of Resident #63's June 2023 physician's orders revealed an order entry with a start date of 06/20/2023 for Coumadin 2.5 mg tablet, take one tablet by mouth every day.
Resident #84.
Resident #84 was admitted on [DATE] with diagnoses that included Atrial Fibrillation, Anxiety disorder, and Unspecified displaced fracture of right humerus.
Review of Resident #84's MDS (Minimum Data Set) dated 05/17/2023 revealed she had a BIMS (Brief interview for Mental Status) of 15, indicating that she was cognitively intact.
Review of Resident #84's Plan of Care dated 05/10/2023 revealed the resident was at risk for bruising/bleeding related to Warfarin use. Interventions read in part . monitor for bruises, bleeding gums, nose bleeds and inform medical doctor, weekly skin assessments, lab per medical doctor orders, report abnormal result to doctor.
Review of Physician orders dated 06/2023 read in part:
Warfarin 3 mg every Tuesday and Thursday
Warfarin 4 mg every Monday, Wednesday, Friday, Saturday and Sunday.
Review of Resident #84's eMar (electronic medication administration record) revealed no monitoring was conducted for bruises, bleeding gum, and nose bleeds. Resident #68.
Resident #68 was admitted to the facility on [DATE] with, diagnoses including Adult Failure to Thrive, Lack of Coordination, Muscle Weakness, Abnormalities of Gait, and Contractures to Bilateral Hips and Knees.
Review of Resident #68's MDS (Minimum Data Set) dated 05/03/2023 revealed he had a BIMS (Brief Interview for Mental Status) score of 11, Indicating he was cognitively intact.
On 6/20/2023 at 9:00 a.m., an observation and interview with Resident #68 revealed he both of his knees were severely contracted. Resident #68 stated the he did not go to rehab anymore, and he did not receive range of motion to his lower extremities.
Record review of Resident #68 Physical Therapy Discharge summary dated [DATE] read in part, Patient has made some gains with knee range of motion.
Review of Resident #68's care plan revealed no intervention for the CNA to provide range of motion during care tasks.
On 06/20/2023 at 4:25 p.m., S16MDS Coordinator confirmed Resident #68 was discharged from Physical Therapy's case load on 5/11/2023 and was not ordered to receive restorative care. She stated Resident #68's care plan did not include interventions to provide range of motion during his care task. She confirmed Resident #68 should have had range of motion in his care plan so he didn't lose any gains that he received in therapy.
Based on observation, record review, and interview, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 6 (#6, #15, #22, #63, #68, # 84 ) out of a total of 45 sampled residents by failing to ensure that:
1. CBG (Capillary Blood Glucose) levels were monitored and recorded by the nursing staff prior to administering an insulin injection for 1 resident (#6);
2. Bleeding and side effects of anticoagulants were monitored for 5 (#15, #63, #68, #84, and #22) of 5 (#15, #63, #68, #84, and #22) residents reviewed for anitcoagulants out of 26 residents in the facility who were administered anticoagulants;
3. The plan of care was revised for 1 (#68) of 2 (#47, #68) residents reviewed for position and mobility to ensure CNAs (Certified Nursing Assistant ) provided range of motion during care task
4. A clock or watch was available to assist with orientation for a resident with impaired thought processes for 1 resident (#22).
Findings:
Resident #6.
Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Diabetes, Cerebrovascular Disease and Long Term use of Insulin.
Review of the resident's physician's orders for April 2023 revealed the resident had orders for Levemir 40 units subcutaneous daily at bedtime ***check CBG prior to giving and hold if blood glucose less than 150*** Further review of the physician's orders for April 2023 revealed on 4/18/2023 the order changed from Levemir 40 units subcutaneous at bedtime to Levemir 20 units subcutaneous at bedtime hold if CBG less than 150.
Review of the resident's care plan revealed the resident was care planned for the potential for hypo/hyperglycemia related to Diabetes. The interventions included CBG as ordered and administer insulin as ordered.
Review of the emergency room After Visit Summary dated 4/18/2023 revealed, Your medications have changed. Change how you take: Levemir Flex Touch U-100 Insulin . Inject 20 units into the skin at bedtime. Hold for glucose less than 150 .
Review of the resident's MAR (Medication Administration Record) for April 2023, after return from ER visit revealed a new order, Levemir 20 units subcutaneous daily at bedtime ***check CBG prior to giving and hold if blood glucose less than 150***. Review of the resident's MAR for April 2023 and May 2023 from 4/18/2023 to 5/4/2023 revealed there was no evidence the resident's blood glucose was checked from 4/18/2023 to 5/4/2023.
On 6/20/2023 at 10:30 a.m., an interview was conducted with S6LPN (Licensed Practical Nurse). She reviewed the resident's MAR for April 2023 and reviewed his nurse's notes. She confirmed that there was no evidence the resident's CBGs were performed as ordered prior to administering Levemir 20 units subcutaneous on the dates from 4/18/2023 to 4/30/2023.
On 6/20/2023 at 11:00 a.m., an interview was conducted with S12QA (Quality Assurance). She reviewed the resident's MAR for April 2023 and for May 2023. She confirmed that there was no evidence the resident's CBGs were performed as ordered prior to administering Levemir 20 units subcutaneous on the dates from 4/18/2023 to 5/4/2023.
On 6/20/2023 at 11:05 a.m., an interview was conducted with S2DON (Director of Nursing). She stated that she was unaware of the resident's CBGs not being performed as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interview, the facility failed to ensure 3 of 3 ice machines utilized in the facility were maintained in sanitary conditions. This deficient practice had the potential to eff...
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Based on observations and interview, the facility failed to ensure 3 of 3 ice machines utilized in the facility were maintained in sanitary conditions. This deficient practice had the potential to effect 86 residents that consumed meals and/or beverages prepared and served from the facility staff.
Findings:
On 06/19/2023 at 10:23 a.m., a tour was conducted of the facility's kitchen. An observation was made of IceMachine1 that revealed a buildup of black colored residue located on both hinges of the latching lid and on the inside of the latching lid covering the ice cubes. There was also a black colored residue scattered amongst the rim of the chute.
On 06/20/2023 at 9:05 a.m., an observation was made of IceMachine2 located in the refreshment room designated for Hall A. IceMachine2 was observed to have a black colored residue adhered to both hinges of the latching lid as well as the inside of the latching lid covering the ice cubes. Scattered black colored spots were noted on the inside of the chute.
On 06/20/2023 at 4:02 p.m., an observations was made of IceMachine3 located in the refreshment room designated for Hall B. IceMachine3 was observed to have a black colored residue adhered to both hinges of the latching lid as well as the inside of the latching lid covering the ice cubes. Scattered black colored spots were noted on the inside of the chute.
On 06/20/2023 at 4:07 p.m., an interview was conducted with S11MAINT (Maintenance Supervisor) who stated the maintenance department was responsible for cleaning and maintaining the ice machine in the facility's kitchen and the two ice machines in the two refreshment rooms. S11MAINT accompanied surveyor and observed IceMachine1 located in the facility's kitchen and confirmed the findings of the black colored residue noted to both sides of the hinges of the latching lid and inside the chute.
On 06/20/2023 at 4:14 p.m., a joint observation was made of IceMachine2 with S11MAINT who confirmed the presence of the black colored residue adhered to both hinges of the latching lid, as well as the inside of the latching lid covering the ice cubes, and scattered black colored spots noted on the inside of the chute.
On 06/20/2023 at 4:16 p.m., a joint observation was made of IceMachine3 with S11MAINT who confirmed the presence of the black colored residue adhered to both hinges of the latching lid, as well as the inside of the latching lid covering the ice cubes.
On 06/20/2023 at 4:44 p.m., an interview was conducted with S1ADM (Administrator) who stated he had observed the three ice machines with S11MAINT and confirmed IceMachine1, IceMachine2 and IceMachine3 had not been cleaned and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to ensure the residents wheelchairs were clean and sanitary as required by their policy.
Findings:
Review of the facility's policy titled, Whee...
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Based on observations and interviews the facility failed to ensure the residents wheelchairs were clean and sanitary as required by their policy.
Findings:
Review of the facility's policy titled, Wheelchair Cleaning Policy and Procedures read in part, The Registered Nurse and CNA (Certified Nurse Assistant) Supervisor ensures that all wheelchairs on the unit are cleaned and inspected on a nightly basis for the comfort and safety of patients .
On 06/20/2023 at 09:00 a.m., a tour of the facility revealed the wheelchair's frames and wheels for Residents #39, #74, #38, #48, #13, #22, and #28 were dirty.
On 06/21/2023 at 09:15 a.m., observed Resident #38, #74, and #39 during prayer services. At this time S13AD (Activities Director) confirmed the residents' wheelchair wheels and frames were dirty and needed to be cleaned.
On 06/21/2023 at 09:25 a.m., a tour of the facility with S17Assistant CNA Coordinator confirmed Resident #39, #74, #38, #48, #13, #22, and #28 wheel chairs frames and wheels were dirty. At this time she stated S11MAINT (Maintenance Supervisor) was responsible to ensure the residents' wheelchairs were clean and sanitary.
On 06/21/2023 at 10:01 a.m., S11MAINT was asked to make a tour of the residents' dirty wheelchairs. He stated he didn't need to make a tour of the facility's wheelchairs because he already knew they were dirty. He stated he was to clean all the wheelchairs in the facility at least once a month and had not gotten to most of them.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain an effective infection control and preventio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain an effective infection control and prevention program by:
1. Failing to have a description of the building water systems using text and flow diagrams, knowing the acceptable ranges of the temperature control where Legionella and other opportunistic waterborne pathogens could grow and spread, or ways to intervene when control limits were not met.
2. Failing to apply PPE (Personal Protective Equipment) while cleaning Resident #74's room who was on contact precautions.
3. Failing to sanitize hands after glove changes during wound care for Resident #82.
This deficient practice had the potential to affect the 87 residents residing in the facility.
Findings:
1. Review of the facility's policy, Legionella Water Management Program Policy revealed, in part, the following: 5. The water management program includes the following elements . b. A detailed description and diagram of the water system in the facility . c. The identification of areas in the water system that could encourage the growth and spread of Legionella other waterborne bacteria . f. The control limits or parameters that are acceptable and that are monitored . h. A system to monitor control limits and effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective.
On 06/19/2023 at 11:30 a.m., an interview was conducted with S1ADM (Administrator). S1ADM stated that the facility did not have an assessment of the building water system. S1ADM reported that the temperature control is monitored by S11MAINT (Maintenance Supervisor).
On 06/19/2023 at 11:37 a.m., an interview was conducted with S11MAINT. S11MAINT stated that he did not know the acceptable ranges of temperature control where Legionella and other opportunistic waterborne pathogens could grow and spread or know any ways to intervene when control limits were not met.
2. Review of the facility's policy, Procedure for ESBL (Extended-Spectrum Beta-Lactamases) Isolation revealed, in part, the following: Purpose: To ensure the safety and prevention of transmission from one resident to another through possible contamination or contact with another resident or staff. 4. All staff entering room must apply PPE: gown and gloves
Review of the facility's Contact Precautions sign, revealed, in part, the following: Put on gown before room entry.
Review of Resident #74's record revealed she was admitted to the facility on [DATE] with following diagnoses, but not limited to, Cerebral Palsy, Quadriplegia, and Urinary Tract Infection.
Review of the resident's MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9 indicating his cognition was moderately impaired. Section H-Bladder and Bowel revealed the resident was occasionally incontinent of urine.
Review of the resident's urine culture revealed a positive urine culture on 06/11/2023 for Escherichia coli ESBL.
Review of the resident's comprehensive care plan revealed on 06/11/2023 resident was on isolation precautions related to ESBL of urine with intervention to follow isolation per protocol.
An observation was made on 06/19/2023 at 10:30 a.m., S10HSKP was inside Resident #74's room cleaning and not wearing PPE. S10HSKP was observed wearing a KN95 mask and gloves only.
On 06/19/2023 at 11:16 a.m., an interview was conducted with S10HSKP. S10HSKP stated that the room she cleaned was for a resident that was on contact precautions. S10HSKP confirmed that while cleaning this room she did not have PPE on.
On 06/20/2023 at 9:08 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse) stated that she was the Infection Control Nurse for the facility. S9LPN confirmed that while S10HSKP was cleaning the resident's room, PPE should have been applied before entering Resident #74's room. S9LPN confirmed that PPE included gown and gloves.
Review of the facility's policy titled Handwashing/Hand Hygiene read in part .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (anti-microbial or non- antimicrobial) and water for the following situations: g. Before handling clean or soiled dressing, gauze pads, etc.; j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment , etc.; m. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene .
Resident #82 was admitted on [DATE] with diagnoses including Unspecified Dementia, Pressure Ulcer of Left Buttock Stage 3 and Type 2 Diabetes Mellitus.
Review of Resident #82's plan of care revealed the following in part: Impaired skin integrity related to pressure ulcer 1/3/23 upper left buttock extends to sacral with an intervention for treatment as ordered by MD (Medical Director).
Review of Resident #82's June 2023 Physician's Orders revealed the following in part: Left Buttock Wound- Cleanse with Dakins 0.125% solution, pat dry, apply Santyl ointments plus Flagyl 0.75% topical. Cover with Dakins soaked gauze every day until resolved.
On 06/20/2023 at 9:14 a.m., an observation was made of S3TN (Treatment Nurse) nurse perform wound care on Resident #82. S3TN removed the Resident's soiled dressing and Dakins soaked gauze from the Resident's wound. She then removed her soiled gloves and applied clean gloves. S3TN did not sanitize her hands before applying the clean gloves. S3TN ripped both of her gloves as she adjusted them on her hands. Her right index finger and a small portion of the palm of her right hand could be visualized. Her left index finger and the base of the palm on her left hand could be visualized as well. A CNA (Certified Nursing Assistant) then entered Resident #82's room informing S3TN that the Resident's call light was activated. S3TN stated that she didn't need anything and proceeded to use her right index finger to deactivate the call bell system that was mounted on the wall. S3TN then changed gloves and did not sanitize her hands prior to putting on the clean gloves. S3TN continued with Resident #82's wound care and removed her soiled gloves. She did not sanitize her hands after removing the soiled gloves. S3TN walked out of the Resident's room to get more gloves. She came back into the room and placed several pairs of gloves on the bedside table and applied clean gloves. She did not sanitize her hands before applying the clean gloves. S3TN then placed a new dressing on the Resident #82's wound. She removed her soiled gloves and put on a clean pair of gloves. She did not sanitize her hands prior to putting on the clean gloves.
On 06/20/2023 at 9:38 a.m., an interview was conducted with S3TN. When asked about sanitizing her hands during wound care, she stated that she only sanitized hands before she starts the wound care process and after she completes it. She did not sanitize her hands after removing soiled gloves or in between glove changes. S3TN stated that no one has ever corrected her when performing wound care and she had never sanitized her hands between glove changes during wound care.
On 06/21/2023 4:16 p.m., an interview was conducted with S2DON (Director of Nursing) who confirmed that nurses are expected to sanitize their hands before and after glove changes during wound care for infection control and to decrease the risk of infection.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control.
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Based on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control.
Findings:
Review of the facility's policy, Infection Preventionist revealed, in part, the following: Specialized Training 1. The infection preventionist has obtained specialized IPC training beyond initial professional training or education prior to assuming the role . 2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation.
Review of the facility's Infection Control Records revealed that there was no documented evidence that S9LPN (Licensed Practical Nurse), who was the facility's designated Infection Preventionist, had completed specialized training in infection prevention and control.
On 06/19/2023 at 3:33 p.m., an interview was conducted with S9LPN. S9LPN verified she assumed the role of the facility Infection Preventionist since October 2022. S9LPN confirmed she did not complete the specialized infection prevention and control training required to be certified as the Infection Preventionist.
On 06/20/2023 at 8:53 a.m., an interview was conducted with S1ADM (Administrator). S1ADM confirmed that S9LPN assumed the role of the facility Infection Preventionist since October 2022 and has not completed the specialized infection prevention and control training required to be certified as the Infection Preventionist.
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure protect the each resident's rights to be were free from phy...
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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 protect the each resident's rights to be were free from physical abuse for 1 (Resident #4) of 5 (Residents #1-#5) sampled residents when S4CNA hit Resident #4 in the face.
Findings:
Review of the facility's Abuse Policy revealed the following in-part: Residents in this facility are to be treated with dignity and respect at all times and under any circumstances. Mistreatment in the form of verbal or physical abuse of any nature will not be tolerated. Any employee guilty of abusing a resident is subject to immediate discharge. Local authorities will be notified immediately .
Review of Resident #4's medical record revealed he was admitted to the facility on [DATE] with diagnoses including: Hemiplegia following Cerebral Infarction affecting left side, Hypertensive Heart Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety, Muscle Wasting.
Further review revealed the Minimum Data Set assessment dated [DATE] coded Resident #4 with adequate hearing, speech and vision. The Brief Interview for Mental Status (BIMS) assessment revealed a summary score of 15 which indicated Resident #4 was cognitively intact. The Functional Status section coded Resident #4 as requiring extensive assistance with two person assist for transfers and range of motion (ROM) impairment of upper and lower extremities on one side.
Review of the facility's November 2022 Incident Log revealed Resident #4 had a documented incident dated and timed for 11/03/2022 at 2:00 p.m. (Incident #81382). The narrative of the report documented by witness S3Licened Practical Nurse (LPN) revealed in-part:
Resident and S4Certified Nursing Assistant (CNA) began arguing. CNA was attempting to assist me with repositioning resident when resident lifted right hand and hit CNA in the mouth with the back of his right hand. CNA then hit resident in the face 3 (three) times. Scant amount of blood noted to resident's bottom lip.
During an onsite visit and interview with Resident #4 on 11/28/2022 at 10:51 a.m., Resident #4 said he had been a resident of the facility for about four months and had trouble with only one CNA-S4Certified Nursing Assistant. He said on the day of the incident, it was about 1:00 p.m. and he had been up in his wheelchair since about 6:30 a.m. He said he was uncomfortable and ready for staff to assist him back into bed. He said S4CNA got in his face yelling, so I raised my right hand up to push her out of my face and that was when she began hitting me in the face. Resident #4 said the CNA hit me and kept on beating me in the face. Resident #4 reported another staff member was present in the room at the time and witnessed S4CNA hitting him in the face. He said the other staff member told the CNA to stop, get out the room, go home, and she had no more job. Resident #4 said he was scared, in shock, and could not believe the woman was hitting him like that, I had a little blood on my lip and I was bleeding from the mouth after she hit me.
An interview was conducted with S1Director of Nursing (DON) on 11/28/2022 at 11:30 a.m. S1DON reported she was present in the facility and notified of the incident immediately. S1DON explained that S3Licensed Practical Nurse (LPN) was present in Resident #4's room and had witnessed the incident. S1DON reported she interviewed Resident #4 and he told her S4CNA slapped him in the face. S1DON said she then interviewed S4CNA and S4CNA said Resident #4 slapped her and she (S4CNA) in turn, slapped Resident #4.
Review of S4CNA's written statement signed and dated 11/03/2022 revealed the following in-part:
. the nurse was in the room, trying to make him keep still so he wouldn't fall, he said he didn't want me in his room anymore, I said fine then he called me a B word then he slapped me in my face. I had a bad reflex and hit him back. Sorry, whatever yall have to do just do it I do understand.
During a phone interview with S4CNA on 11/28/2022 at 12:17 p.m., S4CNA said she was no longer employed at the facility because she had an incident with Resident #4. She said S3LPN was present in the Resident's room and witnessed the incident. S4CNA explained Resident #4 was upset because she could not put him back to bed earlier without assistance. She continued and said when she and S3LPN were in his room, Resident #4 called her a Bitch then hit her. S4CNA stated I reacted and hit him I think twice in the face. I'm against that, but I just hit him.
During a phone interview with S3LPN on 11/28/2022 at 2:10 p.m., S3LPN said she was present and witnessed the incident between Resident #4 and S4CNA on 11/03/2022. She said she was assisting Resident #4 in his room as he was sliding out of his wheelchair. She used the call bell to call for assistance and S4CNA responded. S4CNA and Resident #4 were arguing and S4CNA got into Resident #4's face while they were arguing. Resident #4 lifted his right hand to move S4CNA away from him and hit S4CNA in the mouth. S3LPN said S4CNA in turn, hit Resident #4 three times in the face.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • 62 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (30/100). Below average facility with significant concerns.
- • 75% turnover. Very high, 27 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Evangeline Oaks Guest House's CMS Rating?
CMS assigns Evangeline Oaks Guest House an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Evangeline Oaks Guest House Staffed?
CMS rates Evangeline Oaks Guest House's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 75%, which is 29 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Evangeline Oaks Guest House?
State health inspectors documented 62 deficiencies at Evangeline Oaks Guest House during 2022 to 2025. These included: 62 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Evangeline Oaks Guest House?
Evangeline Oaks Guest House is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 190 certified beds and approximately 84 residents (about 44% occupancy), it is a mid-sized facility located in Carencro, Louisiana.
How Does Evangeline Oaks Guest House Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Evangeline Oaks Guest House's overall rating (1 stars) is below the state average of 2.4, staff turnover (75%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Evangeline Oaks Guest House?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Evangeline Oaks Guest House Safe?
Based on CMS inspection data, Evangeline Oaks Guest House has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Evangeline Oaks Guest House Stick Around?
Staff turnover at Evangeline Oaks Guest House is high. At 75%, the facility is 29 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 62%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Evangeline Oaks Guest House Ever Fined?
Evangeline Oaks Guest House has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Evangeline Oaks Guest House on Any Federal Watch List?
Evangeline Oaks Guest House is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.