OAK HAVEN REHABILITATION AND HEALTHCARE CENTER
For profit - Limited Liability company
104 Beds
VENZA CARE MANAGEMENT
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
23/100
#147 of 264 in LA
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Oak Haven Rehabilitation and Healthcare Center has received a Trust Grade of F, indicating poor performance with significant concerns about the care provided. Ranked #147 out of 264 nursing homes in Louisiana places it in the bottom half of facilities statewide, and #6 out of 8 in Avoyelles County means there are only two local options that rank lower. Unfortunately, the facility is worsening, with the number of health and safety issues increasing from 11 in 2024 to 16 in 2025. Staffing is a concern with a turnover rate of 61%, which is above the state average, though the facility does have better RN coverage than 85% of Louisiana facilities. Specific incidents include a failure to provide CPR to a resident who was found unresponsive and a serious fall resulting in a hip fracture when a resident was not given the required two-person assistance. Overall, while there are some strengths in RN coverage, the high turnover and serious incidents raise significant red flags for families considering this facility.
- Trust Score
- F
- In Louisiana
- #147/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $44,606 in fines. Higher than 80% of Louisiana facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 45%
Review needed
11 → 16 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 16 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 61%
15pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $44,606
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: VENZA CARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Louisiana average of 48%
The Ugly 34 deficiencies on record
1 life-threatening 1 actual harm
May 2025
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was p...
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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 right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#4) of 1 Residents reviewed for advance directives. The facility failed to ensure all medical records regarding advance directives consistently reflected Resident #4's wishes to be a DNI (Do not intubate). The total sample size was 29. Findings:
Review of Resident #4's EHR (Electronic Health Record) revealed an admit date of [DATE] with a re-entry date of [DATE] with diagnosis which included: Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Respiratory Failure, Type 2 Diabetes Mellitus without Complications, Morbid Obesity, Non-rheumatic Aortic Valve Stenosis, Atherosclerosis Heart Disease, Hypertension, Depressive Disorder, Chronic Kidney disease.
Further review of Resident #4's EHR's bed board revealed a code status of Full Code.
Review of Resident #4's Significant Change MDS with ARD of [DATE] revealed Resident #4 was interviewable with a BIMS of 14, which indicated intact cognition. Resident #4 was dependent on staff for toileting, showering/bathing, dressing upper and lower body, and personal hygiene. Resident #4 received Hospice Services.
Review of Resident #4's current 05/2025 physician's orders revealed an order dated [DATE] which read code status of Full Code.
Review of the LaPOST (Louisiana Physician Order for Scope of Treatment) revealed Resident #4's code status was listed as CPR (cardiopulmonary resuscitation)/attempt resuscitation with limited additional interventions which included: Do not use intubations, advance airway interventions, or mechanical ventilation. LaPOST was signed by Resident #4's daughter on [DATE].
Review of Resident #4's progress note dated [DATE] at 04:18 p.m. revealed a Hospice nurse visited resident and brought LaPOST. The progress note revealed Resident #4 is officially a DNI.
Review of Resident #4's admission Record Demographic Sheet revealed . Advanced Directive/ Living Will section completed as none on record.
In an interview on [DATE] at 09:52 a.m., S6 LPN stated when transferring a resident to the hospital she would include the resident's advance directive in report to the receiving facility. S6 LPN revealed she determined resident's advance directive by reviewing the EHR bed board or physician orders.
In an interview on [DATE] at 02:15 p.m., S7 LPN stated when transferring a resident to the hospital she would include the resident's advance directive in report to the receiving facility. S7 LPN revealed she determined resident's advance directive by reviewing the EHR bed board or the physician orders.
Interview on [DATE] at 02:40 p.m. with S2 DON revealed each resident should have an order indicating code status within their medical records. S2 DON revealed documents transferred to the hospital would include . transfer form, physician orders, and admission record demographic sheet. S2 DON confirmed that Resident #4's physician orders and EHR's bed board revealed full code only and did not specify Resident #4's request for specific limited interventions, as listed on her LaPOST. S2 DON acknowledged when nurses are giving report to the receiving facility based on the bed board and orders, Resident #4's request for limited interventions would not be communicated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #68) of 29 sampled re...
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Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #68) of 29 sampled residents.
Findings:
Review of Resident #68's electronic medical record revealed an admission date of 11/18/2022, with diagnoses that included, in part .Parkinson's Disease with Dyskinesia.
Review of Resident #68's quarterly MDS with an Assessment Reference Date (ARD) of 02/10/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Resident #68 had adequate hearing and did not use hearing aids.
Observation and interview with Resident #68 on 05/05/2025 at 9:42 a.m. revealed she had difficulty hearing. Resident #68 stated she did not have hearing aids, but wanted them. Resident #68 stated she was provided with headphones during bingo, which improved her hearing and made it possible for her to participate.
Observation and interview with Resident #68 on 05/05/2025 at 1:30 p.m. during Resident Council meeting revealed she had difficulty hearing, which interfered with her ability to participate in the group discussion. Resident #68 stated she had difficulty hearing when there was any background noise, or when more than one person was speaking.
Interview with S15 Charge Nurse and S18 MDS conducted on 05/07/2025 at 9:15 a.m. S15 Charge Nurse stated residents were provided with headphones during bingo if the background noise in the dining area made it difficult for them to hear. S15 Charge Nurse stated the dining room was very noisy due to the noise from the kitchen, the number of people in the area, the facility entrance being in close proximity, and the music played in the area. S15 Charge Nurse and S18 MDS confirmed residents who had difficulty hearing due to the background noise during bingo, would also have difficulty hearing during meals and any time they were in the dining area. S18 MDS stated he was not aware Resident #68 had difficulty hearing, or that she used headphones during bingo. S18 MDS confirmed Resident #68's quarterly MDS with an ARD of 02/10/2025 indicated she had adequate hearing.
Interview with S23 Social Services Director on 05/07/2025 at 12:23 p.m. confirmed Resident #68 had hearing difficulty.
Interview with S17 Activities Director on 05/07/2025 at 12:41 p.m. confirmed Resident #68 had difficulty hearing during bingo, during Resident Council meetings, and any time there were background noises.
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
Resident #76
Review of Resident #76's electronic medical record revealed an admission date of 02/29/2024, with diagnoses that included, in part . Alzheimer's, Dementia with Behavioral Disturbance, An...
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Resident #76
Review of Resident #76's electronic medical record revealed an admission date of 02/29/2024, with diagnoses that included, in part . Alzheimer's, Dementia with Behavioral Disturbance, Anxiety Disorder, and Major Depressive Disorder with Severe Psychotic Symptoms.
Review of Resident #76's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score was not provided due to the resident being rarely or never understood. Resident #76 had 2 or more falls without injury and 1 fall with minor injury.
Review of Resident #76's current care plan revealed, in part .I am at risk for falls related to confusion and being unaware of safety needs, initiated on 03/13/2024. Interventions included, in part .fall mat to left side of bed initiated on 10/22/2024, and fall mat to right side of bed initiated on 10/28/2024.
Observation of Resident #76 on 05/05/2025 at 9:45 a.m. revealed a fall mat placed on the floor to the right side of the bed. The fall mat was against the wall, and 12 inches away from the bedside. No fall mat observed on the left side of the bed.
Observation of Resident #76 on 05/06/2025 at 9:35 a.m. revealed a fall mat placed on the floor to the right side of the bed. The fall mat was against the wall, and 12 inches away from the bedside. A small trash can was placed on top of the fall mat. No fall mat observed on the left side of the bed.
Observation of Resident #76 on 05/07/2025 at 9:50 a.m. revealed a fall mat placed on the floor to the right side of the bed. The fall mat was against the wall, and 12 inches away from the bedside. A small trash can, a chair, and a three-drawer chest were placed on top of the fall mat. No fall mat observed on the left side of the bed.
Interview of S13 LPN on 05/07/2025 at 9:50 a.m. revealed the trash can, chair, and three-drawer chest should not have been placed on Resident #76's fall mat. S13 LPN confirmed Resident #76's fall mat was incorrectly placed on the right side of the resident's bed. S13 LPN confirmed Resident #76 did not have a fall mat on the left side of her bed.
Based on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 2 (#13, #76) out of 29 sampled residents.
Findings:
Resident #13
On 05/07/2025, a review of facility policy titled Medication Monitoring dated 09/01/2024, revealed in part . This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences.
.
Licensed nurses, with periodic oversight by nurse managers, shall: .Adhere to facility polices and current standards of practice for administration and monitoring of medications .
Interventions shall be identified on the residents comprehensive care plan for the systematic monitoring of high risk medications to facilitate early identification of adverse consequences.
Review of the electronic health record for Resident #13 revealed an admit date of 05/01/2024 with diagnoses that included: Type 2 Diabetes, Major Depressive Disorder, Paroxysmal Atrial Fibrillation, Heart Failure, Hypertension, Mild Neurocognitive Disorder due to known physiological condition with behavioral disturbance, and Bipolar Disorder with psychotic features.
The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/2025, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment.
Review of care plan initiated 05/01/2024 revealed Resident #13 was on anticoagulant therapy. Interventions included administer anticoagulant medications as ordered by physician, monitor for side effects and effectiveness each shift, monitor/document/report PRN (as needed) if resident exhibits any adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs.
Review of physician orders for month of 04/2025, revealed an order dated 01/15/2025, for Eliquis (anticoagulant) 5 milligram (MG), one tablet by mouth two times a day related to Paroxysmal Atrial Fibrillation (irregular heart rhythm).
Review of electronic health record on 05/06/2025 at 10:50 a.m. revealed no evidence of anticoagulant monitoring for side effects and effectiveness each shift.
Interview on 05/06/2025 at 02:40 p.m. with S8 RN revealed S8 RN was aware Resident #13 is currently prescribed an anticoagulant. S8 RN confirmed any resident receiving an anticoagulant should be monitored. S8 RN stated if a resident is receiving monitoring for any form of medication, the task would be triggered to be documented in the electronic medication administration record (EMAR). Review of Resident #13's EMAR with S8 RN, revealed no evidence of anticoagulant monitoring.
During interview on 05/06/2025 at 02:50 p.m., S2 DON confirmed Resident #13 was receiving an anticoagulant medication. Electronic health record and EMAR reviewed with S2 DON. S2 DON confirmed Resident #13 was care planned for anticoagulant monitoring for side effects and effectiveness each shift. S2 DON confirmed Resident #13 anticoagulant therapy was not being monitored each shift and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, the facility failed to provide care and services that met professional standards of quality for 1 (#41) of 2 (#41 and #60) residents observed during...
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Based on record review, observation, and interview, the facility failed to provide care and services that met professional standards of quality for 1 (#41) of 2 (#41 and #60) residents observed during medication pass. The facility nurse failed to properly position Resident #41 for administration of a breathing treatment.
Findings:
Resident #41
On 05/06/2025, review of facility policy titled, Medication Administration, with reviewed/revised date of 09/01/2024, revealed in part . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .
Policy Explanation and Compliance Guidelines . Position resident to accommodate administration of medication .Administer medication as ordered in accordance with manufacturer specifications .
Review of Resident #41's electronic medical record revealed an admit date of 02/01/2022 with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), congenital stenosis and stricture of esophagus, Hypertension, and Gastroesophageal Reflux Disease without esophagitis.
Review of Resident #41's care plan initiated 02/01/2022, revealed resident had Chronic Obstructive Pulmonary Disease (COPD) with chronic cough related to smoking. Interventions included administer medications as ordered and monitor document side effects and effectiveness, receive aerosol or bronchodilators as ordered and monitor document side effects and effectiveness, monitor for any signs or symptoms of acute respiratory insufficiency, monitor/document/report PRN (as needed) for any signs and symptoms of respiratory infection, and respiratory therapy program nurse to evaluate and treat as indicated.
Review of Resident #41's physician orders for month of 04/2025, revealed the following:
11/29/2024: Elevate HOB (head of bed) secondary to resident being short of breath when lying flat.
04/23/2025: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally three times a day for SOB (shortness of breath) for 14 days.
Medication pass observation was conducted on 05/06/2025 at 08:00 a.m. with S5 Licensed Practical Nurse (LPN).
Observation on 05/06/2025 at 08:18 a.m. revealed S5 LPN administered Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution via nebulizer facemask to Resident #41. Resident #41 was lying in bed, with head of the bed elevated at approximately 10 to 15 degrees during administration of Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution.
On 05/06/2025 at 08:26 a.m., review of manufacturer instructional insert from Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution box with S5 LPN, revealed in part . Sit in comfortable, upright position; place the mouth piece in your mouth or put on the face mask; and turn on compressor .
S5 LPN confirmed Resident #41 was not in the correct position for proper administration of Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution. S5 LPN confirmed Resident #41 should have been placed in an upright position during the administration of Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to provide the necessary care and services to ensure a resident maintained the ability to carry out activities of daily living....
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Based on observation, interviews, and record review, the facility failed to provide the necessary care and services to ensure a resident maintained the ability to carry out activities of daily living. The facility failed to provide a communication aid for 1 (Resident #26) of 2 (Resident #26 and Resident #68) residents sampled for communication and sensory concerns.
Findings:
Review of Resident #26's electronic medical record revealed an admit date of 07/03/2019 with diagnoses including, in part .Aphasia following Unspecified Cerebrovascular Disease, Mixed Receptive-Expressive Language Disorder, and Dementia.
Review of Resident #26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score was not provided due to resident being rarely or never understood. Resident #26 had unclear speech.
Review of Resident #26's current Care Plan revealed, in part . I have a communication problem related to aphasia, initiated on 07/05/2019. Interventions included, in part .use alternative communication tools as needed.
Observation of Resident #26 on 05/05/2025 at 12:00 p.m. revealed impaired communication. Resident #26 was lying on her bed. She repeatedly stated P .P! while lifting her arm and indicating toward the wall behind her head. No communication aid was noted in the resident's room.
Interview with S16 CNA Supervisor on 05/05/2025 at 12:04 p.m. revealed Resident #26 used a communication board to communicate with staff. She stated the communication board should have been on the resident's bedside table.
Interview with S16 CNA Supervisor and S12 CNA on 05/05/2025 at 12:05 p.m. revealed Resident #26 did not have a communication board in her room, but should have.
Interview with S13 LPN on 05/05/2025 at 12:13 p.m. revealed Resident #26 was able to communicate with staff using a communication board. S13 LPN confirmed Resident #26 should have had a communication board, but did not.
Interview with S15 Charge Nurse on 05/07/2025 at 9:24 a.m. revealed Resident #26 used a communication board to communicate with staff. S15 Charge Nurse confirmed Resident #26 did not have a communication board on 05/05/2025, but should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident received proper treatment and assistive devices to maintain and/or improve hearing ability for 1 (Resident ...
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Based on observation, interview, and record review, the facility failed to ensure a resident received proper treatment and assistive devices to maintain and/or improve hearing ability for 1 (Resident #68) of 2 (Resident #26 and Resident #68) residents reviewed for communication and sensory.
Findings:
Review of Resident #68's electronic medical record revealed an admission date of 11/18/2022 with diagnoses including, in part, Parkinson's Disease with Dyskinesia.
Review of Resident #68's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score BIMS Score of 13, indicating intact cognition. Resident #68 had adequate hearing and did not use a hearing aid.
Observation and interview of Resident #68 on 05/05/2025 at 9:42 a.m. revealed she had difficulty hearing. Resident #68 stated she did not have hearing aids, but wanted them.
Observation and interview of Resident #68 on 05/05/2025 at 1:30 p.m. revealed she had difficulty hearing during the Resident Council meeting. Resident #68 stated she had difficulty hearing when there was background noise, or when more than one person was speaking.
Interview with S23 Social Services Director on 05/07/2025 at 12:23 p.m. revealed she was responsible for scheduling residents with hearing difficulty for an audiology evaluation. She stated the facility assisted residents with obtaining hearing aids, if needed. S23 Social Services Director revealed Resident #68 did have difficulty hearing, had not had an audiology evaluation, and did not have hearing aids. S23 Social Services Director confirmed Resident #68 should have been scheduled for an audiologist evaluation and screened for hearing aids, but had not.
Interview with S17 Activities Director on 05/07/2025 at 12:41 p.m. confirmed Resident #68 had difficulty hearing during bingo and Resident Council meetings.
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 record review and interview the facility failed to ensure a resident with limited range of motion received appropriate ...
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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 a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion by failing to provide restorative therapy for 1 (#80) of 3 (#16, #54, and #80) residents reviewed for limited range of motion. Findings:
Review of Resident #80's medical record revealed she was admitted to the facility on [DATE]. Resident #80 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebrovascular Accident affecting Left Dominant side.
Review of Resident #80's Quarterly MDS with ARD of 02/10/2025 revealed Resident #80 had a BIMS of 15, which indicated cognition was intact. Resident #80 had upper and lower extremity impairment on one side. Resident #80 required substantial/maximal assistance from staff for: Eating, Oral Hygiene, Toileting, Showering/Bathing, Dressing, and Personal Hygiene.
Review of Resident #80's CPOC (Comprehensive Person Centered Plan of Care) with a target completion date of 05/11/2025 revealed in part . Limited physical mobility related to Stroke, Weakness, and Hemiplegia. Interventions included; I will have gentle range of motion as tolerated with daily care with an initiation date of 09/14/2024.
Record Review of Resident #80's tasks report with a 14 day lookback period revealed she was to receive gentle passive range of motion with each personal care task and as needed. Review of the report revealed staff did not perform this task as care planned for Resident #80 with the exception of dates 05/05/2025 and 05/06/2025.
Interview on 05/05/2025 at 11:53 a.m. with Resident #80 and her husband stated she did not receive physical therapy services. Resident #80 revealed staff did not perform range of motion exercises with her. Resident #80 stated she would like for staff to perform range of motion exercises with her to prevent further decline. Resident #80 stated when she asked staff to help her perform some exercises they respond That's not my job.
Interview on 05/06/2025 at 3:48 p.m. with Resident #80 and her husband revealed nursing and CNA staff did not perform range of motion exercises with her at any point in time during her admission.
Interview on 05/06/2025 at 3:53 p.m. with S10 CNA whom was assigned to care for Resident #80 revealed she did not perform range of motion exercises with resident.
Interview on 05/06/2025 at 4:00 p.m. with S9 Director of Rehab Services confirmed Resident #80 had not received physical therapy services since 11/2024. S9 Director of Rehab Services stated he would speak with S1 Administrator about getting Resident #80 evaluated, so that she could possibly get some hours for therapy services. S9 Director of Rehab Services revealed Resident #80 would benefit from having nursing staff perform range of motion exercises daily to prevent further decline.
Interview on 05/06/2025 at 4:11 p.m. with S2 DON confirmed Resident #80 was care planned since 09/2024 to received range of motion exercises daily and as needed by staff. S2 DON confirmed this intervention had not been set up as a task, so there was no documentation of that intervention being implemented in accordance with Resident #80's CPOC. S2 DON acknowledged Resident #80 should have had range of motion exercises completed to prevent further decline, but had not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with profession...
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Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 94.
Findings:
Review of a facility policy on 05/06/2025 at 12:08 p.m. titled, Sanitation Inspection with a revised date of 09/01/2024 revealed the following in part .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.
Review of a facility policy on 05/06/2025 at 12:08 p.m. titled, Food Safety Requirements with a revised date of 09/01/2024 revealed the following in part .Food will also be stored in accordance with professional standards for food service safety. Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. 3. iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping food covered or in tight containers. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g. hairnet hat, and/or beard restraint) to prevent hair from contacting food. Hairnets should be worn when cooking, preparing, or assembling food.
Observation on 05/05/2025 at 8:37 a.m. of the facility kitchen accompanied by S3 Dietary Manager revealed the following:
Main Refrigerator:
1. One undated, opened plastic container of beef broth with an expiration date of 04/23/2024.
Main Freezer:
2. One undated, opened frozen bag of broccoli spears.
Dry Pantry Storage:
3. Six 5lb. (pound) bags of Ramsen non-fat dry milk with an expiration date of 04/20/2025.
Walk-In Refrigerator:
4. One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of breakfast sausage patties (over 20 individual loose patties).
5. One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of sliced bacon strips (over 20 individual loose bacon strips).
S3 Dietary Manager confirmed all of the above findings during the kitchen walk-through observation. S3 Dietary Manager confirmed the above listed items were expired, opened, unsealed, and/or undated and should have been disposed of properly.
Observation of meal preparation on 05/05/2025 at 10:20 a.m. of S11 [NAME] revealed he had a long curly beard without hair/beard restraints. Observed S11 Cook's beard uncovered throughout meal preparation. S11 [NAME] stated he was unaware to wear a hair/beard restraint while in the kitchen.
In an interview on 05/05/2025 at 4:25 p.m., S1 Administrator confirmed the kitchen should not have any expired, unsealed, and/or undated food items available for usage and these food items should have been disposed of properly. S1 Administrator confirmed S11 [NAME] is aware to wear a hair/beard restraint while in the kitchen and should have worn a hair/beard restraint while preparing meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 94 residents who resided in the f...
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Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 94 residents who resided in the facility.
Findings:
Review of a facility policy on 05/06/2025 at 12:08 p.m. titled, Disposal of Garbage and Refuse with a revised date of 09/01/2024 revealed the following in part .The facility shall properly dispose of kitchen garbage and refuse. 7. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. 8. Garbage should not accumulate or be left outside the dumpster.
Observation on 05/05/2025 at 8:37 a.m. of the facility dumpsters accompanied by S3 Dietary Manager revealed two facility dumpsters. Observed one dumpster's surrounding area with debris scattered on the grounds. Observed several dirty/brown stained briefs, two clear plastic garbage bags filled with debris, one plastic garbage bag opened with debris overflowing out of it, and one opened package of wipes located directly on the grounds near the dumpster.
S3 Dietary Manager confirmed the above findings during the tour of the dumpster area. S3 Dietary Manager confirmed that the dumpster area should have been kept clean and the debris picked up in the surrounding area, but was not.
In an interview on 05/05/2025 at 4:25 p.m., S1 Administrator confirmed the dumpster surrounding areas should be kept clean and free of debris at all times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to include the Administrator or designee in the Quality Assessment and Assurance Process Quarterly meeting. Total sample size 29.
Findings:
Re...
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Based on interview and record review the facility failed to include the Administrator or designee in the Quality Assessment and Assurance Process Quarterly meeting. Total sample size 29.
Findings:
Review of the facility's policy titled Quality Assurance Performance Improvement Program and Plan, with a revision date of 01/25/2025 revealed in part .The QAPI Committee shall be multidisciplinary in nature. Names and titles of meeting attendees will be maintained with the minutes. The Committee shall consist of a representative from the following areas:
Medical Director
Director of Nursing
Administrator
Social Worker
Dietician-Nutritionist
Infection Preventionist
Facility team members: Activities, Dietary, Staff Development, Maintenance, Housekeeping, Staff representatives.
Interview and record review on 05/07/2025 at 1:20 p.m. with S1 Administrator revealed the facility's Administrator or designee had not been included on the Quality Assessment and Assurance Process Quarterly meeting sign-in-sheet for October 2024, November 2024 and December 2024. S1 Administrator confirmed the facility had no documented evidence of the Administrator attending the Quality Assessment and Assurance Process Quarterly meetings in October 2024, November 2024 and December 2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on 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 ...
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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:
1.
failing to ensure staff wore masks as directed;
2.
failing to ensure staff followed proper infection control practices during wound care for Resident #28; and
3.
failing to ensure S19 Infection Preventionist performed accurate infection surveillance and reporting.
Findings:
Review of the facility's policy entitled, Infection Prevention and Control Program revised on 09/01/2024 revealed, in part .the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The IP is responsible for oversight of the program. Surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases. The IP serves as the leader in surveillance activities, and maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee.
Review of the facility's policy entitled, Infection Preventionist revised on 09/01/2024 revealed, in part .responsibilities of the IP included: Develop and implement an ongoing Infection Prevention and Control (IPC) program to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary and comfortable environment.
Review of the facility's policy entitled, Infection Reporting revised on 09/01/2024 revealed, in part .the IP was responsible for reporting findings of surveillance activities, including incidence rates and types of infections, to the QAA committee, physicians, and other appropriate staff.
Review of Resident #28's electronic medical record revealed an admission date of 10/11/2024 with diagnoses which included, in part .Neuropathy and Chronic Obstructive Pulmonary Disorder.
Review of Resident #28's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition.
Review of Resident #28's current physician orders revealed, in part .treatment of mass to left cheek - clean area with wound cleanser and gauze, pat dry with gauze, apply mupirocin ointment 2% to open areas and leave open to air every day until resolved, dated 05/05/2025.
Review of Resident #28's current care plan revealed, in part .
Resident had potential/actual impairment to skin integrity, initiated on 10/11/2024. Interventions included, in part . EBP were required during high contact care activities.
Enhanced Barrier Precautions (EBP) were required due to wounds, initiated on 10/12/2024.
Resident was at risk for infection, initiated on 10/14/2024. Interventions included, in part .staff were to use universal precautions when providing care.
Interview with S1 Administrator on 05/05/2025 at 8:34 a.m. confirmed the facility was in a COVID outbreak and required all staff/visitors to wear masks while inside the facility.
1.
Observation on Hall W on 05/05/2025 at 9:31 a.m. revealed S12 CNA was not wearing a mask. Interview of S12 CNA confirmed she was required to wear a mask, but was not.
Interview of S15 Charge Nurse on 05/05/2025 at 10:32 a.m. revealed staff are required to wear masks at all times due to the COVID outbreak. S15 Charge Nurse confirmed S12 CNA had not worn her mask earlier in the day, but should have.
2.
Observation of S14 Treatment Nurse on 05/06/2025 at 9:43 a.m. revealed she removed a 4x4 gauze from the treatment cart with her ungloved, unsanitized hand. During performance of wound care, S14 Treatment Nurse used the gauze to wipe away crusted drainage from an open, weeping, mass on Resident #28's left cheek.
Interview of S14 Treatment Nurse on 05/06/2025 at 9:49 a.m. confirmed she had touched the gauze used for Resident #28's wound care with her unwashed, unsanitized hand, but should not have.
3.
Review of the facility's 01/2025 Infection Surveillance data revealed the facility had a total of 4 MDROs, which included 2 Methicillin-resistant Staphylococcus aureus (MRSA) and 2 Extended-Spectrum Beta-Lactamase (ESBL) infections. The facility's Infection Surveillance Monthly Report Summary revealed only 1 MDRO infection was documented in 01/2025.
Review of the facility's 02/2025 Infection Surveillance data revealed the facility had a total of 7 MDROs, which included 4 MRSA infections and 3 ESBL infections. The facility's Infection Surveillance Monthly Report Summary revealed only 2 MDRO infections were documented in 02/2025.
Review of the facility's 03/2025 Infection Surveillance data revealed the facility had a total of 3 MDROs, which included 2 ESBL infections and 1 unspecified MDRO infection. The facility's Infection Surveillance Monthly Report Summary revealed only 2 MDRO infections were documented in 03/2025.
Review of the facility's 04/2025 Infection Surveillance data revealed the facility had a total 3 MDROs, which included 2 MRSA infections and 1 ESBL infection. The facility's Infection Surveillance Monthly Report Summary revealed 6 MDRO infections were documented in 04/2025.
Interview with S19 Infection Preventionist on 05/06/2025 at 1:50 p.m. the Infection Surveillance Monthly Report Summary for 01/2025, 02/2025, 03/2025, and 04/2025 were incorrect. S19 Infection Preventionist confirmed the facility's infection surveillance reports for 01/2025, 02/2025, 03/2025, and 04/2025 reflected inaccurate data, but should not have. S19 Infection Preventionist confirmed she presented incorrect data during the facility's Quality Assurance and Performance Improvement meetings, but should not have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings.
Findings:
Review of the facility's record ...
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Based on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings.
Findings:
Review of the facility's record of the Resident Council meeting held on 02/26/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals.
Review of the facility's record of the Resident Council meeting held on 03/26/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals.
Review of the facility's record of the Resident Council meeting held on 04/30/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals.
During the facility's Resident Council meeting on 05/05/2025 at 1:30 p.m., residents complained that staff continued to talk loudly down the hallways and on their phones, and that they were still not being offered a choice of meals. The residents stated these issues had been discussed at multiple Resident Council meetings, but had not been resolved by the facility.
Interview on 05/05/2025 at 1:50 p.m., S17 Activities Director confirmed residents had complained of CNAs talking loudly down the hallways and on telephones, and CNAs not offering the residents a choice of meals during the 02/26/2025, 03/26/2025, and 04/30/2025 Resident Council meetings. S17 Activities Director confirmed residents' complaints remained unresolved.
Interview on 05/06/2025 at 12:05 p.m., S1 Administrator confirmed she was aware of the residents' complaints of CNAs talking loudly down the hallways and on telephones, and CNAs not offering the residents a choice of meals. S1 Administrator stated these complaints had been documented as unresolved at the Resident Council meetings held on 02/26/2025, 03/26/2025, and 04/30/2025. S1 Administrator confirmed she had not performed any monitoring related to these issues. S1 Administrator confirmed these complaints had not been resolved, but should have been. S1 Administrator confirmed all resident complaints should be resolved promptly, but had not been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure controlled medications were stored in separately locked compartments in 1 (Medication Room A) of 2 (Medication Room A and Medication R...
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Based on observation and interview, the facility failed to ensure controlled medications were stored in separately locked compartments in 1 (Medication Room A) of 2 (Medication Room A and Medication Room B) medication rooms observed.
Findings:
Observation on 05/06/2025 at 09:45 a.m. of Medication Room A revealed one bottle of Lorazepam oral concentrate (controlled medication) in medication refrigerator placed next to medication lockbox.
Interview on 05/06/2025 at 09:46 a.m. with S5 LPN (Licensed Practical Nurse) confirmed the above findings. S5 LPN confirmed the bottle of Lorazepam oral concentrate should have been in the medication refrigerator lockbox and was not because the key to the lockbox would not unlock the lockbox. S5 LPN stated she did not notify anyone of her inability to open medication lockbox.
On 05/06/2025 at 09:46 a.m. S2 DON arrived to Medication Room A during above interview with S5 LPN. S2 DON confirmed Lorazepam and any other controlled medications that require refrigeration should be locked securely in medication refrigerator in lockbox.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to provide an uncluttered neat and well-kept room for 1 (Resident #2) of 3 ...
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Based on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to provide an uncluttered neat and well-kept room for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
Review of Resident #2's medical record revealed an admit date of 02/01/2024 with diagnoses that included in part .Type 2 Diabetes Mellitus with Diabetic Retinopathy, Bipolar Disorder, Borderline Personality Disorder, Pain Unspecified and Legal Blindness.
Review of Resident #2's Quarterly MDS with ARD of 12/06/2024 revealed a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #2 was coded as setup or clean-up assistance for eating, toileting, oral hygiene, and supervision or touching assistance with bathing.
Review of Resident #2's Care Plan with a review date of 04/13/2025 revealed in part .
1. I have an ADL self-care performance deficit related visual deficit: Diagnosis of Macular Degeneration with interventions which included assist me with bed mobility, toileting, eating, personal hygiene, grooming, dressing and bathing as needed.
2. I have impaired visual function related to Macular Degeneration with interventions which included I prefer to have my room and things arranged to promote independence.
Interview on 02/04/2025 at 11:00 a.m. with Resident #2 revealed she was concerned about a recent room change that occurred while she was out of the facility in the hospital. Resident #2 revealed when she returned to the facility all of her personal belongings had been thrown into a new room. Resident #2 revealed her closet was a mess and her personal belongings were packed in boxes and thrown in drawers. Resident #2 revealed she was legally blind and had difficulty seeing and kept her room arranged so she could easily find items. Resident #2 revealed it was hard for her to find her belongings in the new room and no one had offered to assist her in rearranging the new room.
Review of a nurse's progress note dated 11/29/2024 at 3:47 p.m. read in part .Resident returned from behavioral hospital per facility van. Diagnosis Bipolar. Awake alert x 3 ambulatory per walker. Resident seems content with new room assignment.
Observation and interview on 02/05/2025 at 8:32 a.m. revealed Resident #2 sitting in her room on the side of her bed. In the corner by Resident #2's bathroom were four boxes on the floor stacked on top of one another, which contained clothes and personal items. Observation with Resident #2 of her nightstand drawers revealed numerous personal items in disarray. Resident #2 revealed she couldn't find anything in her nightstand drawers. Resident #2 revealed in her previous room she had her closet organized so she could find her clothes easier due to her blindness.
Observation and interview on 02/05/2025 at 8:46 a.m. with S3 Administrator in Resident #2's room revealed four boxes sitting in the corner by the bathroom stacked on top of one another. Resident #2 revealed to S3 Administrator that the boxes contained her clothes and personal belongings from her recent room change and that was how staff had left them. S2 Administrator shown Resident #2's night stand drawers and personal items in disarray. S2 Administrator confirmed the above findings and stated staff should have assisted Resident #2 in unpacking her clothes and personal belongings when she changed rooms.
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 interview and record review the facility failed to develop/implement a Person-Centered Care Plan for 1 (Resident #1) out of 3 (Resident #1, Resident #2 and Resident #3), sampled residents to ...
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Based on interview and record review the facility failed to develop/implement a Person-Centered Care Plan for 1 (Resident #1) out of 3 (Resident #1, Resident #2 and Resident #3), sampled residents to include smoking and appropriate nursing interventions.
Findings:
Review of Resident #1's medical record revealed an admit date of 10/25/2024 with diagnoses that included in part .Multiple Sclerosis, Paraplegia Unspecified, Anxiety Disorder, Personality Disorder, Pressure Ulcer of Left Buttock Stage 2, Bipolar Disorder and Insomnia.
Review of Resident #1's Admission's MDS with an ARD of 11/1/2024 revealed a BIMS score of 12 which indicated moderately impaired cognition. The MDS revealed Resident #1 was coded as extensive assistance with 2 person assistance for bed mobility and toilet use; Dependent for transfers and Independent with eating.
Review of a progress note dated 12/04/2024 at 1:18 PM by S2 LPN revealed in part .reassessed blisters on Resident's abdomen. NP diagnosed them as burns. Resident stated that she did not burn herself and that she does not have a lighter.
Telephone interview on 02/04/2025 at 11:15 a.m. with Resident #1 revealed she was a safe smoker at the nursing home and smoked whenever she wanted to.
Review of Resident #1's Care Plan revealed no documentation of Resident #1 being a smoker.
Interview on 02/04/2025 at 12:55 p.m. with S1 DON confirmed Resident #1 smoked when she was a resident at the facility. S1 DON confirmed a Care Plan had not been developed with appropriate nursing interventions for Resident #1 having been a smoker, and it should have been.
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 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 ...
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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 staff performed hand hygiene after touching contaminated areas during wound care for 1 (Resident #3) out of 3 (Resident #1, Resident #2 and Resident #3), sampled residents.
Findings:
Review of the Facility's Policy titled Dressing Clean with an effective date of 09/01/2023 read in part .
Purpose: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection.
Process:
4. Wash hands and put on clean gloves.
5. Loosen the tape and remove the existing dressing, moisten with prescribed cleaning solution if needed to remove dressing, discard old dressing.
6. Wash hands and put on clean gloves
11. Discard disposable items and gloves into appropriate trash receptacle and wash hands.
Review of Resident #3's medical record revealed an admit date of 06/06/2024 with diagnoses that included in part .Cerebral Palsy, Unspecified Protein-Calorie Malnutrition, Pressure induced deep tissue damage Left Heel, Dysphagia, Cognitive Communication Deficit, Gastrostomy Status and Unspecified Intellectual Disabilities.
Review of Resident #3's 02/2025 Physician's Order with an order date of 11/01/2024 read in part .Pressure Stage 3 Left Heel Distal-cleanse with Dakins and gauze, pat dry with gauze, apply Zinc to Peri-wound, apply Medi-Honey and Calcium Alginate to wound bed and cover with ABD pad and wrap with gauze bandage every day and as needed until resolved.
An observation of wound care for Resident #3 on 02/05/2025 at 11:10 a.m. with S4 RN Treatment Nurse revealed she donned a pair of gloves and removed a soiled dressing from Resident #3's Left Heel. S4 RN Treatment nurse then donned a clean pair of gloves without washing/sanitizing hands. S4 RN Treatment Nurse cleansed the wound to the Left Heel, then removed gloves and donned a new pair without washing/sanitizing hands. S4 RN Treatment Nurse applied medications to Left Heel and wrapped it. S4 RN Treatment nurse removed soiled gloves without washing/sanitizing hands.
Interview on 02/05/2025 at 11:15 a.m. with S4 RN Treatment Nurse confirmed she had not washed or sanitized her hands at any time while providing wound care to Resident #3's Left Heel.
Interview on 02/05/2025 at 1:27 p.m. with S1 DON confirmed that hand hygiene should have completed prior to S4 RN Treatment Nurse donned gloves and after removing soiled gloves.
Dec 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide adequate supervision, and use extensive, 2 person physical assistance for turning, repositioning and bed mobility for ...
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Based on observation, interview and record review, the facility failed to provide adequate supervision, and use extensive, 2 person physical assistance for turning, repositioning and bed mobility for 1 (#1) of 2 (#1 and #2) residents reviewed for falls.
This failed practice resulted in an actual harm situation on 11/07/2024 at 9:35 a.m., when Resident #1, who was severely impaired cognitively; had diagnoses that included Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side; Unspecified Dementia; and required substantial/ maximal assistance for shower/ bathing and rolling left and right; rolled out of bed while receiving a bed bath by S4 CNA. Resident #1 fell onto the floor, and sustained a Closed Right Hip Fracture.
Findings:
Review of the facility's policy and procedure with revision date of March 2018, and titled Activities of Daily Living (ADLs), Supporting read in part .
Policy Interpretation and Implementation
5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the ARD and the following MDS definitions in part .
d. Extensive Assistance - While resident performed part of activity over the last 7 days, staff provided weight-bearing support.
6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.
7. The resident's response to interventions will be monitored, evaluated and revised as appropriate.
Review of Resident #1's medical record revealed an admission date of 07/03/2019, with diagnoses that included in part . Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Unspecified Dementia.
Review of Resident #1's Quarterly MDS with an ARD 10/30/2024, revealed a BIMS score of 00 (severely impaired cognitively). The MDS revealed in part . Resident #1 was coded for functional limitations in ROM with impairment on one side for upper and lower extremities. Resident #1 required substantial/ maximal assistance for shower/ bathing, toileting, dressing, and rolling left and right.
Review of Resident #1's Care Plan with a target date of 12/02/2024, revealed the following:
1. High risk for falls r/t limited mobility, r/t previous CVA affecting right side; right side hemiplegia. I scoot myself around in bed at times, with a goal to be free of falls. Interventions included in part . I am a fall risk. Follow facility fall protocol - Initiated 07/03/2019.
09/15/2024 - Fall without injury. Ensure resident is in middle of bed upon rounds.
11/07/2024 - Fall with major injury. Leave resident's door open for frequent rounding and increased visualization.
2. ADL self-care performance deficit r/t CVA with right sided hemiplegia and dementia, with a goal to maintain current level of ADL function. Initiated on 07/03/2019.
Interventions included in part . Assist me with dressing, bed mobility, personal hygiene, toileting, eating and transfers - revision on 06/14/2024; Assist me with bathing as needed; and honor my choice for type of bath I prefer - revision on 01/09/2024.
Observation on 12/02/2024 at 11:00 a.m., and 12/03/2024 at 10:00 a.m., revealed Resident #1 lying in bed with call light within reach. Resident #1 was not interviewable. Resident #1's bed was in low position, with mattress with bolsters on each side of Resident #1, and a fall mat was observed on the window side of the bed. Signage was noted over the HOB that revealed a fall leaf, a picture of a bed with the number 2 (2 person assist), a red heart (DNR), a blue triangle (color of the lift pad), fall mat, a red circle (use lift for transfers), a coffee cup (to prevent scalding when drinking), nectar thick liquids, no ice, no straws, turn schedule, pillow under right arm, and elevate right wrist.
Interview with S6 CNA Supervisor on 12/04/2024 at 9:35 a.m. revealed that a binder was located at each nurses' station for the HOB signage with pictures and meanings of each picture. S4 CNA was in-serviced on the overhead bed signage and its meanings when she was hired and throughout orientation, and S4 CNA was aware that the book was located at the nurses' station. S6 CNA Supervisor stated that the HOB signage on 11/07/2024, revealed Resident #1 was required to have 2 person extensive assistance with ADLs, bed mobility and transfers, and should have had 2 persons assisting with her bathing and turning while in bed.
Interview on 12/04/2024 at 10:15 a.m. with S7 FNP revealed that prior to fall with injury of hip fracture, Resident #1 was bed bound. S7 NP stated the nurse called her and she came shortly, assessed Resident #1 and initially c/o her right arm and waiting for mobile x-ray. S7 FNP revealed Resident #1 continued to complain with facial grimacing, and sent her out to the hospital for further evaluation and x-rays.
Telephone interview on 12/04/2024 at 12:30 p.m. with S4 CNA, revealed Resident #1 was on her list of residents to receive a bed bath that day; however, she stated she didn't remember looking at the over-head bed signage before providing Resident #1's care to see what assistance with care was needed. She stated she knew she could check the kiosk, but didn't look at the kiosk either, prior to caring for Resident #1, and should have.
Interview on 12/04/2024 at 2:30 p.m. with S2 ADON, revealed the information that was included on each resident's HOB signage and in the Kiosk, was generated directly from the current MDS assessment, and that Resident #1's intervention for 2 person extensive assistance for bed mobility, turning and repositioning in bed was initiated on 01/08/2024.
Interview on 12/05/2024 at 1:55 p.m. with S4 CNA, revealed she provided care to Resident #1 3-4 months ago, prior to the incident. During that time the resident was bathed by bath aides. S4 CNA stated she worked with Resident #1 on 11/07/2024, and Resident #1 was scheduled to have her bed bath right after breakfast. S4 CNA stated she was giving Resident #1 a bed bath on 11/07/2024 by herself, and rolled Resident #1 onto her left side, on the opposite side of the bed she (S4 CNA) was on. S4 CNA stated she had her arm on Resident #1 when she (Resident #1) started scooting closer to the edge of her bed, and rolled out of the bed, and onto the floor. S4 CNA stated she called for help and pressed the call light for assistance, and the nurse and 2 CNAs came into room to assist. S4 CNA stated she had been trained on the over bed signage and use of the kiosk for resident care, but didn't remember looking at Resident #1's HOB signage prior to providing her bed bath.
Interview on 12/05/2024 at 2:50 p.m. with S3 LPN revealed that she cared for Resident #1 on 11/07/2024, and was summoned to her room after she fell out of her bed. She stated Resident #1 was found lying on the floor on her side. S3 LPN reported according to Resident #1's overhead bed signage and ADL Documentation on 11/07/2024, Resident #1 was required to have 2 person extensive assistance with ADLs, bed mobility and transfers, and should have had 2 persons assisting with her bathing and turning while in bed.
Review of Resident #1's Radiology results dated 11/07/2024 at 3:01 p.m. read in part .History/ Reason for X-Ray: Fall, Right shoulder, elbow pain; fall, Right hip pain. Procedure: Pelvis AP 1 view/ Right Hip AP and Lateral. Impression: Right Trans-Cervical Femoral Neck Fracture.
Review of Nursing Progress Notes dated 11/07/2024 at 9;35 a.m., revealed in part .S3 LPN stated she was summoned to Resident #1's room and noted the resident lying flat on her back. Resident #1 assisted up times 3 person assist. Neuro-checks in progress. S7 FNP notifed with new orders for x-ray of bilateral upper arms, and bilateral hip and legs.
Interview on 12/05/2024 at 3:50 p.m. with S1 DON, and review of the ADL documentation located in the Kiosk, revealed Resident #1 required extensive assistance with 2 person assistance. The ADL documentation revealed in part . 3,3, which indicated Resident #1 required extensive assistance with 2 person assistance for bed mobility and transfers. S1 DON revealed the X-rays showed Resident #1 had a fracture to her Right Femur. S1 DON confirmed S4 CNA should not have attempted to provide ADLs and turn Resident #1 in her bed by herself.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the comprehensive plan of care was reviewed and revised to ensure staff provided extensive assistance with 2 person physical assista...
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Based on interview and record review, the facility failed to ensure the comprehensive plan of care was reviewed and revised to ensure staff provided extensive assistance with 2 person physical assistance for turning, repositioning and bed mobility, when providing ADL care (bed bath), for 1 (#1) of 2 (#1 and #2) residents reviewed for falls.
Findings:
Review of the facility's policy and procedure dated 09/01/2024, and titled Fall Prevention Program read in part . Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines:
8. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.
a. Interventions will be monitored for effectiveness.
b. The plan of care will be revised as needed.
9. When any resident experiences a fall, the facility will:
e. Review the resident's care plan and update as indicated.
Review of Resident #1's medical record revealed an admission date of 07/03/2019, with diagnoses that included in part . Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Unspecified Dementia.
Review of Resident #1's Quarterly MDS with an ARD 10/30/2024, revealed a BIMS score of 00 (severely impaired cognitively). The MDS revealed in part . Resident #1 was coded for functional limitations in ROM with impairment on one side for upper and lower extremities. Resident #1 required substantial/ maximal assistance for shower/ bathing, toileting, dressing, and rolling left and right.
Review of Resident #1's Care Plan with a target date of 12/02/2024, revealed the following:
1. High risk for falls r/t limited mobility, r/t previous CVA affecting right side; right side hemiplegia. I scoot myself around in bed at times, with a goal to be free of falls. Interventions included in part . I am a fall risk. Follow facility fall protocol - Initiated 07/03/2019.
09/15/2024 - Fall without injury. Ensure resident is in middle of bed upon rounds.
11/07/2024 - Fall with major injury. Leave resident's door open for frequent rounding and increased visualization.
2. ADL self-care performance deficit r/t CVA with right sided hemiplegia and dementia, with a goal to maintain current level of ADL function. Initiated on 07/03/2019.
Interventions included in part . Assist me with dressing, bed mobility, personal hygiene, toileting, eating and transfers - revision on 06/14/2024; Assist me with bathing as needed; and honor my choice for type of bath I prefer - revision on 01/09/2024.
Interview on 12/04/2024 at 2:30 p.m. with S2 ADON, and review with S2 ADON of the Care Plan Item Task Listing Report, revealed an intervention initiated on 01/08/2024 for 2 person extensive assistance for bed mobility, turning and repositioning in bed for Resident #1, should have been listed on the report form, and was not listed. S2 ADON stated the report lists all residents that required extensive 2 person assistance for bed mobility, and the report was generated from the residents' care plans. S2 ADON stated Resident #1 was not listed on the report, because the information was not on her comprehensive plan of care, and should have been. S2 ADON stated she would update Resident #1's care plan interventions today (12/04/2024), to include Resident #1 required extensive assistance by 2 staff to turn and reposition in bed. S2 ADON confirmed Resident #1 should have been care planned for 2 person extensive assistance for ADL care and bed mobility, and was not.
Mar 2024
7 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility personnel failed to provide basic life support, including CPR, to a resident requi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders, and the resident's advance directives for 1 (Resident #76) of 2 (Resident #76 and Resident #77) closed records reviewed out of a total sample of 23.
The facility failed to:
1. Ensure S4 LPN acted in accordance with Resident #76's Advanced Directives and Physician Orders, and initiated CPR when the resident was found unresponsive and without a pulse; and
2. Ensure EMS and the physician were notified when Resident #76 was found unresponsive, without a pulse.
This deficient practice resulted in an Immediate Jeopardy for Resident #76 that began on [DATE] at approximately 6:00 a.m., when S6 CNA found Resident #76 in bed, unresponsive, and not looking right. S6 CNA notified S4 LPN, who failed to initiate CPR when she found Resident #76 unresponsive and without a pulse. Resident #76's Advanced Directives revealed that extraordinary measures should be taken in case of an extreme emergency, and Physician's Orders revealed a Full Code Status. The facility did not notify EMS and Resident #76's physician. Resident #76 was pronounced deceased on [DATE] at 6:30 a.m. by the Coroner.
The administrator was notified of the Immediate Jeopardy situation on [DATE] at 2:18 p.m.
The Immediate Jeopardy was removed on [DATE] at 2:08 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
This deficient practice continued at a potential for more than minimal harm for all 41 residents identified as a Full Code who resided in the facility.
Findings:
Review of the facility's undated policy titled: Resident Right - Advanced Directive Tracking Program, read in part . Intent: It is the policy of the facility to honor the advance directives of all residents. Procedure: 18. In the event that a resident experiences cardiopulmonary arrest the nurse on duty shall immediately determine the resident's status as a code or no-code. 19. If the person is a full code, the nurse or designee shall begin Cardiopulmonary resuscitation and direct someone to call 911.
Review of Resident #76's EHR revealed an admit date of [DATE], with the following diagnoses: Acute and Chronic Respiratory Failure with Hypoxia; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation; Acute and Chronic Systolic (Congestive) Heart Failure; and Critical Illness Myopathy.
Review of Resident #76's Advanced Directive dated [DATE] revealed that extraordinary measures should be taken in case of an extreme emergency.
Review of Resident #76's physician orders dated [DATE], read in part . Full Code Status.
Review of Resident #76's Care Plan read in part .I am a full code. No interventions noted.
Review of Resident #76's Nurse's Notes dated [DATE] 10:22 a.m., and written by S4 LPN read in part .Resident #76 non-responsive. S4 LPN went to resident room to reassess resident, noted resident nonresponsive, no pulse, no respirations. S5 LPN notified family of resident unresponsiveness via phone call. RP son notified staff that he was ok and aware of present outcome/death, would notify his siblings and would contact funeral home and call us back. Notified Sheriff's Dept. and called Coroner. Time of death noted at 6:30 a.m. Resident's son called and notified that he contacted funeral home. Coroner released body to funeral home at 8:15 a.m.
Interview on [DATE] at 8:12 a.m. with S4 LPN revealed S6 CNA came to her and told her Resident #76 did not look right, her color was different. S4 LPN stated she went to get her stethoscope, and asked S6 CNA to get S5 LPN to come meet her. S4 LPN stated that she told S5 LPN that Resident #76 may have passed, and S5 LPN told her she was a full code. S4 LPN stated that she started the assessment, and S5 LPN ran to call the resident's son. S4 LPN stated that she was still assessing Resident #76 when S5 LPN returned and told her Resident #76's son said to let her go. S4 LPN stated she had not started CPR because she was still assessing. S4 LPN confirmed she should have begun CPR immediately after determining the resident did not have a pulse. She stated she notified the coroner, but did not alert EMS or notify the MD.
Interview on [DATE] at 8:20 a.m. with S5 LPN, revealed S6 CNA told her that S4 LPN needed her because Resident #76 may have passed. S5 LPN stated that she told S4 LPN that
Resident #76 was a full code, and that she was going to contact the resident's son. S5 LPN stated Resident #76's son asked not to perform CPR on the resident. S5 LPN stated when she walked into Resident #76's room (unable to remember time), S4 LPN was preparing to start CPR, and S5 LPN told her Resident #76's son stated not to do CPR.
Interview on [DATE] at 8:25 a.m. with S6 CNA revealed that she normally got Resident #76 out of bed every morning around 6:00 a.m. at the beginning of her shift. S6 CNA stated that when she went to get the resident out of bed, the resident's color was not right, and she was unresponsive. S6 CNA stated she did not start CPR, but notified S4 LPN. S6 CNA stated S4 LPN sent her to get another nurse.
Telephone interview on [DATE] at 9:08 a.m. with Resident #76's son, revealed the nurse called him around 6:30 a.m. and told him Good morning, we were passing breakfast trays this morning and mama passed. Resident #76's son stated those were her exact words. Resident #76's son stated the nurse did not ask him about performing CPR. Resident #76's son stated that his mother was a full code and that he expected that the facility had performed CPR and called the ambulance.
Interview on [DATE] at 9:30 a.m. with S1 Administrator revealed all nursing staff had up-to-date CPR certifications. S1 Administrator stated that CNAs are not CPR certified, and they should notify the nurse if a resident was found nonresponsive. S1 Administrator stated the LPN should have immediately started CPR on Resident #76 because she was a full code.
Interview on [DATE] at 12:18 p.m. with S2 DON and S4 LPN revealed that S4 LPN stated that she should have initiated CPR on Resident #76, but chose not to do so after S5 LPN told her what the resident's son said. S4 LPN stated she should not have made the decision not to do CPR based on a call made to the family, and she should have followed MD Orders instead. S2 DON confirmed S4 LPN should have followed MD orders, and performed CPR on Resident #76 immediately after finding her unresponsive, and without a pulse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview the facility failed to ensure cognitively impaired residents were treated with respect and dignity, and cared for in a manner that promoted enhanceme...
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Based on record review, observation, and interview the facility failed to ensure cognitively impaired residents were treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 1 (#68) of 1 Resident reviewed for dignity in a total sample of 23. The facility failed to ensure Resident #68, who received PEG tube feedings and was NPO, was not placed within sight of the dining area during meal service. Findings:
Review of Resident #68's medical record revealed an admit date of 11/25/2023 with diagnoses that included in part . Unspecified Dementia with unspecified severity, Cerebral Infarction, Hemiplegia and Hemiparesis affecting Left Non Dominant Side, Phonological Disorder, Dysphagia, Major Depressive Disorder, GERD, Gastrostomy, and Anxiety Disorder.
Review of Resident #68's Yearly MDS with ARD of 01/03/2024 revealed Resident #68 had a BIMS of 99 (assessment of mental status not completed). Resident #68 was totally dependent on staff for eating, and required extensive 2 person physical assistance for bed mobility, toileting, and transfers. Resident #68 had a feeding tube and received 51% or more of calories through PEG.
Review of Resident #68's current 03/2024 physician orders revealed: Clear liquid diet, NPO, Nectar consistency, no food by mouth at this time, allow nectar thick liquids. 08/18/2023
Observation on 03/18/2024 at 10:55 a.m. of Resident #68 revealed she was sitting up in a gerichair with tube feeding in progress, and was located in the front common area that was connected to the dining room. Resident #68 was observed with concerned facial expression noted upon her face. Resident #68 observed calling out for staff to come see. Observation revealed several staff members approached Resident #68 and tried redirecting her. Observation revealed Resident#68 continued to express vocal disappointment, and had concerned facial expression upon her face, as she watched other Resident's eat lunch.
Interview and observation on 03/18/2024 at 11:09 a.m. with Resident #68 revealed she was observed watching other residents eat their lunch meal with a concerned and sad look on her face. Surveyor asked Resident #68 if she ate anything by mouth and she replied No, but I'd like to. Resident #68 continued with sadness reflected on her face. Resident #68 began expressing vocal disappointment again by calling out things that were not understandable.
Observation on 03/18/2024 at 11:12 a.m. revealed S1 Administrator approached Resident #68 and stated to the resident that she would turn her chair, so that she would face the television, and not the dining room. Interview with S1 Administrator at time of observation revealed she acknowledged Resident #68 should not have been able to observe the other residents during meal service, since Resident #68 was not able to eat. S1 Administrator placed Resident #68 in a position faced towards the television of the front common area. Following position change Resident #68 observed no longer calling out for assistance, or with a concerned and sad expression on her face.
Interview on 03/18/2024 at 11:21 a.m. with S8 CNA revealed Resident #68 was always up to the front dining area during meal service.
Interview on 03/18/2024 at 2:05 p.m. with Resident #68's responsible party revealed Resident #68 could communicate basic needs, and was able to express her feelings. Resident #68's responsible party revealed Resident #68 currently did not eat food, but could drink thickened liquids. Resident #68's responsible party stated the facility's speech therapist was working with Resident #68, so she would be able to eat again. Resident #68's responsible party stated he felt it would upset Resident #68 to see others eating, because she was unable to eat.
CONCERN
(D)
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 interview and record review the facility failed to immediately consult with the resident's physician concerning a signi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult with the resident's physician concerning a significant change in a resident's physical, mental or psychosocial status for 1 (Resident #76) of 23 sampled residents. Findings:
Review of the facility's policy dated [DATE] and titled Notification of Changes revealed the following in part . Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. Additional considerations: Death of a resident: The resident's physician is to be notified immediately in accordance with State law.
Review of Resident #76's EHR revealed an admit date of [DATE] with the following diagnoses including: Acute and Chronic Respiratory Failure with Hypoxia; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation; Acute and Chronic Systolic (Congestive) Heart Failure; and Critical Illness Myopathy.
Review of [DATE] and [DATE] Nurse Notes revealed on [DATE] at 11:30 a.m., Resident #76 was too sedated to take medication; on [DATE] at 12:05 p.m. a Skilled Evaluation which included the following statement under Neurologic: Resident does not obey commands. New onset change in LOC; Mental Status: Resident is stuporous. Oriented to person. Stuporous: New; and on [DATE] at approximately 6:00 a.m. Resident #76 was found unresponsive by staff and expired. There was no documentation that the MD was notified on [DATE] or [DATE].
Interview on [DATE] at 12:18 p.m. with S1 Administrator, S2 DON, S7 Corporate Nurse and S4 LPN present revealed S4 LPN stated she should have notified the Medical Doctor of Resident #76's change in LOC on [DATE] and death [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to replace the tube feeding syringe and labe...
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Based on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to replace the tube feeding syringe and label the flush set bag for 1 (#68) of 3 (#68, R1, R2) Residents who received Enteral Tube Feedings. Findings:
Review of the facility's policy titled Tube Feeding-Kangaroo E-Pump with effective date of 07/03/2023 read in part . General Startup: Fill the flush set bag with 1000ml of water and close/lock the top. Label the flush set bag with the date, time, initial and amount of water.
Review of Resident #68's medical record revealed an admit date of 11/25/2023 with diagnoses that included in part . Unspecified Dementia with unspecified severity, Cerebral Infarction, Hemiplegia and Hemiparesis affecting Left Non Dominant Side, Phonological Disorder, Dysphagia, Major Depressive Disorder, GERD, Gastrostomy, and Anxiety Disorder.
Review of Resident #68's Yearly MDS with ARD of 01/03/2024 revealed Resident #68 had a BIMS of 99 (assessment of mental status not completed). Resident #68 was totally dependent on staff for eating, and required extensive 2 person physical assistance for bed mobility, toileting, and transfers. Resident #68 had a feeding tube and received 51% or more of calories through PEG.
Review of Resident #68's current 03/2024 physician orders revealed:
Clear liquid diet, NPO, Nectar consistency, no food by mouth at this time, allow nectar thick liquids. 08/18/2023
Enteral Feed Order: Every night shift, Tube feeding administration set changed. 03/13/2024
Enteral Feed Order: Every shift, Flush instructions: 300mls every 3 hours. 03/13/2024
Enteral Feed Order: Every shift, Isosource 1.5 @ 50cc/hr. 03/13/2024
Observation on 03/19/2024 at 9:02 a.m. of Resident#68 revealed she had tube feeding of Isosource 1.5 infusing at 50ml/hr via pump. The feeding bag was labeled and dated 03/19/2024 5:00a.m. The water flush bag was observed with approximately 1300ml in bag, and flush set for 300ml every 3hrs on pump. The water flush bag was observed without a label with no date, time, initials, or amount of water documented on bag. The feeding tube syringe was observed on Resident #68's bedside table with a thick tan substance within the syringe that was located within a plastic bag and dated 03/17/2024.
Interview on 03/19/2024 at 9:22 a.m. with S4 LPN within Resident #68's room revealed tube feedings are replaced on the night shift. S4 LPN confirmed the tube feeding syringe was in need of replacing. S4 LPN confirmed the flush bag should be labeled with date and time when hung, and the tube feeding syringe should be replaced with each tubing change, but had not been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 1(Resident #31) of 2 Residents (Resident #27 and Resident #...
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Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 1(Resident #31) of 2 Residents (Resident #27 and Resident #31) reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly changed, labeled and stored. Total sample was 23.
Findings:
The Facility's Policy Titled Nebulizer with an effective date of 08/01/2023 read in part .
Process:
After completion of therapy
e. Store in plastic bag
VII. Discard/replace administration setup every seven (7) days.
Review of Resident #31's medical record revealed an admit date of 09/19/2022 with a BIMS score of 15 (indicating intact cognition) and diagnoses which included: Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and Cardiomyopathy.
Review of Resident #31's Physician's Orders dated 03/2024 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours as needed for cough /wheeze/SOB.
Review of Resident #31's care plan with a target date of 05/01/2024 revealed a problem for Chronic Obstructive Pulmonary Disease with interventions that included in part . I will receive aerosol or bronchodilators as ordered.
Observation on 03/18/2024 at 9:30 a.m. revealed Resident #31 lying in bed with oxygen per nasal cannula on connected to an oxygen concentrator. A mouthpiece connected to a nebulizer machine was observed on Resident #31's bedside table uncovered and undated. Resident #31 revealed she used the mouthpiece as needed to receive her nebulizer medications.
Interview on 03/19/2024 at 9:17 a.m. with S3 LPN revealed she checked Resident #31's respiratory equipment on 03/18/2024, and the mouthpiece to her nebulizer machine was uncovered and undated and confirmed it should have been covered and dated. S3 LPN stated all respiratory equipment should be changed every Sunday by the 10p.m.-6a.m. nurse.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts in the facility. Findings:
Review of the fa...
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Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts in the facility. Findings:
Review of the facility policy titled Medication Storage dated 05/16/2023 revealed in part .All drugs and biologicals will be stored in locked compartments.
Observation on 03/19/2024 at 8:50 a.m. on the Hall W of the facility revealed an unlocked, unattended medication cart located outside the team meeting room. All cart medication drawers were unlocked and able to be opened. There were medications noted in the three drawers of the cart with a locked narcotics drawer located in one of those drawers.
Interview and observation on 03/19/2024 at 9:02 a.m. with S2 DON confirmed the medication cart on Hall W was unlocked; contained medications accessible to residents, and it should not be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 5 (#7, #8, #16, #279 and #280) of 5 Re...
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Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 5 (#7, #8, #16, #279 and #280) of 5 Residents who were ordered and served pureed diets. Findings:
Review of the facility's approved 2024 Lunch Menu revealed the facility was on Week: 2, Day: Monday and would be serving Chicken and Sausage Jambalaya as the main course food item.
Review of the facility's approved recipe for Pureed Chicken & Sausage Jambalaya read in part . Instructions: Measure number of servings using the regular prepared recipe portion. Drain well to minimize the use of thickener to obtain appropriate consistency. Place in a blender or food processor. Add liquid, if needed (ex: reserved liquid, broth, milk, gravy, or sauce), to assist with pureeing. Puree with a blender or food processor until smooth. NOTE: Water should not be used as a liquid to puree foods.
Resident #7
Review of Resident #7's EHR (Electronic Health Record) revealed she was admitted to facility on 05/17/2023 and had a diet order for Dysphagia, Pureed texture, Thin consistency.
Resident #8
Review of Resident #8's EHR revealed she was admitted to facility on 05/17/2017 and had a diet order for Regular, Pureed texture, Honey consistency.
Resident #16
Review of Resident #16's EHR revealed she was admitted to facility on 04/18/2021 and had a diet order for Regular, pureed texture, thin consistency.
Resident #279
Review of Resident #279's EHR revealed he was admitted to facility on 01/31/2024 and had a diet order for Regular, Pureed texture, Nectar consistency, Double portions, No straws.
Resident #280
Review of Resident #280's EHR revealed she was admitted to facility on 03/14/2024 and had a diet order for Regular, Pureed texture, Nectar Consistency.
Observation on 03/18/2024 at 10:44 a.m. of S11 Dietary preparing pureed Chicken & Sausage Jambalaya in a blender. S11 Dietary added an unmeasured amount of tap water to the jambalaya when blending the food in blender. S11 Dietary stated during the observation she always used unmeasured water as an additive to puree all foods, and she did not refer to the recipe for meals, because she worked at the facility for 10 years and did not have to refer to the recipe when preparing meals.
Interview on 03/18/2024 at 10:57 a.m. with S9 Dietary Manager revealed dietary staff should refer to recipes when cooking and preparing all meals. S9 Dietary Manager stated he would have to review the recipe to determine if the use of water to prepare the pureed jambalaya was acceptable.
Interview on 03/18/2024 at 3:44 p.m. with S9 Dietary Manager revealed S11 Dietary should not have used water to prepare the pureed jambalaya as it disrupted the nutritional value.
Telephone interview on 03/18/2024 at 3:51 p.m. with S10 RD confirmed water should not be used when preparing pureed meals as it disrupted the nutritional value and most of the time a broth is used. S10 RD confirmed staff should refer to the recipe when preparing meals to determine what liquid should be added to pureed food items.
Feb 2024
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to make a prompt effort to resolve grievances filed by a resident's representative, and submit a report of findings for 1 (#2) of 3 (Resident ...
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Based on interview and record review, the facility failed to make a prompt effort to resolve grievances filed by a resident's representative, and submit a report of findings for 1 (#2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
The facility's Policy Titled Resident Care Grievance read in part .The facility will investigate all grievances and filed complaints relating to any facility Resident. Policy date 11/26/2019.
Any resident, his or her representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc. without fear of threat or reprisal in any form.
Grievances or complaints may be submitted orally or in writing.
Upon receipt of a grievance or complaint, the Grievance Official or designee will lead a thorough, impartial investigation of the allegations, and submit a written report of such findings an all evidence within 5 working days of receiving the grievance or complaint.
Review of Resident #2's medical record revealed an admit date of 12/21/2022, with diagnoses that included: Major Depressive Disorder recurrent with Psychotic Symptoms, Delirium due to known physiological condition, Type 2 Diabetes Mellitus, Anxiety Disorder and Metabolic Encephalopathy.
Review of Resident #2's Quarterly MDS with a target date of 01/26/2024, revealed a BIMS score of 5 (indicating severe cognitive impairment); required partial/moderate assistance for dressing, toileting/personal hygiene, and bathing; and independent with eating.
Telephone interview on 02/19/2024 at 9:24 a.m. with Resident #2's spouse, revealed he complained to S1 Administrator and S2 DON regarding the fact that Resident #2 had tested positive for Escherichia Coli (a bacteria) in her urine each time she was sent to the behavioral hospital in 12/2023 and 01/2024 (couldn't remember the exact dates). Resident #2's spouse stated he was very concerned, and contacted the facility twice regarding this matter. Resident #2's spouse revealed the facility had not given him any plan of action to prevent the reoccurrence of Resident #2 contracting Escherichia Coli in her urine again.
Interview on 02/21/2024 at 11:00 a.m. with S2 DON, revealed she and S1 Administrator had spoken to Resident #2's spouse regarding her recent diagnosis of Escherichia Coli in her urine. S2 DON stated they talked for approximately 45 minutes on the phone, but she couldn't remember exactly what was discussed. S2 DON revealed she did not document anything regarding the Responsible Party's (Resident #2's spouse) concerns, or initiate a grievance, because she felt like a grievance was not warranted.
Interview on 02/21/2024 at 1:30 p.m. with S1 Administrator revealed she and S2 DON had spoken to Resident #2's spouse regarding her recent diagnosis of Escherichia Coli in her urine. S1 Administrator stated Resident #2's spouse had called the facility to see why his wife had not been treated for a Urinary Tract Infection. S1 Administrator revealed it was explained to Resident #2's spouse that she did not meet the facility's protocol for doing a urinalysis. S1 Administrator revealed Resident #2's spouse had also called corporate regarding his wife's recent Urinary Tract Infections. S1 Administrator acknowledged she did not do a grievance.
Telephone interview on 02/21/2024 at 2:02 p.m., with S3 Corporate Regional Director revealed he reached out to Resident #2's spouse because S1 Administrator had asked him to. S3 Corporate Regional Director revealed Resident #2's spouse was frustrated about the resident having been at the behavioral hospital and having a Urinary Tract Infection. S3 Corporate Regional Director acknowledged a grievance was not done.
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 facility failed to develop an individualized person-centered plan of care to meet the needs of 1 (#2) of 3 (Resident #1, Resident #2 and Resident #3) sampled r...
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Based on record review and interview the facility failed to develop an individualized person-centered plan of care to meet the needs of 1 (#2) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. The facility failed to ensure a plan of care was developed with approaches for aggressive behavior.
Findings:
Review of Resident #2's medical record revealed an admit date of 12/21/2022, with diagnoses that included: Major Depressive Disorder recurrent with Psychotic Symptoms, Delirium due to known physiological condition, and Anxiety Disorder.
Review of Resident #2's Quarterly MDS with a target date of 01/26/2024, revealed a BIMS score of 5 (indicating severe cognitive impairment). The MDS revealed Resident #2 had verbal behavioral symptoms directed toward others such as: threatening others, screaming at others, cursing at others.
Interview on 02/19/2024 at 3:48 p.m. with S2 DON revealed Resident #2 had behaviors of pouring water in her bed, being aggressive and throwing meal trays at staff, cursing at staff, and inappropriate sexual behavior.
Review of Resident #2's care plan revealed she did not have a problem developed for her behaviors or any interventions.
Interview on 02/20/2024 at 9:15 a.m. with S2 DON confirmed Resident #2 was coded as having behaviors on her Quarterly MDS with a target date of 01/26/2024. S2 DON confirmed Resident #2 was not care planned for her behaviors.
May 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 3 (Resident #3, Resident #4 and Resident #5) of 5 (Resident #1, Resident #...
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Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 3 (Resident #3, Resident #4 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) residents reviewed for abuse.
Findings:
Review of the facility policy titled: Abuse Components Plan revealed in part
Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.
Misappropriation of resident property as defined at 483.5, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.
Review of a facility investigation dated 03/17/2023 revealed Residents #3, #4 & #5 had been victims of misappropriation of medications by a staff nurse on or about 03/15/2023. Review of the report revealed in part .On 03/16/2023 at 3:30 p.m. S2 ADON was notified by nursing staff that Resident #3 received Hydrocodone 10-325mg at 9:30 p.m. on 03/15/2023 per S4 LPN. In review of narcotic record Resident #4 received Hydrocodone 5/325mg at 10:00 p.m. per S4 LPN. Resident #3 interviewed by S2 ADON and DON and denied receiving Hydrocodone on 03/15/2023. Resident #4 interviewed by S2 ADON and DON and denied receiving Hydrocodone on 03/15/2023. S4 LPN was interviewed by the ADON and DON and admitted to taking a Hydrocodone 5-325mg from Resident #5 and not administering the medication to Resident #5 in addition to Residents #3 and #4.
Interview on 05/30/2023 at 11:44 a.m. with S2 ADON revealed that on 03/16/2023 a 2:00 p.m.-10:00 p.m. nurse (S6 LPN) reported to her that while counting narcotics she noticed Resident #3 had received Hydrocodone at 9:30 p.m. on 03/15/2023. S2 ADON stated S6 LPN said this was odd because Resident #3 never asks for pain medication.
Interview on 05/30/2023 at 3:17 p.m. with S6 LPN revealed that a week prior to 03/16/2023 she noted a pill on Resident #3's Hydrocodone card had tape behind it but the pill was still there. S6 LPN stated after noticing a 3rd taped pill blister on 03/16/2023 she asked S5 LPN to take a look because the taped pills did not match the other pills in the blister pack. S6 LPN stated she and S5 LPN took the card to the DON and reported what they found.
Review of Resident #3's Individual Narcotic Log revealed doses of Hydrocodone 10-325mg were signed out on 03/01/2023 and 03/15/2023 by S4 LPN.
Review of Resident #3's MAR revealed no documentation that doses of Hydrocodone signed out on 03/01/2023 and 03/15/2023 had been administered to Resident #3.
Review of Resident #4's Individual Narcotic Log revealed a dose of Hydrocodone 5-325mg was signed out on 03/08/2023 and 03/15/2023 by S4 LPN with no documentation of administration on Resident #4's MAR.
Review of Resident #5's Narcotic Log revealed a dose of Hydrocodone 5-325mg was signed out by S4 LPN on 03/03/2023, 03/04/2023 and 03/12/2023 with no documentation of administrations on Resident #5's MAR.
Review of a signed statement by S4 LPN revealed she had taken a total of 3 doses of Hydrocodone 5-325mg from Residents #3, #4 and #5 from the facility to give to a family member.
Interview on 05/31/2023 at 1:51 p.m. with S2 ADON confirmed Medication Administration Record and Individual Narcotic Log findings for Residents #3, #4 and #5. S2 ADON stated all medications signed out, should have been administered to residents and had not been. S2 ADON stated they could not prove S4 LPN took all the undocumented doses of Hydrocodone 5-325mg only the doses she admitted to.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure a resident with a diagnosis of Dementia rece...
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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 a resident with a diagnosis of Dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The facility failed to develop and implement a person-centered care plan regarding a resident's new onset of exhibiting sexual behaviors for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) residents reviewed for abuse.
Findings:
Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
Review of Resident #1's Quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) 04/12/2023 revealed Resident #6 had a BIMS score of 6, indicating severe cognitive impairment.
Review of a facility investigation dated 04/13/2023 revealed that on 04/11/2023, 04/12/2023 and 04/13/2023, video footage revealed Resident #1 engaged in sexual behaviors with a male resident (Resident#2). Resident #1 was seen on video to look down the hall as if trying to determine if anyone was looking, then raise her blouse and untie the drawstring on her pants.
Review of Resident #1's PCPOC (Person Centered Plan of Care) revealed in part
I have impaired cognitive function/dementia, or impaired thought process related to diagnosis of Dementia. Approaches noted as: I will be called by my preferred name. Identify yourself at each interaction. Face me when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated.
I will be asked yes/no questions in order to determine my needs.
I will be observed/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.
I will have my medications administered as ordered. Observed/document for side effects and effectiveness.
I have a preference to not wear a bra. Approach noted as: I require that the staff have knowledge of my preferences.
Review of Resident #1's Psychiatric Evaluation dated 01/06/2023 and completed by S3 APRN revealed no documentation of reports of sexual behaviors.
Review of Resident #1's Psychiatric Progress Note dated 05/25/2023 and completed by S3 APRN, revealed no documentation of reports of sexual behaviors.
Interview on 05/30/2023 at 3:15 p.m. with S2 ADON revealed Resident #1's care plan had not been updated to reflect new sexual behaviors.
Telephone interview on 05/31/2023 at 1:333 p.m. with S3 APRN revealed she was not aware of sexual behaviors exhibited by Resident #1. S3 APRN stated a psychiatric evaluation was completed on Resident #1 in 01/2023, and a follow-up on 05/25/2023. S3 APRN stated she made no recommendations when she saw Resident #1 on 05/25/2023 because she was unaware of any sexual behaviors. S3 APRN stated Resident #1's new sexual behaviors should have been reported to psychiatric services. S3 APRN also stated Resident #1's plan of care should have been updated to reflect the new behaviors, and sexual behavior monitoring initiated.
Interview on 05/31/2023 at 2:42 p.m. with S2 ADON confirmed Resident #1's Psychiatric Health Care Provider had not been notified of Resident #1's new sexual behaviors.
Mar 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview the Facility failed to ensure that the Nurse Staffing information was posted daily and in a place readily accessible for Residents and Visitors. Findings:
Observatio...
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Based on observation and interview the Facility failed to ensure that the Nurse Staffing information was posted daily and in a place readily accessible for Residents and Visitors. Findings:
Observation on 02/27/2023 at 10:00 a.m. of the posted Nurse Staffing Form revealed a date of 02/26/2023. The Nurse Staffing Form was posted in a corner in the Facility, near the Therapy Department, on a bulletin board over a wheelchair scale. The nurse staffing information was not posted in an area that was readily accessible to Residents and Visitors.
Observation on 02/28/2023 at 7:54 a.m. of the posted Nurse Staffing revealed a date of 02/26/2023. The Nurse Staffing information was not posted in an area that was readily accessible to Residents and Visitors.
Observation on 02/28/2023 at 9:39 a.m. of the posted Nurse Staffing revealed a date of 02/27/2023. The Nurse Staffing information was not posted in an area that was readily accessible to Residents and Visitors.
Observation on 02/28/2023 at 1:48 p.m. of the posted Nurse Staffing revealed a date of 02/28/2023. The Nurse Staffing information was not posted in an area that was readily accessible to Residents and Visitors.
Observation on 03/01/2023 at 7:55 a.m. of the posted Nurse Staffing revealed a date of 02/28/2023. The Nurse Staffing information was not posted in an area that was readily accessible to Residents and Visitors.
Interview on 03/01/2023 at 8:00 a.m. with S2 DON revealed she was not familiar with the Staff posting. S2 DON stated that S4 ADM Assistant was responsible for posting the Nurse Staffing.
Interview on 03/01/2023 at 10:00 a.m. with S4 ADM Assistant confirmed she was responsible for posting the Nurse Staffing daily. S4 ADM Assistant stated she had only been in this position since December 2022 and assumed this duty.
Interview on 03/01/2023 at 10:15 a.m. with S1 ADM confirmed the posted Nurse Staffing information for 02/27/2023, 02/28/2023, and 03/01/2023 were not posted on the correct dates, and the staffing information was not visible to Residents and Visitors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, record reviews, and interviews the facility failed to ensure accurate accounting and reconciliation for controlled medications for 1 (Hall C) of 2 medication carts reviewed for c...
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Based on observation, record reviews, and interviews the facility failed to ensure accurate accounting and reconciliation for controlled medications for 1 (Hall C) of 2 medication carts reviewed for controlled medication reconciliation.
The facility failed to:
1. Ensure accurate accounting for controlled medications were completed at the time of receiving narcotics on Hall C for Resident #R1; and
2. Ensure controlled medications were reconciled for the Hall C medication cart by the nurse coming on duty and the nurse going off duty.
Findings:
Review of the facility's Controlled Substance policy read in part .
3. Controlled substance must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication must count the controlled substance together.
9. Nursing staff must count the controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.
Observation and review of Hall C medication cart on 03/01/2023 at 9:50 a.m. with S10 LPN revealed a medication card for Resident #R1 for Lorazepam 0.5mg tablet give 1 tablet by mouth 2 times a day, with a receive date of 02/07/2023, 2 pills noted in card. A second medication card for Resident #R1 for Lorazepam 0.5mg tablet give 1 tablet by mouth 2 times a day with receive date of 02/27/2023, had 28 pills noted in card with a total of 30 pills between both cards.
Review of the Individual Resident Narcotic Record for Resident #R1 read as follows:
C/O - 02/27/2023 - amount on hand 5.
S11 LPN - 02/27/2023, 4 p.m., amount on hand 5, amount give 1, amount remaining 4.
Received from pharmacy 02/27/2023 +30, amount remaining 34.
S17 LPN 02/28/2023, 8 a.m., amount on hand 34, amount given 1, amount remaining 32.
S11 LPN 02/28/2023, 4 p.m., amount on hand 32, amount given 1, amount remaining 31.
Staff interview with S11 LPN on 03/01/2023 at 11:15 a.m. revealed that she received the new Lorazepam narcotic card for Resident #R1 on her shift on 02/27/2023, and that she overlooked that there were 28 pills in the blister pack instead of 30. S11 LPN stated that she did not catch the discrepancy with shift change at 10:00 p.m. with oncoming nurse and noted on 02/28/2023 that Hall C's locked narcotics were not counted between the ongoing and off going nurses. S11 LPN revealed that she was aware that narcotics are to be counted at the beginning and end of every shift by oncoming and off going nurse.
Staff interview on 03/01/2023 1:10 p.m. with S12 LPN revealed that on 02/28/2023 she did not complete a narcotic count at the end of her shift for all narcotics for Hall C with oncoming nurse S17, so therefore she did not catch the discrepancy.
Staff interview with S3 ADON on 03/01/2023 at 10:00 a.m. confirmed that the nurse coming on duty and the nursing going off duty are to count narcotics at beginning and end of every shift, and the Individual Resident Narcotic Record for Resident #R1 was not correct and accurately reconciled according to the locked narcotics on hand.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interview and record review the Facility failed to develop and implement written policies and procedures to protect Residents from abuse, neglect, exploitation and misappropriation of their p...
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Based on interview and record review the Facility failed to develop and implement written policies and procedures to protect Residents from abuse, neglect, exploitation and misappropriation of their property, by failing to screen Agency/Contract Staff's background prior to allowing 2 of 2 unlicensed sampled Agency/Contract Staff (S13 Agency CNA and S14 Agency CNA), to work in the Facility. This practice had the potential to affect all Residents in the Facility. Findings:
Review of the Facility's sampled personnel records revealed there were no personnel records for S13 Agency CNA and S14 Agency CNA.
Interview on 03/01/2023 at 2:42 p.m. with S18 Neighborhood Coordinator confirmed the Facility had no personnel records for S13 Agency CNA and S14 Agency CNA.
Interview on 03/01/2023 at 4:18 p.m. with S1 ADM revealed the Facility had not developed a written policy concerning the completion of criminal history background checks for unlicensed Agency staff. S1 ADM confirmed the Facility had no personnel records for S13 Agency CNA and S14 Agency CNA. S1 ADM stated according to the contract between the Facility and the Agency, the Agency maintains records on all contracted CNAs.
During the exit conference on 03/01/2023 at approximately 4:45 p.m., S1 ADM presented copies of S13 Agency CNA and S14 Agency CNA's criminal background check and CNA Registry. S1 ADM confirmed she obtained these documents from the Staffing Agency prior to entering the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide 3 (Resident #32, Resident #33 and Resident #45) of 4 (Resident #25, Resident #32, Resident #33 and Resident #45) sampled Residents wi...
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Based on observation and interview, the facility failed to provide 3 (Resident #32, Resident #33 and Resident #45) of 4 (Resident #25, Resident #32, Resident #33 and Resident #45) sampled Residents with food served at an appetizing and satisfying temperature. Findings:
Review of Resident Council meeting minutes dated June 2022 and July 2022 revealed documented concerns of cold food.
Interview on 02/27/2023 at 1:30 p.m. with S1 ADM confirmed Residents have voiced concerns in Resident Council meetings about cold food temperatures.
Review of the Facility's Assistance with Meals Policy revised March 2022 revealed in part for all residents .
Hot foods shall be held at a temperature of 135 degrees or above until served. Nursing and dietary services will establish procedures such that delivery of food to serving areas accommodates this requirement.
Resident # 32
Review of Resident #32's Medical Record revealed Resident #32 was admitted to facility on 03/24/2022 with an admitting diagnosis of Type 2 Diabetes Mellitus.
Review of Resident #32's Quarterly MDS Assessment with an ARD date of 02/15/2023 revealed Resident #32 had a BIMS score of 15 (cognitively intact) and is independent and required setup help only for eating.
Review of Resident #32's February 2023 Physician Orders revealed an order for a Regular Diet.
Interview with Resident #32 on 02/27/2023 at 2:05 p.m. revealed she consumes her meals in her room always. Resident #32 stated the temperature of the food is always cold, and this dissatisfies her, as she would like her food to be served at a warm temperature.
Interview with Resident #32 on 02/28/2023 at 8:27 a.m. revealed Resident was dissatisfied with her breakfast this morning. Resident #32 stated that her eggs and pancakes were served ice cold.
Observation on 02/28/2023 at 11:18 a.m. revealed staff began serving Residents on Hall A, and at 11:34 a.m. the last Resident on Hall A was served. Temperature check of test tray was performed at 11:34 a.m. Test tray consisted of rice, gravy, beef meat, a cold green salad, and bread roll. Temperature check of the rice, gravy, and beef meat revealed a temperature of 110 degrees Fahrenheit. The temperature of the green salad was 68 degrees Fahrenheit. Resident #45
Interview with Resident #45 on 02/27/2023 at 03:18 p.m. revealed that she eats most meals in her room, and stated that the food served is cold 50 percent of the time. Resident #45 stated that she often asked staff to bring her food tray to the microwave to reheat.
Observation on 02/28/2023 at 11:27 a.m. revealed staff began serving Residents on Hall C at 11:28 a.m. leaving the door open to cart while serving trays. The last Resident on Hall C was served at 11:39 a.m. Temperature check of test tray was performed at 11:39 a.m. Test tray consisted of rice, gravy, beef meat, a cold green salad, and bread roll. Temperature check of the rice, gravy, and meat revealed a temperature of 120 degrees Fahrenheit and 58 degrees Fahrenheit for the salad.
Resident #33
Review of Resident #33's medical record revealed an admission date of 02/16/2022 with diagnoses that included in part . Essential Primary Hypertension, Type 2 DM with Hyperglycemia, Overactive Bladder, GERD, Iron Deficiency Anemia, Idiopathic Gout and Ischemic Cardiomyopathy.
Review of Resident #33's Physician's orders dated 02/16/2022 revealed an order for Regular diet, regular texture, and regular thin liquids consistency.
Review of Resident #33's Quarterly MDS with an ARD 12/14/2022 revealed a BIMS score of 15 which indicated intact cognition. Resident #33 was independent and required setup help only for eating.
Observation on 02/27/2023 from 11:35 a.m. to 12:10 p.m. revealed the door to the insulated food cart served on Hall B was left open throughout the duration that S15 CNA and S16 CNA removed lunch trays from the food cart and delivered to resident's rooms.
Observation on 02/27/2023 at 11:40 a.m. revealed Resident #33 awake lying in bed with head of bed elevated eating lunch. Resident #33 stated her lunch was cold.
Observation on 02/27/2023 at 12:10 p.m. on Hall B revealed the insulated food cart door remained opened as S15 CNA and S16 CNA served lunch trays to resident's room on Hall B.
Observation on 02/28/2023 at 12:25 p.m. on Hall B revealed the door to the insulated food cart remained open throughout duration of S15 CNA and S16 CNA serving lunch trays down Hall B.
Temperature testing of the test tray on the Hall B lunch cart on 02/28/2023 at 12:26 p.m. with S5 DM revealed the following. The meal consisted of beef stew, rice, gravy, and dinner roll. The temperature of the beef stew, rice and gravy was 132 degrees Fahrenheit. Interview at this time with S5 DM confirmed the temperature should have been 135 degrees Fahrenheit and was not.
Interview with S5 DM on 02/28/2023 at 12:26 p.m. verified the temperature was 110 degrees Fahrenheit for the lunch test tray for Hall A, and the temperature was 120 degrees Fahrenheit for the lunch test tray for the Hall C. S5 DM confirmed the temperature of the lunch trays should have been 135 degrees Fahrenheit or above and was not.
Interview on 02/28/2023 at 4:26 p.m. with S1 ADM clarified the temperature of the meals for all of the Residents should be above 135 degrees Fahrenheit served to Residents in the dining areas and/or in the Resident's rooms.
Interview on 03/01/2023 at 8:32 a.m. with S5 DM verified the Facility's Assistance with Meals Policy stated the temperatures of all meals are to be 135 degrees Fahrenheit or above when meals are served to all Residents. S5 DM confirmed the temperature checks on 02/28/2023 for Hall A, Hall B, and Hall C lunch test food trays were out of range and should not have been.
Observation on 03/01/2023 at 11:25 a.m. revealed S9 CNA removed a food tray from the insulated food cart on Hall A in the Facility. S9 CNA left the door to the cart open while she was taking a tray to a Resident's room down the hall.
Interview on 03/01/2023 at 11:28 a.m. with S9 CNA confirmed she left the door to the insulated food cart open while delivering a food tray to a Resident's room. S9 CNA stated there were more trays on the cart to be delivered, and stated she should not have left the door open.
Observation on 03/01/2023 at 11:39 a.m. on Hall C revealed the door to the insulated food cart was open on Hall C. There was no staff visible on the hall. At 11:41 a.m. S7 CNA came out of a Resident's room and obtained a carton of milk from the milk tray. The door to the food cart was left open. At 11:45 a.m. S7 CNA and S8 CNA approached the food cart. Interview at this time with S7 CNA and S8 CNA confirmed the door to the food cart was left open while they were delivering trays to Residents. S7 CNA revealed they always left the door to the food cart open because it made passing the food trays quicker.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the Facility failed to serve food in accordance with professional standards for food service safety for 16 of 16 random Residents dining in the front dining room of ...
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Based on observation and interview the Facility failed to serve food in accordance with professional standards for food service safety for 16 of 16 random Residents dining in the front dining room of the Facility. Findings:
Observation on 02/27/2023 at 10:57 a.m. in the Facility's front dining room revealed 2 Staff members passing lunch trays to Residents seated at dining tables. The observation revealed that the 2 staff members did not use hand sanitizer or wash their hands in between passing food trays to different Residents. There were 16 Residents in the dining room who were served by 2 Staff members who failed to use hand sanitizer or wash their hands.
Observation on 02/28/2023 at 11:05 a.m. in the Facility's front dining room revealed S5 DM and S6 Dietary passing trays to Residents seated at dining tables. S5 DM and S6 Dietary did not sanitize or wash their hands in between Residents when passing out food trays.
Review of the Facility's Handwashing/Hand Hygiene Policy revealed in part Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: p. Before and after assisting a resident with meals;
Interview on 02/28/2023 at 11:07 a.m. with S2 DON confirmed S5 DM and S6 Dietary did not sanitize or wash their hands in between Residents when passing their food trays and they should be.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $44,606 in fines. Review inspection reports carefully.
- • 34 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $44,606 in fines. Higher than 94% of Louisiana facilities, suggesting repeated compliance issues.
- • Grade F (23/100). Below average facility with significant concerns.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Oak Haven Rehabilitation And Healthcare Center's CMS Rating?
CMS assigns OAK HAVEN REHABILITATION AND HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Oak Haven Rehabilitation And Healthcare Center Staffed?
CMS rates OAK HAVEN REHABILITATION AND HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 61%, which is 15 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 64%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Oak Haven Rehabilitation And Healthcare Center?
State health inspectors documented 34 deficiencies at OAK HAVEN REHABILITATION AND HEALTHCARE CENTER during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 32 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Oak Haven Rehabilitation And Healthcare Center?
OAK HAVEN REHABILITATION AND HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VENZA CARE MANAGEMENT, a chain that manages multiple nursing homes. With 104 certified beds and approximately 93 residents (about 89% occupancy), it is a mid-sized facility located in CENTER POINT, Louisiana.
How Does Oak Haven Rehabilitation And Healthcare Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, OAK HAVEN REHABILITATION AND HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 2.4, staff turnover (61%) 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 Oak Haven Rehabilitation And Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Oak Haven Rehabilitation And Healthcare Center Safe?
Based on CMS inspection data, OAK HAVEN REHABILITATION AND HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Oak Haven Rehabilitation And Healthcare Center Stick Around?
Staff turnover at OAK HAVEN REHABILITATION AND HEALTHCARE CENTER is high. At 61%, the facility is 15 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 64%. 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 Oak Haven Rehabilitation And Healthcare Center Ever Fined?
OAK HAVEN REHABILITATION AND HEALTHCARE CENTER has been fined $44,606 across 3 penalty actions. The Louisiana average is $33,525. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Oak Haven Rehabilitation And Healthcare Center on Any Federal Watch List?
OAK HAVEN REHABILITATION AND HEALTHCARE CENTER 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.