Does Colfax Nursing and Rehab, LLC have any serious inspection findings?

Yes, Colfax Nursing and Rehab, LLC has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 48 total deficiencies from recent inspections.

What are the staffing levels at Colfax Nursing and Rehab, LLC?

Colfax Nursing and Rehab, LLC has a one-star staffing rating from CMS with 0.20 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Colfax Nursing and Rehab, LLC located?

Colfax Nursing and Rehab, LLC is located in COLFAX, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Colfax Nursing and Rehab, LLC have?

Colfax Nursing and Rehab, LLC has 140 certified beds.

Who owns Colfax Nursing and Rehab, LLC?

Colfax Nursing and Rehab, LLC is a for profit - limited liability company facility and operates independently (not part of a chain).

How does Colfax Nursing and Rehab, LLC compare to other nursing homes?

Colfax Nursing and Rehab, LLC has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

Colfax Nursing and Rehab, LLC

Q: What is Colfax Nursing and Rehab, LLC's CMS rating?

Colfax Nursing and Rehab, LLC has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Do nurses at Colfax Nursing and Rehab, LLC stick around?

Colfax Nursing and Rehab, LLC has average staff turnover at 54%, which is typical for the nursing home industry.

Q: Was Colfax Nursing and Rehab, LLC ever fined?

Yes, Colfax Nursing and Rehab, LLC has been fined $99,730 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is Colfax Nursing and Rehab, LLC on any federal watch list?

No, Colfax Nursing and Rehab, LLC is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

366 WEBB SMITH DRIVE, COLFAX, LA 71417 · (318) 627-3207

For profit - Limited Liability company 140 Beds Independent Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#192 of 264 in LA

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Last Inspection: August 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Colfax Nursing and Rehab, LLC has received a Trust Grade of F, indicating significant concerns and a poor overall rating. It ranks #192 out of 264 nursing homes in Louisiana, placing it in the bottom half, although it is the top facility in Grant County. The facility is showing signs of improvement, with the number of issues decreasing from 17 in 2024 to 16 in 2025. However, the staffing rating is only 1 out of 5 stars, and turnover stands at 54%, which is average for Louisiana. Additionally, the facility has faced concerning fines totaling $99,730, higher than 78% of Louisiana facilities, suggesting ongoing compliance issues. Recent inspection findings revealed serious shortcomings, including a failure to consult with a resident's physician when their condition worsened, which created an immediate jeopardy situation. This resident experienced increased pain and a decline in their ability to perform daily activities but did not receive timely medical attention. The facility also did not provide adequate pain management for this resident, which led to further suffering and a decline in their well-being. While Colfax Nursing and Rehab has some strengths, such as being the only option in its county, the significant weaknesses highlighted in recent inspections raise important concerns for families considering this facility.

Trust Score: F
In Louisiana: #192/264
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $99,730 in fines. Lower than most Louisiana facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 11 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 17 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

1-Star Overall Rating

Below Louisiana average (2.4)

Significant quality concerns identified by CMS

Staff Turnover: 54%

Near Louisiana avg (46%)

Higher turnover may affect care consistency

Federal Fines: $99,730

Well above median ($33,413)

Moderate penalties - review what triggered them

The Ugly 48 deficiencies on record

3 life-threatening

Aug 2025 13 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observations and interviews, the facility failed to treat each resident with respect, dignity and care in a manner that promotes maintenance of his or her quality of life by failing to ensure residents sitting at dining room table were served together at the same time during mealtime. This deficient practice had the potential to affect all Residents that used the facility's dining room during mealtime. Findings: Review of the facility's policy on 08/26/2025 at 11:26 a.m., titled Dignity, revealed the following in part.Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 5. When assisting with care, Residents are supported in exercising their rights. For example, Residents are: e. provided with a dignified dining experience. Observation on 08/26/2025 at 11:53 a.m. revealed 4 residents sitting at a dining room table together. At this time 1 of the Residents seated at this table were served their meal tray. Further observation revealed staff members delivering meal trays to other Residents seated at different tables. Each table in the dining room seated 2 to 4 people, all Residents seated together at the same table were not served their meals at the same time. At 12:08 p.m., the 3 remaining Residents seated were served their meal. Interview on 08/26/2025 at 2:00 p.m., S3 Dietary Manager stated that all Residents seated in the dining room during meal service should be served their meals together when seated at the same table. S3 Dietary Manager acknowledged that Residents seated at the same table were not served their meals at the same time but 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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a resident received a reasonable accommodation of their needs by failing to ensure the call light was accessible to a resident for 1 (Resident #32) of 43 sampled residents.Review of the facility policy titled, Call System, Residents, dated September 2022, revealed in part. Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities, and from the floor.Review of Resident #32's demographic record revealed an admission date of 12/02/2021 with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Unspecified Combined Systolic (Congestive) and Diastolic Heart Failure, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance and Psychotic Disturbance, Epilepsy, and Schizophrenia.Review of Resident #32's MDS, with an ARD of 08/13/2025, revealed Resident #32 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #32 required substantial/maximal assistance for toileting, bathing, and personal hygiene. Resident #32 required partial/moderate assistance for all transfers.Review of Resident #32's Care Plan initiated 06/17/2024, revealed the resident had history of falls, with 7 documented falls in August 2025. Interventions included in part. Encourage the resident to call for assistance. Keep the call bed in reach when in the room. The resident had an ADL self-care performance deficit related to Confusion, Dementia, Impaired Balance, Limited Mobility, and Shortness of Breath. Interventions included in part. Encourage the resident to use the call bell to call for assistance. On 08/25/2025 at 9:43 a.m., observation revealed Resident #32 was lying in bed awake and alert. Call light was observed on the floor under a piece of furniture. The call light was not accessible to Resident #32.On 08/26/2025 at 12:12 p.m., observation revealed Resident #32 was lying in bed awake. Resident #32's call light was observed on the floor. The call light was not accessible to Resident #32. On 08/26/2025 at 2:46 p.m., observation revealed Resident #32 was sleeping in bed. Resident #32's call light was observed on the floor. The call light was not accessible to Resident #32.On 08/27/2025 at 9:01 a.m., observation revealed Resident #32 was sitting up in bed awake and alert. Resident #32's call light was observed on the floor. The call light was not accessible to Resident #32.On 08/27/2025 at 9:03 a.m., surveyor summoned S16 LPN to Resident #32's bedside. S11 LPN confirmed Resident #32's call light was on the floor. S16 LPN confirmed the call light was not accessible to Resident #32 and should have been.

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

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Based on interview and record review, the facility failed to ensure a physician's order was implemented as required in the person centered plan of care for 1 (Resident #64) of 43 sampled residents.Findings: Review of the facility's 03/2022 policy titled Care Plans, Comprehensive Person-Centered read in part.Policy statement: A Comprehensive, person centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of Resident #64's medical record revealed an admit date of 05/01/2025 with diagnoses that included: Bipolar Disorder, Schizophrenia, Unspecified Dementia, Catatonic Disorder due to known Physiological Condition, Idiopathic Peripheral Autonomic Neuropathy, and Extrapyramidal Movement Disorder. Review of Resident #64's Quarterly MDS with an ARD of 07/30/2025 revealed a BIMS score of 10, indicating moderately intact cognition. Review of Resident #64's Physician orders read in part.05/01/2025- Full Code status Review of Resident #64's Care Plan with a review date of 10/31/2025 revealed no Code status information on the care plan. An interview on 08/26/2025 at 10:38 a.m., with S8 Corporate RN confirmed that Resident #64 does not have a code status care planned, but should had.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to ensure all care and services were provided according to accepted professional standards of clinical practice. The facility failed to ensure proper physician orders were obtained for Resident #30's oxygen therapy requirements. Total sample size was 43 residents. Findings:Review of a facility policy on 08/27/2025 at 10:41 a.m. titled, Oxygen Administration with a revision date of 10/2010 revealed the following in part.Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Equipment and Supplies: 2. Nasal cannula, nasal catheter, mask (as ordered). Review of Resident #30's medical record revealed an admission date of 03/04/2025, with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Heart Failure, and Essential (Primary) Hypertension. Review of Resident #30's Quarterly MDS with an ARD of 06/04/2025 revealed a BIMS score of 4, which indicated severe cognitive impairment. Resident #30 was independent with bed mobility and personal hygiene and required supervision assistance with oral and toileting hygiene. Review of Resident #30's current 08/2025 physician orders revealed no orders for oxygen therapy. Review of Resident #30's completed and discontinued physician's orders revealed no orders for oxygen therapy. Review of Resident #30's medical record revealed a nursing progress note that read in part.08/23/2025 at 5:21 a.m. - Resident reports to be feeling better. O2 sat 94% on 2L/NC. In an interview on 08/25/2025 at 11:52 a.m., Resident #30 revealed he uses oxygen every night. In an interview on 08/26/2025 at 11:54 a.m., S9 CNA revealed she is familiar with Resident #30's care. S9 CNA stated that Resident #30 uses oxygen daily such as when he takes a nap, comes back from smoking, and at night. S9 CNA stated the nurse helps him apply the oxygen when he needs. In an interview on 08/26/2025 at 12:43 p.m., S10 LPN revealed she is familiar with Resident #30's care. S10 LPN confirmed that Resident #30 uses oxygen PRN when he has shortness of breath such as while in bed or after smoking. S10 LPN confirmed that she will apply the oxygen to the resident when he needs. In an observation on 08/26/2025 at 1:49 p.m. revealed Resident #30 in bed, asleep with oxygen therapy in progress via concentrator set at 2 liters via nasal cannula. In an interview on 08/27/2025 at 9:18 a.m., Resident #30 confirmed he used oxygen therapies while sleeping last night (08/26/2025). In an interview on 08/27/2025 at 9:22 a.m., S2 DON revealed all residents have standing physician orders for oxygen therapies and once any resident is administered oxygen (continuous or PRN) a physician's order would be obtained and put into the medical record. In an interview and record review on 08/27/2025 at 9:33 a.m., S2 DON confirmed that Resident #30 did not have any current physician's orders for oxygen therapy (continuous or PRN). S2 DON stated Resident #30 returned from a hospital stay on 08/08/2025 and was using oxygen therapies since this date. S2 DON confirmed that Resident #30's oxygen orders should had been obtained and transcribed into the medical record, but were not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents while smoking for 1 (#34) of 1 Residents reviewed for smoking in a total sample of 43 Residents. Findings: Review of the Facility's undated policy titled Smoking Policy read in part.For safety reasons, this policy is in place to ensure increased safety and decreased fire and burn risk for our residents. The facility provides appropriate ashtrays and supervision. Protective items such as burn aprons, extenders, or smoking gloves may be utilized if deemed necessary to prevent burns. Review of Resident #34's medical record revealed an admit date of 10/28/2015 with a readmission on [DATE] with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-dominant Side, Squamous Cell Carcinoma of Skin, Chronic Pain Syndrome, Alzheimer's Disease with Early Onset, Chronic Kidney Disease, Acute Chronic Diastolic Disease, Stage 3, Major Depressive Disorder, and Recurrent Sever without Psychotic Features. Review of Resident #34's Smoking assessment dated [DATE] read in part.Supervision will be required for all residents during designated smoking times. This evaluation will be utilized for the Resident's smoking care plan on admission and as indicated.Does resident have any of the following- Poor Vision or blindness- Yes. Review of Resident #34's Care plan with a review date of 10/23/2025 revealed in part.Tobacco use- Resident will adhere to tobacco/smoking policy. Interventions: Conduct smoking safety evaluation on admission and as needed. The Resident requires supervision while smoking. An observation on 08/25/2025 at 9:46 a.m. revealed Resident #34 sitting up in wheelchair with 5 burn holes observed to the raised centered ridge of the pommel cushion. An observation on 08/25/2025 at 11:35 a.m. revealed Resident #34 sitting in dining area in wheelchair. Pommel cushion continues with burn holes in center ridge of cushion. Resident #34 is observed with ashes to pant legs near center ridge of pommel cushion. An interview on 08/27/2025 at 9:30 a.m. with S17 CNA stated that if staff do not pull Resident #34's wheelchair under the table close to the ashtray she will drop ashes on herself. An interview on 08/27/2025 at 9:35 a.m. with S1 Administrator stated the holes in Resident #34 wheelchair cushion appears to be from cigarette burns. An interview on 08/27/2025 at 9:43 a.m. with S8 Corporate RN, stated that she is responsible for the smoking assessments and completed Resident #34's last assessment in 07/2025. S8 Corporate RN stated that when she observed Resident #34 during the smoking assessment, she had no issues. S8 Corporate RN observed the holes in the pommel cushion at this time and stated that she could not confirm that the holes were from smoking or not. S8 Corporate RN stated she is not aware of anyone notifying her or S2 DON that Resident #34 had any issues with putting out her cigarettes of dropping ashes on herself.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure respiratory equipment was stored properly for 1 (Resident #30) of 1 residents reviewed for respiratory care. The total sample size was 43 residents.Findings:The facility could not provide an oxygen storage policy. Review of Resident #30's medical record revealed an admission date of 03/04/2025, with diagnoses that included in part. Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Heart Failure, and Essential (Primary) Hypertension. Review of Resident #30's Quarterly MDS with an ARD of 06/04/2025 revealed a BIMS score of 4, which indicated severe cognitive impairment. Resident #30 was independent with bed mobility and personal hygiene and required supervision assistance with oral and toileting hygiene. Review of Resident #30's medical record revealed no documentation in the current plan of care regarding refusal of oxygen storage or equipment. Review of Resident #30's medical record revealed a nursing progress note that read in part.08/23/2025 at 5:21 a.m. - Resident reports to be feeling better. O2 sat 94% on 2L/NC. Observation on 08/25/2025 at 10:07 a.m. of Resident #30's oxygen concentrator revealed oxygen tubing draped over the oxygen concentrator. No storage bag observed. In an interview on 08/25/2025 at 11:52 a.m., Resident #30 revealed he uses oxygen therapies every night and the nurse helps him apply it. Observation on 08/26/2025 at 10:27 a.m. of Resident #30's oxygen concentrator revealed the oxygen tubing and nasal cannula placed directly on the floor. No storage bag observed. In an interview on 08/26/2025 at 11:54 a.m., S9 CNA revealed she is familiar with Resident #30's care. S9 CNA stated that Resident #30 uses oxygen daily such as when he takes a nap, comes back from smoking, and at night. S9 CNA stated the nurse helps him apply and take off the oxygen when he needs. In an interview on 08/26/2025 at 12:43 p.m., S10 LPN revealed she is familiar with Resident #30's care. S10 LPN confirmed that Resident #30 uses oxygen PRN when he has shortness of breath such as while in bed or after smoking. S10 LPN confirmed that she will apply and take off the oxygen when he needs. In an interview on 08/27/2025 at 9:18 a.m., Resident #30 revealed he used oxygen therapies while sleeping last night (08/26/2025). Observed the resident's oxygen tubing and nasal cannula draped over the oxygen concentrator. No storage bag observed.In an interview on 08/27/2025 at 9:22 a.m., S2 DON revealed the nurses are aware that all resident oxygen equipment such as tubing and nasal cannula should be stored in a Ziploc bag when not in use. In an interview on 08/27/2025 at 9:25 a.m., S2 DON accompanied this surveyor to Resident #30's room. S2 DON confirmed the oxygen tubing/nasal cannula was placed hanging and draped over the oxygen concentrator when not in use. S2 DON confirmed Resident #30's oxygen tubing and nasal cannula was not stored appropriately due to not being stored in an Ziploc bag when not in use, but should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administration of medications to meet the needs of each resident for 1 (Hall X) of 2 (Hall X and Hall Z) medication carts reviewed for narcotic reconciliation. Findings:A review of the facility's policy dated 11/2022, titled Controlled Substances, read in part.1) Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2) The system of reconciling the receipt, dispensing, and deposition of controlled substances includes the following:a) Records of personal access and usage;b) Medication administration records;c) Declining inventory records; andd) Destruction, waste, and return to pharmacy records.Review of Resident #80's 08/2025 Physician Orders read in part:- Lorazepam Oral Tablet 2 MG (milligrams), Give 2 mg by mouth every 6 hours as needed for anxiety related to Generalized Anxiety Disorder (with an order date of 08/18/2025)- Lacosamide Oral Tablet 100 MG, Give 1 tablet by mouth two times a day related to Other Seizures (with an order of 08/19/2025)An observation on 08/27/2025 at 11:08 a.m. of Hall X medications cart with S18 LPN revealed the medication blister pack with Resident #80's Lorazepam 2 mg tablets with a count of 18 tablets remaining and a blister pack for Resident #80's Lacosamide 100mg with 50 tablets remaining. Review of Resident #80' narcotic record log for Lorazepam 2mg revealed a total count of 19 tablets remaining, with the last date given notated as 08/19/2025 at 11:44 p.m. Review of Resident #80's Lacosamide 100mg narcotic log revealed a total count of 49 tablets remaining, with the last date given notated as 08/27/2025 at 8:30 a.m.An interview on 08/27/2025 at 11:10 a.m. with S18 LPN confirmed that Resident #80's narcotic log was not completed correctly. S18 LPN stated she gave Resident #80 the PRN Lorazepam 2 MG on 08/27/2025 at 8:30 a.m., but failed to log the administration of the medication on the narcotic log sheet. S18 LPN confirmed that, on accident, she documented that she had given Resident #80's Lacosamide 100 mg on the narcotic log sheet on 08/27/2025 at 8:30 a.m., but the medication had not been given.An interview on 08/27/2025 at 11:12 a.m. with S2 DON confirmed there were 50 tablets of Lacosamide 100 mg remaining in the blister pack and that S18 LPN marked that she had given Resident #80 the medication, but had not. S2 DON confirmed that S18 LPN failed to update the narcotic log for Resident #80's Lorazepam 2 mg, but should have.

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 F0605 (Tag F0605)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a gradual dose reduction for 4 (#5, #7, #12, #38) of 5 (#5, #7, #8, #12, and #38) residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction. Findings:Resident #5 Review of Resident #5’s clinical record revealed an admission date of 11/21/2022 with a readmission date of 10/21/2024 with diagnoses that included in part., Cerebral Infarction; Bipolar Disorder, current episode manic without Psychotic features, Mild; Unspecified Dementia, without Behavioral disturbance, Psychotic disturbance, Mood disturbance, and Anxiety. Review of Resident #5’s Quarterly MDS with an ARD of 07/30/2025 revealed a BIMS score of 10, indicating moderately impaired cognition. Resident #5 received an antipsychotic and antidepressant medication. Review of Resident #5’s 08/2025 physician’s orders revealed the following: -Brexpiprazole Oral Tablet-give 1mg (milligram) by mouth at bedtime related to Bipolar Disorder (order date of 10/21/2024) -Sertraline HCl (Hydrochloride) Oral Tablet 100mg-give 1 tablet by mouth one time a day related to Bipolar Disorder, give with Sertraline 50mg to equal 150mg every day (order date of 01/07/2025) -Sertraline HCl Oral Tablet 50mg-give 1 tablet by mouth one time a day related to Bipolar Disorder, give with Sertraline 100mg to equal 150mg every day (order date of 01/07/2025) -Divalproex Sodium Oral Tablet Delayed Release give 750mg by mouth two times a day related to Bipolar Disorder (order date 01/06/2025) Review of the Pharmaceutical Consultant Report that was signed and undated by S11 NP (Nurse Practitioner), the pharmacy consultant requested a gradual dose reduction for the following medications: Brexpiprazole Oral Tablet-give 1mg at bedtime, Divalproex Sodium Oral Tablet Delayed Release-give 750mg by mouth two times a day, Sertraline HCl Oral Tablet 100mg-give 1 tablet by mouth one time a day, and Sertraline HCl Oral Tablet 50mg-give 1 tablet by mouth one time a day. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a hand written valid clinical rationale as to why the reduction is not desired at this time. S11 NP documented “NO” for if a dose reduction is appropriate. S11 NP failed to provide a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated. Resident #38 Review of Resident #38’s clinical record revealed an admission date of 01/08/2024, with an initial admission date of 05/23/2022, and diagnoses that included, in part, Alzheimer’s Disease, Bipolar Disorder, unspecified, Major Depressive Disorder, recurrent, and Anxiety Disorder, unspecified. Review of Resident #38’s Quarterly MDS with an ARD of 08/20/2025 revealed that a BIMS was not completed because the resident was rarely understood. Resident #38 received an antipsychotic, an antianxiety, and an antidepressant medication. Review of Resident #38’s 08/2025 physician’s orders revealed the following: - Ativan Oral Tablet- Give 1 MG (milligram) by mouth four times a day for anxiety (order date of 04/27/2025) - Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG (milligram), Give 2 capsule orally two times a day related to Bipolar disorder, unspecified (order date 06/03/2024) - Quetiapine Fumarate Tablet 25 MG (milligram), Give 1 tablet by mouth two times a day related to Bipolar disorder, unspecified (order date 04/24/2025) Review of the Pharmaceutical Consultant Report dated 07/29/2025, that was signed with an undated signature by S11 NP (Nurse Practitioner), the pharmacy consultant requested a gradual dose reduction for the following medications: 1) Ativan Oral Tablet 1 MG (milligram) (Lorazepam) Give 1 mg by mouth four times a day; 2) Divalproex Sodium Capsule Delayed Release Sprinkle 125 MG Give 2 capsule orally two times a day; 3) Quetiapine Fumarate Tablet 25 MG Give 1 tablet by mouth two times a day. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a handwritten, valid clinical rationale as to why the reduction is not desired at this time. S11 NP documented “NO” for whether a dose reduction is appropriate, but did not indicate if the resident is receiving the minimal effective dose. S11 NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. Resident #7 Review of Resident #7’s clinical record revealed an admission date of 09/02/2021, and diagnoses that included, in part, Type 2 Diabetes Mellitus without complications, Unspecified Dementia, unspecified severity, with Anxiety, Chronic Obstructive Pulmonary Disease, unspecified, and Schizoaffective disorder, unspecified. Review of Resident #7’s Quarterly MDS with an ARD of 07/30/2025 revealed a BIMS score of 3, indicating severe cognitive impairment. Resident #7 received an antipsychotic and an antidepressant medication. Review of Resident #38’s 08/2025 physician’s orders revealed the following: - Haloperidol Decanoate IM (Intramuscular) Solution 50 MG (milligrams)/ML (milliliter), Inject 1 ml intramuscularly one time a day every 2 weeks on Wednesday related to Schizoaffective disorder, unspecified (order date of 6/06/2024) - Zoloft Oral Tablet 100 MG (milligrams) (Sertraline HCl), Give 1 tablet by mouth one time a day related to Schizoaffective Disorder (order date of 6/03/2025) Review of the Pharmaceutical Consultant Report dated 07/29/2025, that was signed with an undated signature by S11 NP revealed the pharmacy consultant requested a gradual dose reduction for the following medications: 1) Haloperidol Decanoate IM (Intramuscular) Solution 50 MG (milligrams)/ML (milliliter), Inject 1 ml intramuscularly one time a day every 2 weeks; 2) Zoloft Oral Tablet 100 MG (Sertraline HCl), Give 1 tablet by mouth one time a day. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a handwritten, valid clinical rationale as to why the reduction is not desired at this time. S11 NP did not document whether a dose reduction was appropriate or if the resident was receiving the minimal effective dose. S11 NP also failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. Resident #12 On 08/27/2025, a review of the facility’s policy titled “Tapering Medications and Gradual Dose Reduction” last revised on 07/2022 revealed in part…13. For any individual who is receiving a psychotropic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, schizophrenia, bipolar mania, or depression with psychotic features), the GDR may be considered contraindicated, if: a. the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or b. the resident’s target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. Review of Resident #12’s medical record revealed an admit date of 12/12/2024 with diagnoses that included in part .Psychotic Disturbance, Mood Disturbance, and Anxiety; Schizoaffective Disorder, Depressive Type; and Depression. Review of Resident #12’s Quarterly MDS with an ARD date of 08/13/2025 revealed a BIMS score of 12, indicating moderately impaired cognition. Resident #12 received antianxiety, antidepressant, and antipsychotic medications. Review of Resident #12’s August 2025 physician’s order revealed the following:12/31/2024-Zoloft 100 MG give 2 tablets for depression once a day; 03/13/2025-Buspirone Hydrochloride Tablet 5 MG .1 tab twice a day related to Depression, Unspecified; 07/01/2025-Haloperidol Tab 5 MG…1 tablet one time a day related to Schizoaffective disorder, unspecified; 12/15/2024-Haloperidol Decanoate Intramuscular Solution 50mg/ml.inject 50mg intramuscularly one time a day starting on the 15th and ending on the 15th every month related to Schizoaffective Disorder, Depressive Type. Review of the Pharmaceutical Consultant Report dated 07/29/2025 revealed the pharmacy consultant requested a gradual dose reduction for Buspirone Hydrochloride 5mg, Haloperidol Decanoate Intramuscular Solution 50mg/ml, Haloperidol tablet 5mg, and Zoloft tablet 100mg (2 tablets). The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a handwritten valid clinical rationale as to why the reduction is not desired at this time. S11 NP documented “No” for if a dose reduction was appropriate and signed her name but did not date it. S11 NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. On 08/27/2025 at 8:32 a.m., S2 DON confirmed that 07/2025 GDRs were not completed by the medical provider but should have been.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to ensure nurse staffing data requirements were completed and posted appropriately. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings:Observation on 08/25/2025 at 2:06 p.m. of the facility entrance revealed no display of the daily nurse staffing data. Observation on 08/26/2025 at 10:50 a.m. revealed no display of the daily nurse staffing data throughout the entire facility. In an interview on 08/26/2025 at 10:52 a.m., S7 Corporate revealed that the previous ADON was responsible for completion of the daily nurse staffing data form. S7 Corporate stated that since the ADON was no longer employed at the facility he was unaware of who was responsible for completion of the task currently. In an interview on 08/26/2025 at 10:55 a.m., S7 Corporate confirmed the daily nurse staffing data form was not completed and displayed appropriately. S7 Corporate stated, It's not posted, so it is not done. S7 Corporate revealed the previous ADON's last day of employment was 06/06/2025 and was unable to verify or provide evidence that the daily nurse staffing data had been completed since this date. S7 Corporate confirmed that the Administrator and/or DON were responsible for overseeing that the daily nurse staffing data was completed and posted, but did not.

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 F0807 (Tag F0807)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to provide drinks, including water, consistent with resident needs and preferences. The facility failed to ensure staff, in the dining room, provided water to 32 residents with their meal during lunchtime. Findings:Interview on 08/26/20025 at 11:36 a.m. with Resident #1 revealed that he eats most meals in the dining room. Resident#1 stated that water is never served with the trays unless it is asked for. Observation on 08/26/2025 at 12:10 p.m. revealed staff serving resident lunch trays in the dining room with only tea observed on the lunch tray. A resident in the dining area was heard hollering out for water, instead of the tea that was served. Interview on 08/25/2025 at 12:22 a.m. with S2 DON stated that residents are only served water with meals if they ask for it. S2 DON stated that residents are usually only given tea or the choice of beverage. Interview on 08/26/2025 at 1:00 p.m. S1 Administrator stated that the facility does not serve water on meal trays unless the resident specifically asks for it.

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 74 residents who resided in the facility. The facility failed to ensure:1. Kitchen staff did not handle food with dirty gloves during food preparation; and 2. Kitchen staff wore beard restraints to prevent hair from contacting food.Findings::On 08/26/2025, a review of the facility's undated policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revealed in part.Employees must wash their hands:.after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and/or after engaging in other activities that contaminate the hands. Further review of the policy revealed.Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.On 08/25/2025 at 11:10 a.m., an observation was made in the kitchen of S5 Dishwasher rolling silverware in napkins. S5Dishwasher was noted to have a beard, which was not covered with a beard restraint. On 08/25/2025 at 11:18 a.m., S4 [NAME] was observed preparing the puree meals. S4 [NAME] was noted to have a beard which was not covered with a beard restraint. S4 [NAME] was then observed as he donned gloves, grabbed the garbage can by the handle and pulled it to the puree table area. S4 [NAME] then picked up the cooked chicken thighs and began to debone them to put in the blender wearing the same gloves. In an interview at that time, S4 [NAME] confirmed he had just moved the garbage can and then handled the chicken with the same gloves. On 08/25/2025 at 11:23 a.m., S3 Dietary Manager confirmed the above two kitchen employees were not wearing beard restraints because the facility did not have any on hand, but should have been. S3 Dietary Manager acknowledged S4 [NAME] had just touched the garbage can and then handled the chicken with the same, contaminated gloves, but should not have.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of infectious communicable diseases. The facility failed to ensure the following:1. Staff adhere to Enhanced Barrier Precautions (EBP) for Resident #4. 2. Staff follow the chemical manufacturer's dwell-time guidelines for proper sanitation.The total sample size was 43 residents.Review of the facility's undated policy titled, Enhanced Barrier Precautions revealed in part. Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multidrug-resistant organisms (MDRO's) to residents. EBPs employ targeted gown and glove use during high-contact care activities. Examples of high-contact resident care activities requiring the use of a gown and gloves for EBPs include, in part, changing briefs, providing hygiene, and wound care. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Staff are trained prior to caring for residents on EBPs.Review of a facility policy titled, Cleaning and Disinfection of Environmental Surfaces last revised on 08/2019 revealed in part.Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the labels safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. By Law, all applicable label instructions on EPA-registered products must be followed. 1.Review of Resident #4's medical record revealed an admission date of 06/12/2017 with diagnoses that included in part. Chronic Multifocal Osteomyelitis of the Right Femur, Stage 4 Pressure Ulcer of the Right Hip, Stage 3 Pressure Ulcer of the Sacral Region, and Quadriplegia.Review of Resident #4's Quarterly MDS with ARD of 08/06/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #4 was dependent on staff for toileting hygiene.Review of Resident #4's current Care Plan revealed in part. the resident had impaired mobility- quadriplegic, bedbound, and totally dependent on staff for care. Resident #4 had a chronic Stage 4 Pressure Ulcer to the right hip, an open lesion to the right lateral foot, a Stage 3 Pressure Ulcer to the sacrum, and Moisture-Associated Skin Damage (MASD) to bilateral feet.On 08/25/2025 at 10:01 a.m., observation revealed Resident #4 had an EBP sign posted above her bed. EBP sign indicated gown and gloves must be worn for all direct patient care for Resident #4.In an interview on 08/26/2025 at 12:18 p.m., S12 CNA revealed she provided incontinent care to Resident #4 throughout her shift. S12 CNA revealed she was unaware Resident #4 required the use of EBP during incontinent care. On 08/26/2025 at 12:42 p.m., S12 CNA accompanied the surveyor to Resident #4's room. S12 CNA acknowledged the EBP sign posted above Resident #4's bed. S12 CNA confirmed she did not wear a disposable gown earlier that day when she provided incontinent care to Resident #4, but should have.In an interview on 08/27/2025 at 9:59 a.m., S2 DON acknowledged the above findings. S2 DON confirmed that Resident #4 required EBP and S12 CNA should have worn a gown and gloves when providing incontinent care to Resident #32, but did not.2.In an interview on 08/27/2025 at 9:23 a.m., S15 Housekeeping revealed the resident room disinfecting process in part.Room Sense 200 Lemon Disinfectant cleanser was utilized for bathroom cleaning and wiped up after 2-3 minutes of contact time. After review of the Room Sense 200 Lemon Disinfectant cleanser bottle, with S15 Housekeeping, revealed a dwell time of 10 minutes. S15 Housekeeping confirmed she was unaware of the above chemical's 10-minute dwell time. In an interview on 08/27/2025 9:33 a.m., S14 Housekeeping revealed the resident room disinfecting process in part . Room Sense 200 Lemon Disinfectant Cleanser and hdqC2 Neutral Disinfectant were used for bathroom cleaning. S14 Housekeeping confirmed he was unaware that these chemicals had dwell times. On 08/27/2025 at 09:43 a.m., an interview was conducted in Hall X cleaning supply closet with S13 Maintenance Supervisor. S13 Maintenance Supervisor revealed he was also the Housekeeping Supervisor and provided training to the housekeeping staff. The above findings were discussed with S13 Maintenance Supervisor during review of Room Sense 200 Lemon Disinfectant Cleanser and hdqC2 Neutral Disinfectant bottles. S13 Maintenance Supervisor confirmed he was unaware of the proper 10-minute dwell time for the above chemicals, but should have been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to maintain an effective pest control program by having multiple flies in several areas of the facility including residents' rooms, dining room, and kitchen. There were 74 residents who resided in the facility according to the facility's census. Findings:Observation on 08/25/2025 at 8:45 a.m., of Resident #1 revealed two flies flying around him and landing on him. Observation on 08/25/2025 at 8:50 a.m. of Hall Y revealed multiple flies flying around. Interview on 08/25/2025 at 9:54 a.m., with Resident #29 revealed multiple flies flying around in his bedroom. Resident #29 stated there is a fly problem in the facility. Resident #29 stated “yea, I keep my fly swatter right over there”. Review of Resident #29's Quarterly MDS with an ARD of 08/20/2025 revealed a BIMS score of 15, which indicated intact cognition. Observation on 08/25/2025 at 10:12 a.m., of Hall Y revealed a fly in the hallway. Observation on 08/26/2025 at 8:11 a.m., of Resident #1 revealed him lying in bed and two flies sitting on top of him. Observation on 08/26/2025 at 12:39 p.m., of Hall Y revealed multiple flies flying around in the hallway. Dining observation on 08/26/2025 at 11:58 a.m., revealed multiple flies flying throughout the dining room during meal service. Observation of a Resident eating lunch and yelling loudly at flies flying around him and landing on his food. Staff members observed walking over to Resident to swat away the flies. At 12:08 p.m., another observation of a Resident pulling out her fly swatter, flies observed flying around her. Facility’s Pest Control policy reviewed on 08/26/2025 at 10:50 a.m. with a revision date of May 2008 revealed in part .Our facility shall maintain an effective pest control program to ensure that the building is kept free of insects and rodents. A kitchen observation on 08/25/2025 at 11:18 a.m. revealed a fly flying above the table where kitchen staff were preparing puree meals. At 11:33 a.m., flies were noted flying around steam table and landing on the rim of an uncovered glass of tea about to be served. Observation of Resident #10 on 08/25/2025 at 9:30 a.m. revealed in part…Four flies on Resident #10 lying in bed. Observation of Resident #10 on 08/25/2025 at 12:10 p.m. revealed in part…Resident #10 had multiple flies on top of her. Resident #10 interview on 08/26/2025 at 09:51 a.m. revealed Resident #10 stated she has flies in her room, and they are very bad. She stated, It’s because of that over there” and pointed to her roommate. Resident #10 stated her roommate eats in her bed and throws everything on the floor. Observation of Resident #10’s room on 08/26/2025 at 9:51 a.m. revealed 2 flies on the floor in Resident #10’s room. Review of the facility’s Pest Control contract on 08/26/2025 at 10:50 a.m. revealed in part .Basic Services which includes treatment of rats, mice, German, American, brown, Oriental and smokey brown cockroaches, earwigs, crickets, grasshoppers, carpenter ants, pharaoh ants and Argentinian ants. It also included 4 step to fire ant control. Dining observation on 08/26/2025 at 12:06 p.m. revealed a resident observed swatting at flies while eating. Dining observation on 08/26/2025 at 12:08 p.m. revealed a resident yelled out at this time Can't eat for the damn flies. Another resident sitting at the same table pulled out a fly swatter. A couple of flies observed flying in dining room. Observation of Resident #10's room on 08/27/2025 at 9:15 a.m. revealed 1 fly on Resident #10 while she was in bed, one fly on the privacy curtain, and one fly flying around the room. In a telephone interview with Facility’s Pest Control contractor on 08/27/2025 at 8:57 a.m., he stated monthly basic service includes control of flies and he sprayed recently around the dumpsters which is where the flies usually originate from. He also stated he told the facility to have the light bulbs changed in the fly lights, but the facility told him they didn't need to be changed. He says the bulbs in the fly lights typically should be changed every 9 months, the UV light still works but the UV light loses its attraction after this timeframe. He stated the facility can call him out for services anytime in addition to the monthly services and stated he provides receipts to the facility for every visit. Interview on 08/26/2025 at 2:00 p.m., S3 Dietary Manager acknowledged flies were observed in the kitchen on 08/25/2025 during lunch service around the steam table. She acknowledged the facility had a problem with flies, stating “They are everywhere.” S3 Dietary Manger stated she was unsure if the pest control sprays in the kitchen because she was not present when they came. In an interview on 08/27/2025 at 11:40 a.m., S1 Administrator confirmed that she can call the pest control company to come out in addition to the monthly services if needed. She acknowledged the last pest control visit was 08/04/2025. S1 Administrator stated she couldn’t remember if she had called the pest control company since then to come out for flies. Review of the QAPI meeting minutes dated 07/25/2025 revealed the Risk Management Company had identified issues with flies and cleanliness with a corrective measure put in place for department heads to continue rounding on rooms and addressing issues as they arise. Interview on 08/27/2025 at 2:33 p.m., S2 DON stated the facility’s Risk Management Company comes out quarterly to address problems in the facility. She confirmed the Risk Management Company identified the fly problem. S2 DON confirmed pest control can be called to come out whenever needed. Pest control invoices reviewed on 08/26/2025 at 10:50 a.m. revealed once per month services were provided in June, July, and August 2025, with the last visit made on 08/04/2025.

Jul 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, by failing to honor resident's right to have access to the facility patio area outside of smoking times for 3 (#2, #3, and #R1) of 4 (#1, #2, #3, and #R1) sampled resident. Findings: Review of the Facility's undated policy titled Resident's [NAME] of Rights read in part . A. All nursing homes shall adopt and make public a statement of the rights and responsibilities of the residents residing therein and shall treat such resident in accordance with the provisions of the statement. The statement shall ensure each resident the following: 1. The right to civil and religious liberties, including but not limited to knowledge of their available choices, the right to independent personal decision, and the right to encouragement and assistance from staff of the facility in the fullest possible exercise of these rights. Review of the Resident Council minutes dated 05/02/2025 read in part Resident's want to sit outside on the patio, just to go outside and get fresh air, more than 3 times a day. Not to smoke but just to sit outside. Response made by S1 Admin on 05/07/2025 read in part There isn't anything in place that is stopping residents from going outside, however staff must be present in the even that something would happen. Resident #2 Review of Resident #2's medical record revealed and admit date of 09/27/2023 with a readmission on [DATE] with the following diagnoses: Intracranial Injury with loss of conscious, Tremors, Schizoaffective Disorder, and Traumatic Brain Injury. Review of Resident #2's 05/21/2025 Quarterly MDS revealed a BIMS score of 10, indicating moderate cognition impairment. Interview on 06/30/2025 at 10:20 a.m. with Resident #2 revealed that residents aren't allowed outside other than 3 times a day at 9:00 a.m., 3:00 p.m., and 7:00 p.m. during smoke breaks. Interview on 06/30/2025 at 3:15 p.m. with Resident #2 revealed that he has asked to be taken outside at times other than 9:00 a.m., 3:00 p.m., and 7:00 p.m. and has been told by staff (can't recall who) that they would get in trouble if they would let him go outside. Resident #3 Review of Resident #3's medical record revealed an admit date of 10/04/2024 with diagnoses that included: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Morbid Obesity, Tobacco use, Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, and Insomnia. Review of Resident #3''s 06/18/2025 Quarterly MDS revealed a BIMS score of 15, indicating intact cognition. Interview in 06/30/2025 at 10:43 a.m. with Resident #3 revealed residents are only to go outside at 9:00 a.m. 3:00 p.m., and 7:00 p.m. to smoke or just to go outside in general. Resident #3 stated that S1 Admin notified him that if a staff member isn't busy they can bring residents outside. Resident #3 stated that is not happening. Resident #3 stated he has asked to go outside at different time other than the 3 times a day and has been told by staff that they are too busy to bring him outside. Resident #3 stated he doesn't have to smoke but just wants the opportunity to go outside during the day. Resident #R1 Review of Resident #R1's medical record revealed and admit date of 06/19/2023 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction, Amputation of leg below the left knee, Hypertension, Impulse Disorder, and Heart Disease. Review of Resident #R1's 04/16/2025 Annual MDS revealed a BIMS score of 13, indicating intact cognition. Interview on 07/01/2025 at 10:15 a.m. with Resident #R1 revealed that he has asked on different occasions to go outside to smoke or just to be outside and has been told no, and that he is only allowed during the smoking times. Resident #R1 stated he feels confined in the facility like a prison at times. Interview on 06/30/2025 at 1:00 p.m. with S5 LPN revealed that residents are not allowed to go outside by themselves without supervision not matter there cognition. S5 LPN stated that that staff can bring resident outside of the smoke times if they have time, but does not happen often. Interview on 06/30/2025 at 1:45p.m. Staff interview with S6 Regional Admin revealed that resident had some complaints recently about wanting more outside time and the resolution was to add more outdoor activities, which has been put into place. S6 Regional Admin stated that if any residents wants to go outside of the assigned smoking times, they just have to ask staff to bring them outside. Interview on 06/30/2025 at 3:15 p.m. with S4 CNA stated that she has been told by nurses (cant recall who) that residents are only allowed outside at the allowed smoking times. S4 CNA stated if a resident asked to go outdoors, outside of smoking time frames, she has been told to tell them to wait until the smoking times. Interview on 07/01/2025 at 12:55 p.m. with S1 Admin stated that residents have the right to go outside with a staff member present outside of the 3 smoke breaks a day.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to maintain a sanitary and comfortable homelike environment for all residents in the facility by failing to ensure the facility was free of odor. The facility census was 73. Findings: Review of the facility's undated policy titled Homelike Environment read in part Residents are provided a safe, clean, comfortable environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: f. pleasant, neutral scents. Observation upon entrance on 06/30/2025 at 8:15 a.m. revealed a strong urine odor throughout facility. Review of the Resident council minutes for 04/03/2025 revealed resident complained of the hall ways smelling bad. The follow up response made to the resident council grievance read .The rooms and hallways are cleaned, but there are a couple residents that change themselves and leave diapers, clothes and towels that have a smell. Interview on 06/30/2025 at 8:35 a.m. with Resident #1's responsible party revealed that every time she came into the facility she always smelled a very strong urine odor throughout the facility. Observation on 06/30/2025 at 10:19 a.m. revealed a strong odor pungent odor on X hall. Interview and Observation on 06/30/2025 at 10:20 a.m. Resident #2's room revealed a strong urine odor and the floor was sticky. Resident #2 stated the cleanliness is poor in the facility. Resident #2 stated he can't hold his bowel and bladder and the room starts to smell. Interview on 06/30/2025 at 10:43 a.m. with Resident #3 revealed the cleanliness in the facility isn't great. Resident #3 stated the housekeeping staff typically come in daily and change out the trash. Resident #3 stated the floors are usually dirty and only mopped once or twice a week. Interview on 06/30/2025 at 1:30 p.m. with S7 Housekeeping stated there was a strong urine odor in the facility today. S7 Housekeeping stated there are no housekeeping after 3:00 p.m. so the odor may be the linen barrel that hadn't been sent to laundry. Interview on 06/30/2025 at 2:24 p.m. with S8 LPN stated the urine odor was very strong this morning. S8 LPN stated she asked about the odor and was told agency staff had worked last night and they leave diapers in the trash can in the room overnight.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure each resident's environment remained free of accident hazards. The facility failed to ensure hot water temperatures did not exceed 120 degrees for 15 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]., room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 28 resident rooms. Findings: Review of the facility's 12/2009 policy titles Water Temperatures, Safety of read in part . Policy: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Observation on 06/30/2025 at 9:15 a.m. revealed the hot water temperature in the conference room bathroom sink felt hot to surveyor touch. Observation on 06/30/2025 at 10:55 a.m. of S3 Maintenance Supervisor measuring the water temperature in room [ROOM NUMBER] using a digital thermometer. S3 Maintenance Supervisor was observed letting the water flow on the middle of the thermometer versus the tip. where the reading is more accurate. The water temperature observed in the middle of the thermometer was 106 degrees F. After S3 Maintenance Supervisor moved the tip of the thermometer under the running water the thermometer read 126 degrees F. During an interview on 06/30/2025 at 11:00 a.m. with S3 Maintenance Supervisor revealed he has been measuring the water temperature using a digital thermometer but would let the water flow on the middle part of the thermometer and not the tip. Review of the facility's water temperature log by S3 Maintenance Supervisor revealed no water temperature greater than 120 degrees Fahrenheit for the 03/2025, 04/2025, 05/2025 and 06/2025 water temperature logs. Observation of all resident bathroom sinks revealed the following temperatures: room [ROOM NUMBER]-126 degrees F. No resident concerns room [ROOM NUMBER]- 124.0 degrees F. No resident concerns room [ROOM NUMBER]-134.0 degrees F. No resident concerns room [ROOM NUMBER]-133.2 degrees F. No resident concerns room [ROOM NUMBER]- 134.0 degrees F. No resident concerns room [ROOM NUMBER]- 140.0 degrees F. No Resident concerns room [ROOM NUMBER]-132.4 degrees F. No resident concerns room [ROOM NUMBER]- 135.0 degrees F. No resident concerns room [ROOM NUMBER]- 140.0 degrees F. No resident concerns room [ROOM NUMBER]-137.2 degrees F. No resident concerns room [ROOM NUMBER]-140.0 degrees F. No resident concerns room [ROOM NUMBER]-134.7 degrees F. No resident concerns room [ROOM NUMBER]-125.0 degrees F. No resident concerns room [ROOM NUMBER]-123.2 degrees F. No resident concerns room [ROOM NUMBER]-122.0 degrees F. No resident concerns Interview on 06/30/2025 at 12:55 p.m. with S2 DON revealed there were no incidents and denies any scalding, burns, or complaints of water being too hot from any residents in the facility. Interview on 06/30/2025 at 1:00 p.m. with S1 Admin revealed there were no incidents and denies any scalding, burns or any complaints of water being too hot from residents or staff. Interview on 06/30/2025 at 2:13 p.m. with S1 Admin confirmed that the temperatures for the 15 rooms were above the 120 degrees F, and should not have been.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (#4) of 5 (#1, #2, #3, #4, and #5) sampled residents. The facility failed to: 1. Ensure S3 CNA and S4 CNA reported Resident #5's aggressive behaviors, and increased agitation to the nurse; and 2. Ensure Resident #4 was not physically abused by Resident #5. Findings: Review of the facility's undated policy titled Seven Step Abuse Prevention Policy, revealed in part .It is the policy of the facility to have a seven (7) step Plan to assist in preventing abuse, neglect, misappropriation of resident's property, and to keep residents as safe as possible. The policy consists of seven (7) areas: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. Physical abuse defined: the willful infliction of injury, unreasonable confinement (involuntary seclusion), intimidation, or punishment of a person with resulting physical harm or pain or mental anguish. Examples include hitting, slapping, pinching, kicking, or controlling behavior through corporal punishment. Review of a facility Incident Report documented by S1 Administrator, and dated 09/25/2024, revealed in part .At 5:59 p.m. on 09/25/24, Resident #5 entered his room, and Resident #4 (roommate) was in the room. Resident #5 became agitated because he believed Resident #4 smelled like urine and he didn't want to smell him. Resident #5 began to strip linen off of Resident #4's bed, although staff had recently changed Resident #4, and put fresh linen on his bed. Resident #4 did not want the linen changed and voiced to Resident #5 to leave his bed alone. Both residents vacated their room into the hallway where they could be heard by staff. As staff rushed to intervene, Resident #5 hit Resident #4. Resident #4 sustained a small superficial cut on the inside of his lip. No other injuries noted. Resident #4 Review of the clinical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses that include: Paraplegia unspecified; Unspecified Intracranial Injury, Schizophrenia Unspecified; Schizoaffective Disorder, Bipolar Type; Personal History of Traumatic Brain Injury; Depression Unspecified; and Bipolar Disorder unspecified. Review of Resident #4's Quarterly MDS with an ARD of 12/12/2024, revealed a BIMS score of 12 (indicating moderate cognitive impairment). The MDS revealed Resident #4 required setup or clean-up assistance with eating and oral hygiene, supervision or touching assistance with mobility, and is always incontinent of bladder and bowel. Review of Resident #4's Care Plan with a Target Date of 12/25/2024 read in part . 1. The resident is resistant to care related to diagnosis of Schizophrenia, Bipolar, and a history of refusing hygiene care, with interventions which included: Allow the resident to make decisions about treatment regime, to provide sense of control; Give clear explanation of all care activities prior to an as they occur during each contact. 2. The resident has Schizophrenia, Schizoaffective Disorder and Bipolar Disorder, with interventions which included: Monitor behavior episodes and attempts to determine underlying cause, consider location, time of day, persons involved, and situations. Document behavior and potential causes. Resident #5 Review of Resident #5's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included: Epilepsy Unspecified; Unspecified Dementia, Unspecified severity without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; Schizoaffective Disorder; Profound Intellectual Disabilities; Alcohol Abuse uncomplicated; and Paraphilia Unspecified Review of Resident #5's Quarterly MDS with an ARD of 09/18/2024, revealed a BIMS score of 8 (indicating moderate cognitive impairment). The MDS revealed Resident #5 required supervision or touching assistance with oral hygiene, personal hygiene and dressing. Resident #5 was independent with bed mobility and ambulation. Review of Resident #5's Care Plan with a Review Date of 12/13/2024, read in part . 1. The resident has impaired Cognitive Function/ Dementia, or Impaired Thought Processes related to Dementia, Schizophrenia, and Impaired Decision Making with interventions which included: cue, reorient, and supervise as needed. Interview on 10/02/2024 at 10:12 a.m. with S2 DON, revealed on 09/25/2024, Resident #5 became upset because his room smelled like urine. S2 DON revealed Resident #5 ripped Resident #4's bed linen off and threw it on the floor, then proceeded to hit Resident #4 in the face with his fist. S2 DON revealed Resident #4 sustained a cut to his lip. Interview on 10/02/2024 at 10:39 a.m. with Resident #5 revealed staff had changed Resident #4's sheets while he (Resident #5) was asleep. Resident #5 revealed when he awakened, the room smelled like urine and feces. Resident #5 revealed two workers asked him what he was doing, and he stated he changed Resident #4's bed linen because he couldn't stand the odor. Resident #5 revealed Resident #4 came back in the room and told him not to fool with his stuff, and started cursing him (Resident #5) out. Resident #5 revealed Resident #4 was cursing and mad so he (Resident #5) punched Resident #4 in the nose with his fist in the hallway. Resident #5 stated workers came and he got upset at workers for telling him to leave Resident #4's belongings alone. Interview on 10/02/2024 at 11:11 a.m. with Resident #4, revealed he entered his room one evening about a week ago (couldn't remember the date), and Resident #5 had ripped the sheets off of his bed and thrown them on the floor. Resident #4 stated he became upset and started cursing. Resident #4 revealed Resident #5 hit him three times with his fist in the face. Resident #4 revealed his lip had a cut which was painful. Telephone interview on 10/02/2024 at 11:36 a.m. with S3 CNA, revealed on 09/25/2024 at approximately 6:00 p.m., she saw Resident #5 stripping Resident #4's linen off of his bed. S3 CNA revealed she heard S4 CNA ask Resident #5 why he stripped Resident #4's bed. S3 CNA revealed Resident #5 stated because it was pissy. S3 CNA revealed Resident #4 asked Resident #5 to stop touching his stuff. S3 CNA stated I left it alone and went back to changing another resident. S3 CNA revealed she heard yelling, and walked in the hallway, and saw Resident #5 hit Resident #4 in the face. S3 CNA revealed she immediately got between Resident #4 and Resident #5, and told them to stop. S3 CNA revealed Resident #5 pushed her, and hit Resident #4 again. Telephone interview on 10/02/2024 at 11:43 a.m. with S4 CNA, revealed she was at the end of the hall and saw Resident #5 stripping linen off of Resident #4's bed. S4 CNA revealed she stopped and asked Resident #5 why he stripped Resident #4's bed linen off of his bed. S4 CNA revealed she could tell Resident #5 was already aggravated. S4 CNA revealed Resident #5 started yelling and cursing saying I'm tired of smelling piss. S4 CNA revealed she told Resident #5 it was clean linen, and Resident #5 threw it in the hallway. S4 CNA revealed she left Resident #5, and went to assist S3 CNA clean another resident. S4 CNA revealed she heard yelling, and saw Resident #5 hit Resident #4 in the face with his fist. S4 CNA revealed when a resident was aggressive or having behaviors they should report it to the nurse. S4 CNA confirmed she should have reported Resident #5's behavior of increased agitation to the nurse and did not. Interview on 10/02/2024 at 1:32 p.m. with S1 Administrator and S2 DON confirmed that S4 CNA should have notified a nurse about Resident #5's increased agitation on 09/25/2024. S1 Administrator confirmed Resident #4 was a victim of resident to resident physical abuse by Resident #5 on 09/25/2024.

Jun 2024 16 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to inform each resident of the charges for services for which the residents may be responsible for paying for 2 (#21 and #44) of 3 (#21, #44, & #240) sampled residents for Advanced Beneficiary Notice of Non-Coverage (ABN). Findings: Review of the facility's undated policy titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices on 06/04/2024 at 10:00 a.m. revealed in part . Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) 1. If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the services may not be covered and of the resident's potential liability for payment of the non-covered service(s). 2. . 3. The resident (or representative) is informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility. Review of the ABN notices (CMS form 10055) signed by Resident #21's representative on 03/27/2024 and Resident #44's representative on 04/08/2024 revealed the estimated cost section was not completed but left blank. In an interview on 06/03/2024 at 4:38 p.m., S10 Clerical confirmed she was responsible for sending the ABN notices to resident's representatives and sent them to Resident #21 and #44's representatives. S10 acknowledged the estimated cost sections were blank and did not inform the residents/representatives of the amount of charges they may incur if they continued the services. In an interview on 06/04/2024 at 7:50 a.m., S11 Office Manger stated she was the supervisor for S10 Clerical who was responsible for sending the ABN notices and confirmed there was no estimated costs on the ABN notices, but there should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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FACILITY Based on record review and interview, the facility failed to ensure a quarterly assessment was completed timely for 1 (#51) of 1 resident reviewed for Resident Assessments. There were 84 residents in the facility. Findings: Review of Resident #51's medical record revealed an admit date of 11/04/2021 with diagnoses that included in part .Hyperlipidemia, Seizures; Schizoaffective Disorder, Dementia, and Chronic Kidney Disease. Review of Resident #51's MDS assessments revealed a quarterly assessment was completed on 01/24/2024 with no MDS quarterly assessments accepted since that time. In an interview on 06/04/2024 at 3:52 p.m., S3 Corporate Nurse stated the facility did not have an MDS nurse at this time. S3 Corporate Nurse stated she became aware Resident #51's MDS was late and transmitted one last night. S3 Corporate Nurse confirmed Resident #51's quarterly MDS was not submitted timely.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #23 Record review revealed Resident #23 had an admit date of 12/02/2021 with diagnoses that included in part . Retention of Urine, Urinary Tract Infection, Anxiety, Chronic Pain, Heart Failure, Major Depressive Disorder, and Type 2 Diabetes Mellitus. Review of Resident #23's Quarterly MDS with ARD of 03/06/2024 revealed Resident #23 had a BIMS of 13 (Cognition Intact). Resident #23 was dependent on staff for toileting, showering/bathing, personal hygiene and dressing. Resident #23 was always incontinent of bowel and had a urinary catheter. Review of Resident #23's CPOC revealed Resident had potential for complications related to the presence of Foley catheter. Interventions included: Wash around catheter site every day with mild soap and water. Change Foley catheter and bag as needed. Assess, record, and report to physician signs and symptoms of UTI. Labs as ordered, report abnormal results to MD/NP. Review of Resident #23's 04/2024-06/2024 Physician's Orders revealed the following in part . 16 French Foley catheter for retention of urine. Change monthly on the 1st. 03/07/2024 Catheter Care Q Shift 03/07/2024 U/A with C&S 04/03/2024 U/A with C&S 05/04/2024 Review of Resident #23's UA laboratory results dated [DATE] revealed the following in part . Abnormal results of: Blood 5+, Nitrate-Positive, Leukocyte Esterase 3+, Catalase Bacteria Screen-Positive. Review of Resident #23's C&S laboratory results dated [DATE] revealed the following in part . High Pathogens detected- Complex Sample-see note. Note read: Greater than 3 organisms present. Probable contamination. Recommend recollecting with sterile in/out catheter procedure. Review of the 04/08/2024 UA C&S laboratory results revealed the reports were not signed off by facility staff. Review of Resident #23's medical record revealed no documentation that the provider was notified of the abnormal lab results on 04/08/2024, and no record of treatment. Review of Resident #23's UA laboratory results dated [DATE] revealed the following in part . Abnormal results of: UA color- Cloudy, Blood-Trace, Leukocyte Esterase- Large, RBC- 10-20, WBC >50. The 05/04/2024 UA Laboratory results was signed off by facility staff on 05/05/2024 at 5:55 a.m. Review of Resident #23's medical record revealed Macrobid (antibiotic) 100mg capsule po bid x 7 days was ordered on 05/05/2024. Review of Resident #23's EMAR revealed she received the antibiotic as ordered. Interview on 06/02/2024 at 9:21 a.m. with Resident #23 revealed she had frequent UTI's. Resident #23 stated she could not recall the last time she was diagnosed, but felt it was recent. Resident #23 was observed with a Foley catheter hanging in privacy bag on left side of bed frame draining clear yellow urine. Resident #23 denied having signs/symptoms of current UTI. Interview on 06/04/2024 at 11:56 a.m. with S2 DON revealed a review of Resident #23's UA orders and 04/08/2024 laboratory results. S2 DON stated she was unsure why Resident #23 did not receive treatment for abnormal UA results on 04/08/2024. S2 DON reviewed the 04/08/2024 UA results and confirmed the provider should had been notified. S2 DON confirmed there was no staff sign offs on the lab report, so the provider was likely not notified. Interview on 06/04/2024 at 12:28 p.m. with S12 NP revealed a review of Resident #23's 04/03/2024 UA order and results reported on 04/08/2024. S12 NP stated Resident #23 had chronic colonization of Klebsilea (bacteria), so she did not always treat the resident with positive UA results. S12 NP stated Resident #23 was not symptomatic, and based off the 04/08/2024 C&S report stating probable contamination with recollection recommended, she would not have treated the resident with antibiotics, but would expect staff to perform a recollection. S12 NP confirmed she was not notified of the 04/08/2024 abnormal UA results. Interview on 06/04/2024 at 1:00 p.m. with S2 DON confirmed staff did not notify MD/NP of positive UA results on 04/08/2024, but should have. S2 DON stated when staff receive abnormal results, they were to sign off on the lab report, notify md, and make a progress note within the Resident's medical record. S2 DON stated staff did not recollect UA on 04/08/2024 as recommended on C&S report likely because staff did not review the lab results. S2 DON confirmed staff should have notified the MD upon receiving the abnormal UA results and recollected the UA as recommended, but failed to do so. Based on record review, observation, and interview, the facility failed to ensure services were provided to meet professional standards of practice for 2 (#23 and #30) of 38 sampled residents. The facility failed to ensure: 1. Physician's orders for referring Resident #30 to a dermatologist were followed, and 2. Abnormal lab resullts were reported to provider and urine sample was recollected for Resident #23. Findings: Resident #30 Review of Resident #30's medical record revealed an admit date of 05/12/2022 with diagnoses that included in part .Hemiplegia, Cerebral infarction, Type 2 Diabetes Mellitus, and Anxiety Disorder. Review of Resident #30's quarterly MDS with an ARD of 04/03/2024 revealed a BIMS score of 14 which indicated intact cognition. Review of the MDS revealed Resident #30 required supervision/touching assistance with eating, partial/moderate assistance with toileting hygiene and was independent with rolling left and right and sit to lying In an interview on 06/02/2024 at 9:45 a.m., Resident #30 stated he had been trying to get three cysts removed from his face for about 6 months. Resident #30 stated he reported this complaint to the Nurse Practitioner and a male doctor but had never received an appointment to get them removed. In an observation on 06/03/2024 at 1:53 p.m., Resident #30's right temple area near the right eye revealed 2 small cysts, one which was noted to be pea sized and another larger, marble sized cyst. In an interview at this time, Resident #30 stated they were getting larger and now has one on right cheek. Review of a progress note by S12 NP dated 03/21/2024 revealed the following in part . History of Present Illness: On assessment today patient complains of 2 small cysts to right cheek area that he would like to be evaluated by dermatology. Patient reports he has had them in the past and had them removed with no difficulty. Reports they are becoming bothersome. Physical Exam-Skin: 2 small pea-sized nodular cysts noted to right cheek area. Plan: Epidermoid cyst of skin of cheek: Refer to Dermatology for eval and treat. In an interview on 06/03/2024 at 2:33 p.m., S13 [NAME] Clerk stated she was the person responsible for making the dermatology appointment for Resident #30. S13 [NAME] Clerk stated no one notified her of the NP ordering a dermatology referral. S13 [NAME] Clerk stated the nurse probably forgot to tell her. S13 [NAME] Clerk stated no one else would have made the dermatology appointment. In an interview on 06/04/2024 at 10:40 a.m., S2 DON stated she was unaware the dermatology referral wasn't made but should have 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

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Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (#87) of 2 (#40, and #87) sampled residents for respiratory care. The facility failed to ensure Resident #87 had a physician's order to receive oxygen therapy. Findings: Review of the facility's undated policy titled Oxygen Administration on 06/04/2024 at 9:44 a.m. read in part . The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review of Resident #87's medical record revealed an admit date of 03/01/2024. Resident #87 had diagnoses that included in part Unspecified Dementia, Major Depressive Disorder, Alzheimer's Disease, and Coronary Artery Disease. Review of Resident #87's admission MDS with ARD of 03/14/2024 revealed Resident #87 had a BIMS of 10 (indicating moderate cognitive impairment). Review of Resident #87's Comprehensive Person Centered Care Plan revealed Resident had a potential for complications related to diagnoses of Coronary Artery Disease and Hypertension with interventions of; Administer oxygen as ordered. Observe O2 saturation as ordered. Review of Resident #87's 06/2024 orders revealed there was no order for Oxygen Administration. Resident #87 had an order dated 03/02/2024 to monitor temperature and oxygen saturation every shift. Observation on 06/02/2024 at 10:00 a.m. revealed Resident #87 was wearing oxygen via NC at 2L/min. Resident #87 stated he wore oxygen frequently, but mostly while sleeping. Observation on 06/04/2024 at 9:10 a.m. of Resident #87 revealed his Oxygen concentrator was running and set at 2L/min. Resident #87 stated he had just taken his oxygen off to eat breakfast. Interview on 06/04/2024 at 10:07 a.m. with S15 LPN revealed Resident #87 required the use of oxygen. S15 LPN confirmed Resident #87 did not have an order for Oxygen therapy, but should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to include the Medical Director or his designee in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 84. Findings: Review of the quarterly QAA meeting's sign in sheet dated 03/29/2024 revealed the Medical Director was not in attendance. In an interview on 06/04/20204 at 5:25 p.m., S3 Corporate Nurse confirmed the Medical Director did not sign the attendance sheet for the 03/29/2024 quarterly QAA meeting. S3 Corporate Nurse stated when the Medical Director doesn't attend a meeting, he reviews the information later.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected 1 resident

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Based on observations and interviews the facility failed to ensure hallway hand rails were securely affixed to the walls. The facility failed to ensure hand rails were secure on 1 (Hall Y) of 3 (Hall X, Hall Y, and Hall Z) hallways observed in the building. This had to potential to affect 24 residents residing on Hall Y. Findings: Observation on 06/04/2024 at 2:05 p.m. of the Hall Y accompanied by S9 Maintenance Supervisor revealed loose hand rails between rooms L and M. An interview on 06/04/2024 at 2:05 p.m., S9 Maintenance Supervisor confirmed the hand rails on Hall Y between rooms L and M were not secured to provide safety and should have been.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents received housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior. Findings: Review of the facility's undated policy titled Floors on 06/03/2024 at 11:14 a.m. read in part .Floors shall be maintained in a clean, safe, and sanitary manner. All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures. Observation on 06/02/2024 at 9:20 a.m. of Resident #23 in Room A on Hall X revealed a large amount of food debris on the side of her bed. Room A had a large amount of brownish black substance observed throughout the room, and the floor was sticky. Resident #23 stated her room had not been cleaned since Friday 05/31/2024. Hall X was observed with a very strong urine odor throughout the hall. Observation on 06/02/2024 at 9:39 a.m. of Resident #6 in Room B on Hall X revealed the floor had black substances, a large amount of food debris, and the floor was sticky. Resident #6 stated housekeeping staff did not clean her room hardly ever, and she did not know the last time her floor was mopped. Interview on 06/02/2024 at 9:43 a.m. with S18 HK revealed she was the only housekeeper working at the facility today. S18 HK stated she worked full time for the facility, and the facility had been short staffed in housekeeping for a while. S18 HK stated it was extremely hard to complete her duties being the only housekeeper in the facility, and sometimes her duties were not completed during her shift. Interview on 06/02/2024 at 10:17 a.m. with S4 ADON on Hall X confirmed Hall X was in need of cleaning as the floor throughout the hall and within Resident's rooms were unclean, had large amounts of sticky brownish/black substances on floors, and there was a strong urine odor throughout hall. Interview on 06/02/2024 at 10:23 a.m. with S19 HK Supervisor revealed she was currently understaffed with only 3 workers within the house keeping department. S19 HK Supervisor stated the facility had recently reduced housekeeper's hours from 12 hour shifts to 8 hour shifts. S19 HK Supervisor confirmed Hall X was unsanitary and needed to be cleaned. Room F Observation on 06/02/2024 at 9:30 a.m. of Room F revealed loose, cracked and water stained ceiling tiles in the bedroom and bathroom, privacy curtains stained with large red and brown substance in multiple areas. The wall mounted air condition/heating unit was not properly fitted against the wall with a small exposed area of the outside visible. The vertical window blind was not able to open/close nor go up/down. The window pane was covered with light green film, not being able to clearly see out of the window. Interview on 06/02/2024 at 9:30 a.m. with Resident #5 revealed she was bed bound and would like to be able to have the blinds raised to provide some light into her room and to be able to see out of her window. Review of Resident #5's MDS revealed a BIMS of 15 (cognitively intact). Observation on 06/04/2024 at 1:00 p.m. accompanied by SS9 Maintenance Supervisor confirmed the above findings. Room G Observation on 06/02/2024 at 9:00 a.m. of Room G revealed loose, cracked and brown water stains in the bathroom ceiling tile and holes in the sheet rock between the toilet and the sink. The privacy curtain between the two beds, with red and brown stains in multiple places was observed. There were curtain hooks on the curtain track with no privacy curtain for bed b. The wall molding 1x12, approximately 12 inches, behind the bed and night stand was noted with splits in the molding and visible splinters. Observation on 06/04/2024 at 1:16 p.m. accompanied by S9 Maintenance Supervisor confirmed the above findings. Room H Observation on 06/02/2024 at 2:30 p.m. of Room H revealed flies and gnats flying around in the room, landing on both residents in the room. The wall mounted air condition and heating unit was not secure properly to the wall. The floor had a large film of dried grayish substance with a large brown streak approximately 2 feet from the door entrance to the bathroom, floor tile to the bathroom entrance broken, sheet rock below the television peeled and ripped. The wall molding 1x12, approximately 12 inches, behind the bed and night stand had splits in the molding and visible splinters. Two over bed tables had torn and ripped plastic veneers and missing plastic edges. There were two 3 drawer night stand with split wood and jagged wood edges. Observation on 06/04/2024 at 1:32 p.m. accompanied by S9 Maintenance Supervisor confirmed the above findings. Room I Observation on 06/02/2024 at 11:10 a.m. of Room I room revealed tears in the sheet rock across from bed, trash and bread crumbles on floor mat on left side of bed, window blinds not able to open, and window pane with large white film covering it, with outside not visible. The privacy curtains was noted to have large dried brown stains in the center. The wall molding 1x12, approximately 12 inches, behind the bed and night stand had splits in the molding and visible splinters. Interview on 06/02/2024 at 11:10 a.m. with Resident #1 revealed the rooms' and hallways smell like urine and they are not cleaned every day. Resident #1 stated there are not enough housekeepers to keep the facility clean. Resident #1 stated she would like to have her blinds open and to be able to see out of the window. Review of Resident #1's MDS revealed a BIMS of 15 (cognitively intact). Observation on 06/04/2024 at 1:32 p.m. accompanied by S9 Maintenance Supervisor confirmed the above findings. Room J Observation on 06/02/2024 at 1:00 p.m. of Room J revealed flies and gnats flying around resident, and inside a box next to the bed, and the room reeked the smell of feces. There were loose, broken and water stained ceiling tiles in the bathroom. The wall paper on the wall between the bathroom door and the window was noted to be bulky and coming off. Interview on 06/02/2024 at 1:00 p.m. with Resident #33 revealed there was a big problem with flies and gnats. Resident #33 stated his room was not cleaned every day and sometimes the room only gets cleaned twice a week. Resident #33 stated the facility didn't have enough housekeepers to keep the rooms cleaned. Observation on 06/04/2024 at 2:20 p.m. accompanied by S9 Maintenance Supervisor confirmed the above findings. Hall Z Observation accompanied by S9 Maintenance Supervisor on 06/04/2024 at 1:50 p.m. of shower room on Hall Z revealed water stained and loose ceiling tiles, peeling and missing sheet rock and missing molding wall tile near the door. The whirlpool was noted to have water on the bottom surface and water on the seat, with a large soap film ring inside. There were 2 shower chairs in each shower stall with water dripping from the seat, hair and wet yellow stains under the seat ring and between the grooves. S9 Maintenance Supervisor confirmed the above findings at the time of the observation. Hall Y Observation accompanied by S9 Maintenance Supervisor on 06/04/2024 at 1:56 p.m. of shower room on Hall Y revealed water stained loose missing tiles and broken wall molding tile. The whirlpool had a pool of water in the center, dripping from the seat with water pooled in the center of the center, and the front panel with dried water stains. There were 2 shower chairs in each shower stalls which were noted to have brown and yellow substance in the seat grooves, and streaks of long brown and black strings of hair underneath the seat ring. Hall X Observation accompanied by S9 Maintenance Supervisor on 06/04/2024 at 2:15 p.m. of shower room on Hall X revealed water stained, loose and broken ceiling tiles and missing and broken wall tile molding. The whirlpool was noted to have a wet face towel, can of shaving cream, 2 razor covers, and pool of water on the seat, dried dripping streaks on the front panel, black specks of substance in the bottom surface, and a soap scum ring around the tub. The 2 shower chairs located in both shower stalls revealed: One large chair with worn back cushion and leg rest, water dripping on the seat ring, hair and yellow stains underneath the seat ring. The second shower chair was noted to have streaks of hair on the top seat ring, and wet yellow stain underneath the seat ring. S9 Maintenance Supervisor confirmed the above findings at the time of the observation. Observations accompanied by S2 DON of showers on Hall X, Y, and Z on 06/04/2024 at 2:18 p.m., 2:20 p.m. and 2:30 p.m. confirmed the 3 whirlpools, and 6 shower chairs had not been cleaned and/or disinfected after use and should have been. S2 DON identified the yellow substance as urine around the seat rings around the bottom of 3 of 6 shower chairs.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from sexual abuse by another resident, for 1 (Resident #33) of 1 resident reviewed for abuse, in a total sample size of 38. Findings: Review of the facility's undated policy titled Seven Step Abuse Prevention Policy, read in part . Policy: It is the policy of [NAME] Nursing and Rehab to have a 7-step plan to assist in preventing abuse, neglect, misappropriate pf resident's property, and to keep residents as safe as possible. Identification: Sexual Abuse is non-consensual sexual contact of any type with a resident. Resident #33 Review of Resident #33's clinical record revealed an admit date of 02/07/2022, with diagnoses that included: Anxiety Disorder, Osteoarthritis, Peripheral Vascular Disease, Atherosclerotic Heart Disease, and Hyperlipidemia. Review of Resident #33's Quarterly MDS with an ARD of 03/06/2024, revealed a BIMS score of 11, indicating moderate cognitive impairment. Resident #75 Review of Resident #75's clinical record revealed an admit date of 06/14/2023, with diagnosis that included: Depression, Essential HTN, Schizoaffective Disorder, and Mild Intellect Disability. Review of Resident #75's Quarterly MDS with an ARD of 03/27/2024, revealed a BIMS score of 13, indicating intact cognition. Review of Resident #75's Care Plan with review date of 06/27/2024, revealed in part . Socially inappropriate/disruptive behavior as evidenced by judgment or reasoning deficit due to Schizoaffective Disorder. Review of a facility report dated 05/17/2024, revealed on 05/08/2024, Resident #33 awoke feeling something touching his private area, and found his roommate, Resident #75, over him trying to pull his pants down and making inappropriate, sexual comments. Resident #33 reported this incident to the Day Program staff on 05/10/2024, who immediately notified the facility on 05/10/2024. Interview on 06/02/2024 at 10:45 a.m. with Resident #33, revealed on 05/08/2024, he awoke feeling something touching his private area. Resident #33 stated he found his roommate, Resident #75, over him trying to pull his pants down and making inappropriate, sexual comments. Resident #33 stated he told Resident #75 to get away and leave him alone, and Resident #75 left the room immediately. Resident #33 stated he notified staff at the Day Program on 05/10/2024. Resident #33 stated once the facility was notified of the incident, he was moved to a different hall, away from Resident #75. Resident #33 revealed he is not fearful in the facility, and felt the staff were doing a good job of keeping him safe. Interview on 06/03/2024 at 8:55 a.m. with Resident #75, revealed he had touched Resident #33 in his private area, but he was just joking with him. Resident #75 stated he did not want to have sexual relations with any of the staff or residents in the facility. Interview on 06/03/2024 10:22 a.m. with S1 Administrator, confirmed a resident to resident sexual abuse incident occurred between Resident #33 and Resident #75 on 05/08/2024. S1 Administrator stated Resident #75 had not exhibited inappropriate sexual behaviors since the incident occurred.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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Resident #26 Review of Resident #26's medical record revealed an admit date of 02/03/2022 with diagnoses that included in part .Malignant Neoplasm of Parotid Gland, Hypothyroidism, Anemia, and Dementia. Review of Resident #26's quarterly MDS revealed the resident had a BIMS of 11, which indicated moderate cognitive impairment. Review of the MDS revealed Resident #26 required set up or clean up assistance with eating. Review of Resident #26's weights revealed the following which represented a significant weight loss of 11.03%: 05/27/2024-117 pounds 04/29/2024-119 pounds 02/07/2024-130 pounds 01/01/2024-130.5 pounds 12/04/2024-131.5 pounds Review of the nurses' notes revealed the following entry by S8 RD: 05/09/2024: RD assessment related to weight change. Height: 62 Weight 117.5 pounds (05/06/24) -9.6% x 88 days . Nursing reports poor appetite and intakes. House Supplement 8 oz increased to TID on 4/14/24. Tolerating regular, NAS diet. Nursing will continue to encourage oral intake of meals, snack and supplements. Continue w/ diet and supplement as prescribed .Will continue to monitor weight and oral intake. Review of Resident #26's care plan with a target date of 06/20/2024 revealed the resident was care planned for risk for altered nutrition related to decreased appetite, weight loss, due to depression, dementia, CAD, delirium, etc. Interventions included in part .Encourage fluids as tolerated, avoid fluid overload; administer medications as ordered; Record percentage of food intake and follow diet as ordered; Monitor food intake each meal. Record and report decline in intake to MD and RD; Report weight variance to MD and RD; Review of Resident #26's medical record revealed the last weight loss notification was sent to Resident #26's physician and family on 09/06/2023. In an interview on 06/04/2024 at 10:30 a.m., S2 DON stated she could not provide documentation of Resident #26's food intake because no one had been documenting it. S2 DON confirmed staff should have been recording Resident #26's food intake at meals. In an interview on 06/04/2024 at 4:56 p.m., S2 DON stated the last weight loss notification letter sent to Resident #26's medical doctor and family was sent in September 2023. S2 DON confirmed they had not notified the resident's family and physician of her weight loss since September 2023 but should have. Based on record review and interview, the facility failed to develop and implement a person-centered care plan for each resident by failing to: 1. Develop and implement a care plan for Resident #59 related to depression, and 2. Record food intake for and notify Resident #26's physician and family of significant weight loss. There were 38 sampled residents. Findings: Resident #59 Review of Resident #59's EHR revealed an admit date of 09/02/2021 with diagnoses that included in part . Cerebral Infarction, Acute Respiratory Failure, Essential (primary) Hypertension, and Major Depressive Disorder. Review of June 2024 Physician orders revealed: 1. Torsemide 10 mg po qd 2. Aricept 10 mg po hs 3. Buspirone 5 mg po tid Review of Resident #59's quarterly MDS with an ARD of 05/08/2024 revealed the resident had a BIMS of 11, which indicated moderate cognitive impairment. Review of the MDS revealed Resident #59 received Antianxiety and Antidepressant medications with Active Diagnoses that included . CVA, Anemia, Coronary Artery Disease, ESRD, HTN, Heart Failure, Non-Alzheimer's Dementia, Depression, and Pneumonia. Review of Resident #59's care plan with a target date of 08/08/2024 revealed the resident was not care planned for Major Depressive Disorder and Anxiety. In an interview on 06/04/2024 at 2:55 p.m. with S2 DON confirmed Resident #59 was not care planned for Depression and should have been.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6 Record review revealed Resident #6 was admitted to the facility on [DATE] and had diagnoses that included in part . UTI, Bacteriuria, Chronic Kidney Disease- Stage 4, Generalized Muscle Weakness, Dysphagia, Cognitive Communication Deficit, Type 2 Diabetes Mellitus, and Major Depressive Disorder. Review of Resident #6's Quarterly MDS with ARD of 03/13/2024 revealed Resident #6 had a BIMS of 15 (Cognition Intact). Resident #6 had lower extremity Range of Motion impairment on both sides. Resident #6 was dependent on staff for showering/bathing. Review of Resident #6's Comprehensive Person Centered Plan of Care revealed Resident required assistance with ADLS. Review of Resident #6's medical record revealed no documentation of assistance with bathing performed. Interview on 06/02/2024 at 9:38 a.m. with Resident #6 revealed she was to receive baths on Monday-Wednesday-Friday, and stated she was only getting bathed once a week. Interview on 06/03/2024 at 10:18 a.m. with S17 CNA revealed Resident #6 did not have refusals for ADL care. S17 CNA stated she does not document when a resident received a bath, as the computer system did not allow her to. S17 CNA stated Resident #6 required assistance from staff for bathing and was 2 person assist. S17 CNA stated Resident #6 was to receive a bath today. Resident #12 Record Review revealed Resident #12 was admitted to the facility on [DATE] and had diagnoses that included in part .Unspecified Dementia, Schizoaffective Disorder, Primary Generalized Osteoarthritis, Unspecified Abnormalities of Gait and Mobility, and UTI. Review of Resident #12's Quarterly MDS with ARD of 02/14/2024 revealed Resident had a BIMS of 12 (Moderate Cognitive Impairment). Resident #12 required setup assistance for showering/bathing, and personal hygiene. Review of Resident #12's Comprehensive Person Centered Plan of Care revealed Resident required assistance with ADLS. Review of Resident #12's medical record revealed no documentation of assistance with bathing performed. Interview on 06/02/2024 at 10:43 a.m. with Resident #12 revealed she had concerns of only getting a bath once weekly. Interview on 06/03/2024 at 10:18 a.m. with S17 CNA revealed Resident #12 did not have refusals for ADL care, and required assistance of staff for ADL care. Resident # 87 Record review revealed Resident #87 was admitted to the facility on [DATE] and had diagnoses that included in part Unspecified Dementia, Major Depressive Disorder, Alzheimer's Disease, and Coronary Artery Disease. Review of Resident #87' sadmission MDS with ARD of 03/14/2024 revealed Resident #87 had a BIMS of 10 (Moderate Cognitive Impairment). Resident #87 had lower extremity impairment on both sides. Resident #87 required Substantial/Maximal assistance with toileting, showering/ bathing, and dressing. Resident #87 was dependent on staff for personal hygiene. Review of Resident #87's Comprehensive Person Centered Plan of Care revealed Resident required assistance with ADLS. Review of Resident #87's medical record revealed no documentation of assistance with bathing performed. Interview on 06/02/2024 at 10:13 a.m. with Resident #87 revealed he stated he was frustrated because staff left him with a dirty diaper and he called for help, but the CNA's leave him dirty. Resident #87 stated he received a bath once a week, and had complained about not getting bathed multiple times, but could not recall who he spoke to. Observation revealed a strong BM odor within Resident #87's room. Interview on 06/03/2024 at 3:03 p.m. with S2 DON revealed the bathing schedule for Residents was Monday-Wednesday-Friday for women, and Tuesday-Thursday-Saturday for men, and Sundays were a makeup day. S2 DON stated Residents are also bathed as needed. S2 DON confirmed Resident #6, Resident #12, and Resident #87 had no documented baths, but should have. S2 DON confirmed staff should have documented when a Resident received baths per schedule, or PRN within the Resident's medical record, but failed to do so. Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide baths, shaving, and nail care to dependent residents for 5 (#6, #10, #12, #66,and #87) of 7 (#6, #10, #12, #33, #44, #66, and #87) residents reviewed for ADL's. Findings: Review of the facility policy on at 06/03/2024 at 10:35 a.m. titled: Activities of Daily Living (ADL), Supporting, revealed in part .Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care , including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); Review of the facility policy on 06/03/2024 at 10:35 a.m. titled: Fingernails/Toenails, Care of General Guidelines read in part . 1. Nail care includes daily cleaning and regular trimming. #66 Review of Resident #66's Quarterly MDS with an ARD of 05/08/2024 revealed a BIMS of 13 indicating severe cognitive impairment. Resident #66 required supervision and touch assistance with personal hygiene. Review of Resident #66's care plan with a review date of 05/26/2024 read in part Resident #66 has self-care deficit and required assistance with ADL's due to Intellectual Disability and Schizophrenia. Observation on 06/02/2024 at 12:17 p.m. revealed Resident #66's fingernails were 1/4 inch in length, jagged, and with brown substance under all nails. Resident #66 stated that he would like to have his fingernails cleaned and cut. Observation on 06/03/2024 at 9:40 a.m. revealed Resident #66 nails were long, jagged and had a brown substance under all nails. Interview on 06/03/2024 at 9:45 a.m. with S2 DON confirmed Resident #66's nails were long, jagged and dirty and should have been cleaned and clipped, but had not been. Resident #10 Review of Resident #10's current care plan revealed ADL self-care deficit with interventions to remove chin hairs as needed. Observations on 06/02/2024 at 11:17 a.m. revealed Resident #10 had facial hair that was approximately 1/16th to 1/8th inches long. Resident #10 stated that he can't shave himself anymore because of his hands and would like to be shaved. Observation on 06/03/2034 at 8:48 a.m. Resident #10 continues with long facial hair. Resident #10 stated he believes the facility does not have enough razors to shave him. Observations on 06/04/2024 at 08:50 a.m. revealed Resident #10 unshaven. Interview with Resident #10 at that time revealed he had a bath this morning but was not shaved by staff. Interview on 06/04/2024 at 9:15 a.m. S2 DON stated the facility has the necessary equipment available to shave residents. S2 DON stated she is not aware of Resident #10 refusing care. S2 DON confirmed Resident #10 has long facial hair and should have been shaved when he was bathed, but had not been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu to ensure nutritional adequacy. Findings: Record review of the menu for the 06/02/2024 lunch meal revealed in part: Oven roasted turkey breast - 3 ounces Roasted turkey gravy - 2 ounces Au gratin potatoes - ½ cup Green peas - ½ cup Observations on 06/02/2024 at 12:29 p.m. of the food serving line in the kitchen, revealed S6 Dietary [NAME] preparing trays on the serving line for residents in the dining room. As the trays were prepared, they were then given to the CNAs to serve the residents. Observations revealed that roasted turkey gravy was not being served. Interview on 06/02/2024 at 12:30 p.m. with S6 Dietary Cook, confirmed that she had not served roasted turkey gravy to any of the trays that she had prepared, and there was no gravy on the serving line. Interview on 06/02/2024 at 12:30 p.m. with S5 Dietary Manager, confirmed that the menu called for 2 ounces of roasted turkey gravy, and there was no turkey gravy served, and there was no gravy on the serving line.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to ensure pureed foods were prepared according to the approved recipe by methods which conserved nutritional value for 8 residents that are served pureed diets by the facility's kitchen. Findings: Review of the facility's policy on 06/04/2024 at 9:51 a.m. titled Standardized Recipes read in part . Policy Statement: Standardized recipes shall be developed and used in the preparation of food. Policy Interpretation: 1. Only tested, standardized recipes will be used to prepare foods. 2. Standardized recipes will be adjusted to the number of portions required for a meal. 3. The food service manager will maintain the recipe file and make it available to food service staff. Interview on 06/02/2024 at 11:45 a.m. S6 Dietary [NAME] revealed she had already pureed lunch. S6 Dietary [NAME] stated she did not measure the amount of turkey she added to the dish to be pureed. S6 Dietary [NAME] stated she did not use the recipe to prepare the pureed meal. Interview on 06/02/2024 at 12:35 p.m. S5 Dietary Manager confirmed the recipe for the pureed meals were not followed because she could not locate them, but should have been. Interview on 06/03/2024 at 12:30 p.m. with S8 RD revealed the recipe for all meals should be followed to ensure residents are receiving adequate caloric intake.

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 F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

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Based observation, record review, and interview the facility failed to ensure residents received meals at regular times, comparable to normal meal times in the community and in accordance with residents' needs and preferences. This deficient practice had the potential to affect all residents who are served meals in the dining room. Findings: Review of the facility's undated policy titled Frequency of Meals on 06/03/2024 at 11:00 a.m. revealed in part . The facility will serve at least three meals or their equivalent daily at scheduled times. Meals will be served 4 to 6 hours apart to help assure residents receive nutritional requirements. The following meal times have been established by our facility for residents: Breakfast starts at 6:30 a.m. Lunch starts at 11:30 a.m. Dinner starts at 4:30 p.m. Observation of the lunch meal on 06/02/2024 revealed staff began serving residents in the dining room at 12:20 p.m. Observation of the breakfast meal on 06/03/2024 revealed staff began serving residents in the dining room at 8:00 a.m. Observation of the lunch meal on 06/03/2024 revealed staff began serving residents in the dining room at 12:11 p.m. Observation of the breakfast meal on 06/04/2024 at 8:00 a.m. revealed only a few residents in the dining room had been served trays and the others were still waiting on their trays to be served. In an interview on 06/02/2024 at 12:49 p.m., Resident #78 (BIMS of 14) stated most times she gets dinner at 6:00 p.m. but they are supposed to be served at 4:00 p.m. Resident #78 stated most times she received lunch around 2:00 PM. During an interview on 06/02/2024 at 1:30 p.m., Resident #78 stated she received lunch at 1:20 p.m. In an interview on 06/02/2024 at 12:51 p.m., S14 CNA stated lunch should be served at 11:30 a.m. with the dining room served first and then the carts are brought down the halls. S14 CNA stated her hall is served last and most residents don't get their meal until at least 1:30 p.m. In an interview on 06/02/2024 at 8:40 a.m., S6 Dietary [NAME] stated there was only 2 employees working today in the kitchen. S6 Dietary [NAME] stated she was doing everything she could but they are short-handed. S6 Dietary [NAME] stated that they have been short for a few weeks, and that was why breakfast was late. During the Resident Council meeting on 06/02/2024 at 2:00 p.m., the residents voiced concerns of not receiving meals on time. Residents stated they are served anywhere from 1 to 2 hours late. In an interview on 06/04/2024 at 4:00 p.m., S5 Dietary Manager stated she did not have a staffing schedule for June 2024. When asked about the staffing for Sunday, June 2, 2024, she indicated that she does not know if 2 staff members were adequate to get the meals out on time. S5 Dietary Manager indicated that she was recently hired and they have a lot of things that she needs to work on.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Freezer and refrigerator temperatures were monitored; 2. Sanitation levels were checked in the 3 compartment sink; 3. Refrigerated food contents were labeled, dated, and stored in a sanitary manner; and 4. Kitchen equipment was clean and sanitary. Findings: Observation on 06/02/2024 at 8:45 a.m., revealed the refrigerator and freezer temperature logs had not been checked with temperatures documented, from 05/31/2024 through 06/02/2024. Observation on 06/02/2024 at 8:50 a.m., revealed the walk-in freezer had a bag of approximately 20 breadsticks, and a bag of approximately 50 breadsticks that were opened and not dated. An interview with S6 Dietary [NAME] at that time, verified the bags of breadsticks were open and not dated. Observation on 06/02/2024 at 8:59 a.m. revealed the 3-compartment sink had water in all of the compartments. There was a wire screen and several cooking utensils on the sanitizer side sink shelf. Interview with S6 Dietary [NAME] at the time of the observation, revealed she did not check the sanitizer in the 3-compartment sink. She stated that she was too busy, and did not have enough time to check the sanitizer level. Observation on 06/02/2024 at 9:05 a.m. revealed the kitchen's microwave had multiple food particle splatters on the inside of the microwave. Interview with S6 Dietary [NAME] at that time, revealed the microwave should be cleaned after each use. Observation on 06/02/2024 at 9:10 a.m. revealed a dark brown/black substance noted on the upper portion of the inner surface of the ice machine. The inner surface was dripping on the ice below. The ice bin scoop was noted to be stored in a scoop holder, with a dark brown/black substance noted at the bottom of the scoop holder that the scoop was sitting in. Interview with S6 Dietary [NAME] confirmed the observation at that time.

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 F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 84 residents who resided in the facility. Findings: Review of the facility's undated policy titled Pest Control on 06/03/2024 at 10:35 a.m. read in part . Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is free of insects and rodents. Observation on 06/02/2024 at 9:20 a.m. of Resident #23 in Room A on Hall X revealed there were multiple flies observed in the room. Resident #23 stated her room always had flies. Observation on 06/02/2024 at 9:39 a.m. of Resident #6 in Room B on Hall X revealed there were multiple flies flying around room. Resident #6 stated flies were in her room year round, and the facility could not get rid of them, likely because her room stayed dirty. Observation on 06/02/2024 at 9:41 a.m. of Room C, revealed the resident within room had 8 flies on his bed covering while he slept. Observation on 06/02/2024 at 10:13 a.m. of Resident#87 in Room D on Hall X revealed there were 7 flies lying on the covering of his bed. A red fly swatter was observed on his wheelchair. Resident #87 stated the flies were horrible, and the facility had not done anything to get rid of them. Interview on 06/02/2024 at 10:17 a.m. with S4 ADON on Hall X confirmed Hall X had a large amount of flies throughout the hall and within resident rooms, and should not. Observation on 06/02/2024 at 10:34 a.m. with Resident #78 in Room E on Hall X revealed multiple flies within room. Observation on 06/02/2024 at 12:25 p.m. of the dining area revealed multiple flies throughout dining room. Residents were observed swatting flies away while eating meal. Interview with Resident #43 at time of observation revealed she stated flies were always in the dining room and that made it hard to enjoy her meal. Resident #43 stated the facility needed to spray to get rid of the flies. Interview on 06/03/2024 at 10:49 a.m. with S1 Administrator revealed the facility had a pest control service contract. Review of the contract provided by S1 Administrator at time of interview revealed the company came out for monthly services, and as needed. S1 Administrator provided Pests Sighted log and stated this was the facility's pest control log. S1 Administrator stated employees document if pest are seen and the exterminator is called out. S1 Administrator stated when pest control came out for service, he initialed on the log. Review of the Pests Sighted log revealed the exterminator did not come out for flies reported on 10/07/2023 or 11/16/2023. Review of Pests Sighted log revealed no entries for month of June 2024. S1 Administrator confirmed the above findings and stated the facility had a problem with flies within facility. Telephone interview on 06/04/2024 at 4:32 p.m. with the facility's contracted pest control worker revealed he performed monthly services that included the treatment of flies. The contract worker stated he put fly bait out by the dumpster and outdoor areas, and sprayed insecticide on the outside of doors. The contract worker stated he had recommended the use of air curtains near door entries and fly lights, but the facility had not yet implemented those recommendations, and stated he was unaware the facility had a current issue with flies.

Dec 2023 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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure resident's right to be treated with respect and dignity for 2 (#2 and #3) of 4 (#1, #2, #3, and #4) sampled residents reviewed for dignity. Findings: Review of the Facility's policy labeled Dignity read in part . Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation: 12. Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents. Resident #2 Review of Resident #2's medical record revealed an admit date of 03/10/2023 with diagnoses that included: Encephalopathy, Anxiety disorder, Adult Failure to Thrive, Down Syndrome, and Unspecified Mood Disorder. Review of Resident #2's Care Plan with review dated 12/20/2023 read in part . Resident has potential for impaired skin integrity related to incontinence: Incontinence care to be provided every 2 hours. Resident has episode of urinary incontinence related to loss of bladder muscle tone: Use disposable briefs every 2 hours during the day, every 4 hours at night, and as needed for soiling. Review of Resident #2's quarterly MDS with ARD 09/20/2023 revealed a BIMS of 00 indicating severe cognitive impairment. Resident #2 is incontinent of bowel/ bladder and is dependent on staff for personal hygiene and toileting needs. Observation on 12/19/2023 at 10:00 a.m. revealed S3 LPN removed Resident #2's diaper. Resident #2 was observed double diapered with a pull up and diaper on top of the pull up. Resident #2's pull up was soiled with urine. S3 LPN confirmed Resident #2 was double diapered. Interview on 12/19/2023 at 1:30 p.m. with S5 CNA revealed she double diapered Resident #2 because he was going often. S5 CNA stated she did not double diaper often and was not instructed by management staff to double diaper residents but chose to do it on her own because Resident #2 was going often. Resident #3 Review of Resident #3's medical records revealed an admit date of 09/02/2021 with diagnoses that included: Unspecified Mood Disorder, Depression, Paranoid Personality Disorder, Anxiety Disorder, Other Seizures, Type 2 DM, Essential Hypertension, and Cerebral infarct to right side. Review of Resident #3's quarterly MDS with ARD of 09/20/2023 revealed a BIMS of 11 which indicated moderate cognitive impairment and required 1-person assistance with transfers, bed mobility, toilet use, bathing, and personal hygiene. Interview on 12/19/2023 at 9:45 a.m. with Resident #3 revealed that staff double diapered him at times. Resident #3 then stated he was tired and no longer wanted to be interviewed at this time. Interview on 12/19/2023 at 12:18 p.m. with Resident #3 revealed staff at times would put 2 diapers on him, typically during the day shift, but he did not know why. Interview on 12/20/2023 at 2:57 p.m. with S2 ADON revealed double diapering is an issues that has been addressed in the facility before and that staff have been educated to never double diaper a resident. Interview on 12/20/2023 at 3:47 p.m. with S6 CNA revealed staff were to change residents every 2 hours and that some residents require to be changed more often. S6 CNA denied ever double diapering a resident. S6 CNA stated a couple times a week, she had seen residents double diapered when she came on shift.

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

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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 infections for 1 (#4) of 4 (#1, #2, #3, #4.) sampled residents reviewed for infection control practices. The facility failed to ensure resident hands were cleaned prior to dining. Findings: Review of Resident #4's medical records revealed an admit date of 07/13/2016 with diagnoses that included: Cerebral Infarction, Unspecified Convulsions, Anxiety Disorder, Essential Hypertension, Chronic Kidney Disease, Stage 3, Vascular Dementia, Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder. Review of Resident #4's Care plan with review date 11/04/2023 revealed: Resident #4 had ADL self-care deficit and required assistance with ADL's with interventions that included to encourage to participate in simple ADL's such as: wash hands, face, oral care and hair care. Resident #4 required supervision with eating. Resident #4 was at risk for altered nutrition: Supervise dining and encourage to eat. Review of Resident #4's Quarterly MDS with ARD of 10/06/2023 revealed a BIMS of 9 indicating moderate cognitive impairment. Resident #4 required set up or clean up assistance with meals and was incontinent of bowel/bladder and dependent on staff for personal hygiene. Observation on 12/19/2023 at 12:35 p.m. revealed Resident #4 feeding herself lunch with her hands. Resident #4's hands and nails were soiled with large amount of smeared brown substance. Resident #4 was observed licking her soiled hands after putting cinnamon apple slices into her mouth. On 12/19/2023 at 12:40 p.m., S1 DON observed Resident #4 while eating. S1 DON confirmed that Resident #4's hands were soiled with feces after smelling her hands. Interview on 12/19/2023 at 12:50 p.m. with S5 CNA revealed when gave Resident #4 her lunch tray she noticed the brown substance on Resident #4's hands, but did not clean her hands because she figured it was from the brownie that she gave her earlier today. S5 CNA stated when she set up Resident #4's tray, she handed the resident her utensils but Resident #4 will at times put down the utensils and eat with her hands. Interview on 12/20/2023 at 2:50 p.m. with S2 ADON revealed Resident #4 was set up help assist with meals. S2 ADON stated Resident #4 will eat with her hands at times. S2 ADON revealed that she had cleaned the Resident #4's hands after she was observed eating with soiled hands and it appeared to be feces on her right hand. S2 ADON stated the staff member that served resident #1 her tray should have cleaned her hands prior to serving her tray, but did not.

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 F0676 (Tag F0676)

Could have caused harm · This affected multiple residents

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Based on observation, interviews and record review, the facility failed to ensure each resident was given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living for 2 (#2 and #4) of 4 (#1, #2, #3, and #4) residents reviewed for ADLs. The facility failed to ensure: 1. Staff made rounds on Resident #2 every 2 hours 2. Resident #4's hands were cleaned prior to meal time. Findings: Review of the facility's policy Activities of Daily Living read in part Policy statement: Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal/oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene c. Elimination d. Dining Resident #2 Review of Resident #2's medical record revealed an admit date of 03/10/2023 with diagnoses that included: Encephalopathy, Anxiety disorder, Adult Failure to Thrive, Down Syndrome, and Unspecified Mood Disorder. Review of Resident #2's Care Plan with review dated 12/20/2023 read in part . Resident has potential for impaired skin integrity related to incontinence: Incontinence care to be provided every 2 hours. Resident has episode of urinary incontinence related to loss of bladder muscle tone: Use disposable briefs every 2 hours during the day, every 4 hours at night, and as needed for soiling. Review of Resident #2's quarterly MDS with ARD 09/20/2023 revealed a BIMS of 00 indicating severe cognitive impairment. Resident #2 is incontinent of bowel/ bladder and is dependent on staff for personal hygiene and toileting needs. Interview on 12/20/2023 at 3:27 p.m. with S4 CNA revealed she was the aide for Resident #2 today. S4 CNA stated the last time she changed Resident #2 was at 11:00 a.m. S4 CNA stated that she did not make rounds on resident #2 between 11:00 and 3:30 p.m. and that Resident #2 was in his GeriChair. S4 CNA stated that Resident #2 should be seen and changed every 2 hours. Interview on 12/21/2023 at 10:09 a.m. with S1 DON revealed residents that are bed bound or incontinent should have an incontinence check every 2 hours and as needed. Resident #4 Review of Resident #4's medical records revealed an admit date of 07/13/2016 with diagnoses that included: Cerebral Infarction, Unspecified Convulsions, Anxiety Disorder, Essential Hypertension, Chronic Kidney Disease Stage 3, Vascular Dementia, Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder. Review of Resident #4's Care plan with review date 11/04/2023 revealed: Resident #4 has ADL self are deficit and requires assistance with ADL's- encourage to participate in simple ADL's such as: wash hands, face, oral care and hair care. Supervision with eating. Resident is at risk for altered nutrition: Supervise dining and encourage to eat. Review of Resident #4's quarterly MDS with ARD of 10/06/2023 revealed a BIMS of 9 indicated moderate cognitive impairment. Resident #4 requires set up or clean up assistance with meals and is incontinent of bowel/bladder dependent of staff for personal hygiene. Observation on 12/19/2023 at 12:35 p.m. revealed Resident #4 feeding herself lunch with her hand. Resident #4's hands and nails are soiled with large amount of smeared brown substance. Resident #4 was observed licking her soiled hands after putting apple cinnamon slices into her mouth. On 12/19/2023 at 12:40 p.m., S1 DON observed Resident #4 using her hands to eat. S1 DON confirmed that Resident #4's hands were soiled with feces after smelling her hands. Interview on 12/19/2023 at 12:50 p.m. with S5 CNA revealed when gave Resident #4 her lunch tray she noticed the brown substance on Resident #4's hands, but did not clean her hands because she figured it was from the brownie that she gave her earlier today. S5 CNA stated when she set up Resident #4's tray, she handed the resident her utensils but Resident #4 will at times put down the utensils and eat with her hands. Interview on 12/20/2023 at 2:50 p.m. with S2 ADON revealed Resident #4 required set up assistance with meals. S2 ADON stated Resident #4 will eat with her hands at times. S2 ADON stated she cleaned the resident's hands after she was observed eating with soiled hands and it appeared to be feces on her right hand. S2 SDON stated the staff member that served Resident #4 her tray should have cleaned her hands prior to serving her tray to her.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident. The facility failed to honor the resident smoking preferences for 6 (#R1, #R2, #R3, #R4, #R5, and #R6) out of 9 (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, and #R6) sampled residents reviewed for smoking. Findings: Review of the facility's Resident Rights policy read in part . Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: e. Self- Determination g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States Resident #R6 A Review of Resident #R6 quarterly MDS with ARD of 11/23/2023 revealed a BIMS of 15 which indicated the resident is cognitively intact. A review of Resident #R6 Safe Smoking assessment dated [DATE] read in part . Resident #R6 follows the policy and is able to smoke safely. All smokers are supervised. An interview on 11/28/2023 at 9:09 a.m. with Resident #R6 revealed she is allowed to smoke 3 times a day. Resident #R6 stated she would like to smoke at least 4 times a day and has mentioned it in the Resident Council meeting on several occasions but nothing has changed. Resident #R5 A Review of Resident #R5 quarterly MDS with ARD of 10/18/2023 revealed a BIMS of 15 which indicated the resident is cognitively intact. A review of Resident #R5 Safe Smoking assessment dated [DATE] read in part . Resident #R5 follows the policy and is able to smoke safely. All smokers are supervised. An interview on 11/28/2023 at 9:10 a.m. Resident #R5 revealed that she has notified several staff members that she would like 4 cigarette breaks a day but is never allowed more than 3 smoke breaks a day. Resident #R4 A Review of Resident #4 quarterly MDS with ARD of 10/04/2023 revealed a BIMS of 15 which indicated the resident is cognitively intact. A review of Resident #R4 Safe Smoking assessment dated [DATE] read in part . Resident follows the policy and is able to smoke safely. Resident is considered an unsafe smoker and must be monitored when smoking. An interview on 11/28/2023 at 10:07 a.m. with Resident #R4 revealed he is a smoker and is allowed to go out to smoke 3 times a day. Resident #R4 stated he has asked to go more than 3 times a day but staff will not allow him to go or allow him to keep his cigarette. Resident #R4 stated he has never burned himself or had any accidents from smoking. Resident #R4 stated that he was never notified prior to admission that smoking was limited to 3 times and day. Resident #R4 stated he would not have admitted to the facility had he known that information. Resident #R3 A Review of Resident #R3 quarterly MDS with ARD of 09/26/2023 revealed a BIMS of 13 which indicated the resident is cognitively intact. A review of Resident #3 Safe Smoking assessment dated [DATE] read in part . Resident follows the policy and is able to smokes/Dips safely. An interview on 11/28/2023 at 1:25 p.m. with Resident #R3 revealed he smokes and chews tobacco. Resident #R3 stated on days he goes to dialysis he has 1 tobacco break a day in the facility and has asked for more on several occasions but has been denied. Resident #R2 A Review of Resident #R2 quarterly MDS with ARD of 9/13/2023 revealed a BIMS of 15 which indicated the resident is cognitively intact. A review of Resident #R4 Safe Smoking assessment dated [DATE] read in part . Resident #R2 follows policy and smokes safely. An interview on 11/28/2023 at 1:26 p.m. with Resident #R2 revealed he smokes a pipe and his daughter supplies the tobacco for him. Resident #R2 stated he cannot understand why he can't smoke as many times as he wants because he is safe and supplies his own material. Resident #R2 stated he has expressed wanting to smoke more than 3 times a day but has not been allowed to. Resident #R1 A Review of Resident #R1 quarterly MDS with ARD of 10/18/2023 revealed a BIMS 13 of which indicated the resident is cognitively intact. A review of Resident # R1 Safe Smoking assessment dated [DATE] read in part . Resident #R1 follows policy and smokes safely. All Smoke breaks are supervised. An interview on 11/28/2023 at 1:30 p.m. with Resident #R1 revealed that he is given around 20 minutes to smoke 3 times a day. Resident #R1 states staff urge you to smoke fast so that they can go back inside. Resident #R1 stated the facility buys his cigarette with his money but he cannot understand why he can't smoke the cigarettes as he pleases. Resident #R1 stated he has told several staff members that he would like to smoke more than 3 times a day but he has never been allowed. An interview on 11/28/2023 at 9:16 a.m. with S2 CNA stated residents often ask for extra times to smoke outside of the 3 times of day but are not allowed due to the facility's smoking policy. An interview on 11/28/2023 at 1:20 p.m. with S3 CNA stated she has had residents ask to smoke outside of the designated smoking times but she has been told that resident is only to smoke at the allowed times of 9:00 a.m., 1:00 p.m., and 5:00 p.m. An interview on 11/28/2023 at 9:00 a.m. with S1 Admissions Coordinator revealed she is responsible for meeting and going over the facility's smoking policy with all potential residents and their families prior to admission. S1 Admissions Coordinator stated the smoking policy she reads to potential residents does not give specifics on how often a resident is allowed to smoke in the facility. S1 Admissions Coordinator stated the potential resident is notified that they are not allowed to hold their own smoking material and are supervised at all times while smoking. S1 Admissions Coordinator confirmed she does not notify the potential resident or family of a specific amount of times the resident is allowed to smoke in the facility.

Jun 2023 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the Facility failed to ensure a Resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her own quality of life. The Facility failed to ensure a Resident's urinary catheter drainage bag was covered to ensure privacy for 1 (Resident #47) of 1 resident reviewed for dignity out of a total sample of 29 residents. Findings: Review of Resident #47's medical record revealed an admit date of 07/01/2019 with diagnoses which included: Urinary Tract Infection, site not specified, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Cerebral Infarction and Pain. Review of Resident #47's Quarterly MDS with an ARD of 04/12/2023 revealed resident had a BIMS score of 15 (indicating intact cognition) and required total care for bed mobility, transfer, dressing, toilet use, and personal hygiene. Review of Resident #47's care plan with a target date of 08/05/2023 revealed a potential for complications related to the presence of a Foley catheter with interventions to ensure drainage bag is off the floor and below bladder level. Observation on 06/26/2023 at 9:47 a.m. from the hallway revealed Resident #47 was awake in bed. A Foley catheter bag was observed hanging from the right side of the resident's bed frame. There was no privacy bag over the Urinary catheter drainage bag that contained approximately 200 milliliters of yellow urine. Observation on 06/27/2023 at 9:03 a.m. from the hallway revealed Resident #47 was awake in bed. A Foley catheter bag was observed hanging from the right side of the resident's bed frame. There was no privacy bag over the Urinary drainage bag that contained approximately 700 milliliters of yellow urine. Observation and interview on 06/27/2023 at 9:11 a.m. of Resident #47 accompanied by S2 DON confirmed that Resident #47's Foley catheter Urinary drainage bag with urine in it, was not covered and was visible from the hallway. S2 DON confirmed Resident #47's Foley catheter drainage bag should have been in a privacy bag and it was not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to inform each resident as soon as was possible of changes in Medicare covered services as evidenced by the provider's failure to send the Centers for Medicare and Medicaid Services (CMS) Form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage as required for 2 (#24, #143) of 2 residents reviewed for Beneficiary Notification who required the notification. Findings: Resident #24 Review of the SNF Beneficiary Protection Notification Review form completed by the facility on 06/28/2023 revealed Resident #24 was discharged from Medicare Part A Services on 04/12/2023 with benefit days remaining. Further review of the form revealed Form CMS-10055 had not been provided to Resident #24. Review of Resident #24's medical record revealed she was discharged from Medicare Part A Services because her goals had been met. In an interview on 06/28/2023 at 1:19 p.m., S9 Clerical reported she was the person responsible for completing the Advanced Beneficiary Notices and confirmed she had not completed and provided the CMS-10055 to Resident #24 prior to her discharge from Medicare Part A Services. Resident #143 Review of the SNF Beneficiary Protection Notification Review form completed by the facility on 06/28/2023 revealed Resident #143 was discharged from Medicare Part A services on 01/15/2023 with benefit days remaining. Further review of the form revealed CMS-10055 form had not been completed and provided to Resident #143. In an interview on 06/28/2023 at 1:38 p.m., S9 Clerical reported Resident #143 was discharged from Medicare Part A services on 1/15/23 with benefit days remaining and the CMS-10055 form had not been provided to Resident #143 prior to the resident's discharge from Medicare Part A Services.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Resident Assessment Based on record review and interview, the facility failed to ensure a discharge assessment was electronically transmitted in a timely manner within 14 days of completion for 1 (#18) of 1 residents reviewed for resident assessment. Findings: Resident #18 Review of Resident 18's medical record revealed the last MDS transmitted had an ARD of 02/01/2023. Further review revealed a discharge MDS dated [DATE] with a status of open. In an interview on 06/27/2023 at 12:57 p.m., S4 LPN reported Resident #18 was discharged on 04/20/2023. S4 LPN confirmed Resident #18's discharge MDS was never transmitted and should have been.

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

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Based on interview and record review the facility failed to maintain resident's highest practicable physical, mental and psychosocial well-being for 3 (Resident #15, Resident #42 and Resident #192) of 29 sampled residents by failing to implement their comprehensive person-centered care plan. Findings: #15 Review of Resident #15's face sheet revealed an admit date of 05/19/2023 with the following diagnoses including SOB, COPD with acute exacerbation, and Emphysema. Review of Resident #15's Care Plan with target date of 09/09/2023 for Airway clearance, Impaired potential r/t Dx COPD, Emphysema, Refuses to wear oxygen at times even though SOB. Interventions included Assess/record/report to MD prn: Tachypnea, Wheezes, Rales, Rhonchi, Crackles, Dyspnea, SOB, Orthopnea, Cough, Fever, Chills, and Cyanosis. Review of Resident #15's 06/2023 MD Orders revealed the following including: 05/19/2023 - Full set of VS every Monday night 05/30/2023 - Monitor temp and oxygen saturation each shift Review of Resident #15's EHR revealed no documentation that Resident #15's vital signs or oxygen saturation was monitored as ordered by the MD. #42 Review of Resident #42's EHR revealed an admit date of 02/07/2023 with a readmit date of 06/19/2023 with the diagnoses including E. coli, and Staph infection. Review of Resident #42's 06/2023 MD Orders revealed the following including: 06/19/2023 - Full set of VS every Monday night 06/19/2023 - Monitor temp and O2 sat each shift Review of Resident #42's EHR revealed no documentation that the resident's vital signs or oxygen saturation was monitored as ordered by the MD. #192 Review of Resident #192's EHR revealed an admit date of 06/18/2023 with the following diagnoses including: Unspecified Protein-Caloric Malnutrition and COPD. Review of Resident #192's Care Plan with target date of 09/21/2023 for alteration in breathing pattern r/t SOB, decreased oxygen sats r/t COPD, on oxygen continuously with interventions which included assess respiratory status for rate, depth, ease; document findings and notify MD of significant abnormalities; pulse oximetry as ordered and as indicated; pulse oximetry as ordered and as indicated to relieve hypoxia and continued appropriateness of oxygen therapy; and oxygen 2L/NC for oxygen sats less than 90% to relieve SOB and/or hypoxia. Review of Resident #192's 06/2023 MD orders revealed the following: 06/18/2023 - Monitor oxygen sat and temp every shift 06/18/2023 - Vital signs q Monday: BP, Pulse, Resp, Temp, O2 Review of Resident #192's EHR revealed no documentation of that the resident's VS or oxygen sat had been monitored. Interview on 06/27/2023 at 3:53 p.m. with S4 LPN revealed there was no documentation that Resident #15, Resident #42 or Resident #192's temperature and oxygen saturation were checked every shift as ordered by the MD and there should be. S4 LPN also stated there was no documentation that the residents' VS were checked every Monday night as ordered by the MD and there should be.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview the Facility failed to ensure the plan of care had been revised for 1 (#52) of 21 (#15, #58, #35, #62, #23, #87, #192, #91, #42, #64, #75, #68, #6, #29, #90, #30, #33, #47, #37, #54 and #52) Residents reviewed for plan of care out of a total sample of 29. The Facility failed to revise a Resident's plan of care for dialysis. Findings: Review of Resident #52's medical record revealed an admit date of 03/18/2023 with diagnoses which included: Chronic Kidney Disease Stage 5, Dependent on Renal Dialysis and Malignant Pleural Effusion. Review of Resident #52's Significant Change MDS with an ARD of 04/19/2023 revealed resident had a BIMS score of 4 (indicating severe cognitive impairment) and required supervision and set-up assistance with meals; independent with transfer, bed mobility, locomotion, dressing toilet use and personal hygiene. Review of Resident #52's care plan with a target date of 07/18/2023 revealed a potential for complications associated with diagnosis of Chronic Renal Failure and receiving dialysis with approaches to provide fluids with meals and medication pass only, no water pitcher at bedside. Review of Resident #52's physician orders for June 2023 revealed an order for a regular diet with no added salt and a 1200 milliliter fluid restriction. Observation on 06/27/2023 at 3:31 p.m. revealed Resident #52 sitting in a recliner in his room. A water pitcher with red liquid was in front of him on his overbed table. Observation and interview on 06/28/2023 at 10:32 a.m. revealed Resident #52 sitting in a recliner in his room. A water pitcher filled with ice and water sat on an overbed table in front of him. Resident #52 stated the water pitcher was his and he received one every day. Interview on 06/28/2023 at 10:43 a.m. with S7 CNA revealed she gave Resident #52 a watcher pitcher with ice and water earlier that morning. Interview on 06/28/2023 at 10:50 a.m. with S6 DM revealed she was aware of Resident #52 being on a 1200 milliliter fluid restriction per day, but she had never been told he was not supposed to have a water pitcher. S6 DM stated Resident #52 frequently came to the kitchen and got water pitchers filled with tea or whatever he wanted to drink. Interview on 06/28.2023 at 11:20 a.m. with S8 Medical Doctor revealed he was aware of Resident #52 being on a 1200 milliliter fluid restriction per day. S8 Medical Doctor stated he was not aware of Resident #52 having a water pitcher at his bedside and stated the facility should not have been assisting Resident #52 with his fluid restriction noncompliance. Interview on 06/28/2023 at 11:41 a.m. with the dialysis center nurse revealed Resident #52 is on dialysis for 4 hours at each session and only a set amount of fluid can be removed in those 4 hours. Dialysis nurse stated if a resident gained more fluid than can be removed it could lead to the resident having Shortness of Breath, Edema, Fluid Overload and Pnuemonia etc . Interview on 06/28/2023 at 11:50 a.m. Interview with S2 DON revealed Resident #52 was on a 1200 milliliter per day fluid restriction related to his dialysis. S2 DON stated Resident #52 is noncompliant with his fluid restriction and she had met with him several times and educated him on the importance of following his fluid restriction. S2 DON stated she was aware of Resident #52 having a water pitcher at his bed side. S2 DON confirmed Resident #52's care plan had not been revised to reflect he had been receiving a water pitcher and it should have been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0729 (Tag F0729)

Could have caused harm · This affected multiple residents

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FACILITY Sufficient and Competent Nurse Staffing Based on record review and interview, the facility failed to have documented evidence the Certified Nursing Assistant (CNA) Registry was verified for 5 (S10 CNA, S11 CNA, S12 CNA, S13 CNA and S14 CNA) of 5 (S10 CNA, S11 CNA, S12 CNA, S13 CNA and S14 CNA) CNA personnel records reviewed. This failed practice had the potential to affect any of the 95 residents residing in the facility who may receive care and services per the CNAs. Findings: Review of the personnel record for S10 CNA revealed a hire date on 04/13/2015, a rehire date on 06/03/2016. There was no documented evidence the CNA Registry had been checked since 09/09/2016 for S10 CNA. Review of the personnel record for S11 CNA revealed a hire date on 05/23/2018. There was no documented evidence the CNA Registry had been checked since 07/05/2018 for S11 CNA. Review of the personnel record for S12 CNA revealed a hire date on 10/24/2022. There was no documented evidence the CNA Registry had been checked since 10/25/2022 for S12 CNA. Review of the personnel record for S13 CNA revealed a hire date on 12/09/2016. There was no documented evidence the CNA Registry had been checked since 06/13/2017 for S13 CNA. Review of the personnel record for S14 CNA revealed a hire date on 08/31/2016. There was no documented evidence the CNA Registry had been checked since 06/02/2017 for S14 CNA. Interview on 06/28/2023 at 9:10 a.m. with S9 Clerical revealed she had been employed in the facility since 02/24/2021 and was responsible for CNA certification verifications for new hire employees. S9 Clerical confirmed she had checked CNA Registry checks only on the new hire employees and had not checked the CNA certification verifications on a bi-annual basis. S9 Clerical stated she was not aware the CNA Registry verifications were to be done bi-annually. Interview on 06/28/2023 at 9:15 a.m. with S1 Admin revealed she was not aware the CNA certification verifications were not being checked with the CNA Registry and should have been. Interview on 06/28/2023 at 1:55 p.m. with S2 DON revealed HR was responsible for completing certification verifications with background checks prior to hire and the HR staff member was currently out on leave. S2 DON revealed she was not aware CNA certification verifications were required to be checked bi-annually and confirmed it was not done.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, record review and interview the Facility failed to maintain a medication error rate of less than 5% for 1 (Resident #71) of 3 (Resident #71, Resident #4, and Resident #25) Residents observed during medication administration. A total of 31 opportunities were observed which included 2 medication errors for a medication error rate of 6.45%. Findings: Observation on 06/27/2023 at 8:40 a.m. revealed Resident #71 was administered Fluphenazine (antipsychotic) 10 Milligram Tablet by mouth by S3 LPN. Review of Resident #71's current Medication Administration Record (June 2023) revealed an order for Fluphenazine 10 MG Tablet-2 by mouth every night (8:00 p.m.). Review of Resident #71's current Medication Administration Record (June 2023) revealed an order for Torsemide (diuretic) 10 Milligram Tablet 1 by mouth every morning (8:00 a.m.). Observation during medication administration pass on 06/27/2023 at 8:40 a.m. revealed this medication was not administered by S3 LPN. Interview on 06/27/2023 at 10:30 a.m. with S3 LPN confirmed she administered Fluphenazine 10 Milligram tablet by mouth to Resident #71 on 06/27/2023 at 8:40 a.m. and she should not have. S3 LPN confirmed she did not administer Resident #71 Torsemide 10 Milligram Tablet on 06/27/2023 during her morning medication administration pass and she should have. Interview on 06/27/2023 at 11:28 a.m. with S2 DON revealed S3 LPN is an agency nurse who had worked at the facility on and off for a while. S2 DON stated she had in-serviced nurses on following the Medication Administration Record and the expectation is for all nurses to follow the Medication Administration Record.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based on observation and interview the facility failed to dispose of garbage and refuse properly. This could affect all 95 residents in the facility. Findings: Review of the facility's policy titled Food-Related Garbage and Refuse Disposal revealed the following including: Policy Interpretation and Implementation #6. Storage areas will be kept clean at all times, and shall not constitute a nuisance. #7. Outside dumpster provided by garbage pickup services will be kept closed and free of surrounding litter. Observation on 06/26/2023 at 8:15 a.m. of the facility dumpster revealed multiple trash bags and 3 broken bed frames lying on the ground around the dumpster. Interview at this time with S5 Dietary confirmed the above findings. She stated the trash bags and bed frames were on the ground when she last worked on 06/22/2023. Observation on 06/26/2023 at 9:13 a.m. of the facility dumpster with S1 Administrator revealed a trash truck picking up trash from the dumpster and on the ground around the dumpster. S1 Administrator stated that the facility trash was picked up on Monday, Wednesday and Friday. S1 Administrator stated that the facility was not notified when trash was not going to be picked up so she could not confirm how long it had been there. Observation on 06/26/2023 at 9:25 a.m. of the facility dumpster revealed the trash truck was gone and the 3 broken bed frames remained on the ground around the dumpster. Interview on 06/26/2023 at 9:31 a.m. with S1 Administrator revealed the trash truck did not pick up bed frames and she would have staff pick up and dispose.

Mar 2023 3 deficiencies 3 IJ (2 facility-wide)

CRITICAL (K) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0697 (Tag F0697)

Someone could have died · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management cons istent with professional standards of practice for 1 (Resident #1) of 5 (#1, #2, #3, #4, & #5) sampled residents. The facility failed to: 1. Intervene and ensure Resident #1 received the necessary treatment/interventions when Resident #1 voiced and exhibited increased/worsening pain to her right lower extremity, and became bedfast due to the increased pain, after initial treatment of the increased pain by the physician was not effective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. Resident #1, a severely cognitively impaired resident who required limited assistance by one person with ambulation, began complaining of pain in her right leg/knee/ankle on 01/16/2023, and became unable to ambulate on 01/17/2023 due to increased pain. Resident #1 was assessed by the physician on 01/17/2023, and treatment was prescribed. Resident #1's pain continued to worsen, and Resident #1 continued to decline in ADLs. On 01/19/2023, S7 LPN and S3 LPN reported to S2 DON that Resident #1's pain was not being relieved, and that her right leg was swollen, shiny, and cooler than the left leg. On 01/20/2023, S4 LPN reported to S2 DON that Resident #1 was dizzy, pale, and did not look right. Resident #1's change of condition on 01/19/2023 and 01/20/2023 was not reported to the physician until 01/26/2023. Resident #1 was x-rayed on 01/26/2023, which revealed an acute fracture and dislocation of the femoral neck of the right hip. Resident #1 required surgical intervention of a right bipolar hip arthroplasty on 01/27/2023. This deficient practice continued at a potential for more than minimal harm for 33 facility Residents who received treatment for pain. S1 Administrator was notified of the Immediate Jeopardy on 03/02/2023 at 2:20 p.m. The Immediate Jeopardy was removed on 03/03/2023 at 3:33 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews and interviews that the Plan of Removal have been initiated and/or implemented: The Facility's plan of removal include the following: In-services were initiated for all staff by the Administrator and Corporate Managing Member on 03/02/2023 and 03/03/2023 and will be completed by 03/06/2023 at 6:30 p.m. The in-services covered the existing policy on the Clinical Protocol to Provide Pain management which includes: The staff well reassess the Residents pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The staff will evaluate and report the Residents use of standing and PRN analgesics. The in-services also addressed to notify the physician of acute changes in a Residents condition and the policy on Acute condition changes-Clinical protocol which stated Direct care staff including nursing assistants will be trained in recognizing subtle but significant changes in the Resident and how to communicate these changes to the Nurse. The policy also states the Nurse shall assess and document/report the baseline information on Residents current level of pain, and any recent changes in pain level to the physician. Nurses received a copy of the Clinical Protocol for Pain at the time of their in-services. Nursing staff will not be allowed to work until he or she receives training on the Clinical Protocol for Pain Management. All new hire nursing staff will be in-serviced during orientation. A total of 33 Residents were reassessed with pain assessment by the DON or designee ensuring their pain is relieved by medications beginning 03/02/2023 at 4:00 p.m. and completed by 8:00 p.m. The NFA in-serviced CNA's beginning 03/02/2023 from 5:30 p.m.-6:30 p.m. on reporting any pain or change in Residents condition to the floor nurse, DON, and NFA. Each CNA will be in-serviced prior to beginning of their shift with completion by 03/06/2023 at 6:00 p.m. Each new hire CNA will be trained during orientation. NFA in-serviced DON on 03/02/2023 at 4:45 p.m. on the Clinical Protocol to Provide Pain Management by reassessing for increase in pain and notifying the physician of pain worsens. NFA reiterated during in-service training to DON that per facility policy nurses are to report changes of unrelieved pain or changes in condition to primary care physician. In order to monitor performance and assure compliance are sustained NFA or designee will monitor notes and pain checks 5 days a week x 1 month then three times a week for one month then as needed thereafter. Negative issues will be addressed with the respective employee at the time of occurrence. Completion date 03/06/2023 Findings: Review of the Facility's policy titled, Pain-Clinical Protocol revealed in part . Assessment and Recognition 1. The Physician and staff will identify Residents who have pain or who are at risk for having pain. a. The nursing staff will assess each Resident for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Monitoring 1. The staff will reassess the Residents pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Treatment/Management 1. The physician will help identify and authorize appropriate treatments. Monitoring and Follow-Up 1. The staff will monitor and document the Resident's progress and responses to treatment, and the physician will adjust treatment accordingly. Review of the medical record for Resident #1 revealed an admit date of 09/02/2021, and diagnoses that included in part .Parkinson's disease, Unspecified abnormalities of gait, Unspecified Dementia without behaviors, Pain Unspecified, Non-displaced fracture of base of neck of Right Femur. Review of Resident #1's Quarterly MDS with an ARD of 10/19/2022 revealed a BIMS score of 4 (indicating severely impaired cognition). The MDS revealed Resident #1 was independent with set up help only for: bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, personal hygiene and bathing. No impairment of upper or lower extremity Range of Motion. Review of the MDS revealed no indication of pain. Review of Resident #1's Significant Change MDS with an ARD of 12/28/2022 revealed a BIMS score of 5, which indicated severely impaired cognition, and revealed Resident #1 required limited assistance by one person with bed mobility, transferring, toilet use, and walking. Review of Resident #1's Significant Change MDS with an ARD of 02/04/2023 revealed a BIMS score of 3 (indicating severely impaired cognition). The MDS revealed Resident #1 was coded as requiring extensive assistance of one person for bed mobility and personal hygiene, and locomotion on and off unit; extensive assistance of 2 persons with dressing, toilet use and bathing. Impairment of Range of Motion on both sides of lower extremities. Review of the MDS revealed Resident #1 was having occasional moderate pain. Review of Resident #1's current care plan revealed a problem onset of 01/26/2023 for impaired physical mobility due to right hip fracture/repair of closed right hip fracture with right hip precautions implemented. Approaches included notified S14 MD and new order to send to ER for treatment and evaluation related to x-ray findings. New diagnosis of Osteopenia and Osteoarthritis revealed via x-ray on 01/26/2023. Keep abduction pillow in place while in bed and chair. 02/28/2023-discontinue abduction pillow. 02/09/2023 - seen by Orthopedist, D/C staples, follow back up in 12 weeks, noted knee pain associated with hip fracture, obstructed nerve should resolve. Review of Resident #1's Comprehensive Plan of Care revealed a problem onset date of 09/02/2021 for alteration in comfort related pain due to Parkinson's pain with approaches to report any signs of: unrelieved pain or adverse effects of medications, report signs and symptoms of pain of flinching, moaning or crying. Assess for effectiveness of pain medications, notify the physician/nurse practitioner if relief not experienced. Assess characteristics of pain (location, duration, quality, aggravating/alleviating factors, radiation and intensity) and document. Resident #1 was not care planned for knee pain prior to 01/16/2023. Record review of Resident #1's Medication Administration Record for January 2023 revealed there was no documentation of pain medicine given. Record review of nurse's progress note dated 01/16/2023 at 11:35 a.m. for Resident #1 read in part . Resident #1 sitting in chair in room, visiting with roommate. Resident #1 complained of pain to bilateral knees and bilateral lower extremities. Resident #1 having difficulty ambulating with assistive device. Administered two 500 milligram Tylenol tablets (an oral analgesic) by mouth for pain. Record review of nurse's progress note dated 01/17/2023 at 4:27 p.m. for Resident #1 read in part . Physician made rounds - ordered new meds for Edema and Osteoarthritis. New medication orders: Meloxicam (a non-steriod anti-inflammatory) 7.5 MG PO BID x 30 days, Lasix ( a diuretic) 40 MG PO Q Day x 30 days, and Potassium (electrolyte replacement) 10 MEQ PO Q Day x 30 days. Tylenol given for pain not effective. Having difficulty ambulating with Rollator, put Resident #1 in a wheelchair to see physician for visit at the facility. Increase in assistance needed with ADL's due to increase in unsteadiness of gait and weakness in bilateral lower extremities. Record review of physician's progress note dated 01/17/2023 read in part: Resident #1 complained of bilateral leg/knee pain. Diagnosis: Edema. New orders: Meloxicam 7.5 MG PO BID x 30 days, Lasix 40 MG PO Q Day x 30 Days, and Potassium 10 MEQ PO Q Day x 30 days. Record review of Physical therapy note dated 01/19/2023 for Resident #1 read in part .Pain at rest=0/10, pain with movement=4/10. Frequency=intermittent; Location Right lower extremity/knee; pain description/Type: Throbbing. Record review of physical therapy note dated 01/20/2023 for Resident #1 read in part . Precautions=application of Biofreeze (pain relieving gel) to right knee and anterior aspect of proximal right lower extremity to alleviate Resident #1's complaints of pain. Pain at rest=4/10; Frequency=constant; Location: right lower extremity; pain description/Type: it hurts; Pain with movement=10/10 (worst pain possible); Frequency=constant; Location=right lower extremity; Pain description/Type: it hurts. Response to treatment=increased challenge with tasks due to pain. Record review of occupational therapy note dated 01/23/2023 for Resident #1 read in part . Pain at rest=3/10; Frequency=Intermittent; Location=right knee; Pain description/Type: Throbbing. Pain with movement=8/10 (intense pain); Frequency=Intermittent; Location=right knee; Pain description/Type=Throbbing. Record review of occupational therapy note dated 01/25/2023 for Resident #1 read in part . Pain at rest 3/10 (pain is noticeable); Frequency=Intermittent; Location=right knee; Pain description/Type=Throbbing. Pain with movement 8/10 (intense pain); Frequency=Intermittent (with movement of right knee); Location =right knee; Pain description/Type=Throbbing. Response to treatment: Resident #1 tolerated occupational therapy well with complaints of right knee pain, nursing notified. Record review of X-ray results obtained at the facility dated 01/26/2023 read in part . Procedure: Right Hip, Unilateral with Pelvis Impressions: Findings consistent with acute fracture dislocation in subcapital femoral neck. Follow-up as clinically indicated. Record review of hospital progress note dated 01/27/2023 read in part . Preoperative Diagnoses: Right hip pain and Right Femoral neck fracture. Procedure: Right bipolar hip hemiarthroplasty (this surgical procedure replaces the head of a damaged femur with an implant designed to stabilize the femur and restore hip function). Observation and Interview on 02/28/2023 at 10:00 a.m. revealed Resident #1 sitting in her room awake and alert, in a wheelchair. Resident #1 stated she was okay, but did not respond when asked what happened to her hip, or if she was in pain. Interview on 02/28/2023 at 10:10 a.m. with S15 CNA revealed she cared for Resident #1 and assisted her with bathing and dressing. S15 CNA stated since Resident #1 fell and broke her leg, she had not been eating as well as previously, and needed more encouragement to consume. S15 CNA stated before fall Resident #1 had complained of knee pain and S3 LPN was notified. Interview on 02/28/2023 at 1:10 p.m. with S9 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift, and stated Resident #1 complained of Right leg and ankle pain before 01/26/2023 (the date Resident #1 was sent to ER for x-ray results of a Right Hip Fracture). S9 CNA stated she reported Resident #1's complaint of Right leg and ankle pain to S3 LPN when she complained, but stated S3 LPN already knew about Resident #1's complaint of Right leg and ankle pain. Interview on 02/28/2023 at 1:15 p.m. with S8 CNA revealed she provided care for Resident #1 for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S8 CNA stated she left for vacation on 01/02/2023 or 01/03/2023, and returned to work on 01/16/2023 or 01/17/2023 (S8 CNA was unsure of the exact date) to find Resident #1 in the bed. S8 CNA revealed her co-workers informed her of Resident #1 having some swelling and pain to her feet and legs, and had been put on a fluid pill. S8 CNA stated when she repositioned or turned Resident #1 toward the window (right side), Resident #1 would cry out in pain. S8 CNA stated she reported Resident #1's right lower extremity pain to S3 LPN. Interview on 02/28/2023 at 1:30 p.m. with S10 COTA revealed Resident #1 started physical therapy (3 times a week) on 12/21/2023 for a decline in functional mobility and needing increased assistance with ADL's. S10 COTA stated Resident #1 started complaining of right knee pain on 01/19/2023, and it got to the point of the knee pain being so bad, Resident #1 did not want to get out of bed. S10 COTA stated therapy started treating Resident #1 in her room and began mainly addressing her pain. S10 COTA revealed Resident #1's right knee was swollen and therapy did ESTIM with Resident #1 to help with the pain. S10 COTA revealed Resident #1 would verbally state her right knee was hurting, as well as grab her right knee and rub it. S10 COTA stated Resident #1 eventually was unable to walk. S10 COTA stated on 01/26/2023 on the morning shift, Resident #1 was trying to get up from a straight back chair in her room when S12 PTA noticed Resident #1's right leg was rotated. S10 COTA stated S12 PTA reported it to the floor nurse and both of them went to report it to S2 DON. S10 COTA stated S2 DON ordered X-rays that revealed a right hip fracture. Interview on 02/28/2023 at 2:40 p.m. with S3 LPN revealed she provided care for Resident #1, and on 01/16/2023 Resident #1 started complaining of right knee pain. S3 LPN stated Resident #1 was normally ambulatory with her walker, but had begun using the side rails on the hallways to help with ambulation. S3 LPN stated she notified S2 DON on 01/16/2023 of Resident #1's right knee pain and difficulty ambulating. S3 LPN stated S2 DON revealed the physician was coming to the facility on [DATE] and could see Resident #1 then. S3 LPN revealed the physician put Resident #1 on Mobic (Non-steriod anti-inflammatory drug for arthritis), Lasix (a diuretic), and Potassium (electrolyte supplement). S3 LPN stated the new medications did not help Resident #1 with her right lower extremity pain, and by 01/19/2023 Resident #1 was in the bed and not wanting to get up. S3 LPN stated she notified S2 DON on 1/19/2023 of Resident #1 worsening pain to her right lower extremity, and asked S2 DON if something different could be tried for Resident #1's right lower extremity pain. S3 LPN revealed S2 DON replied okay. S3 LPN confirmed she did not notify the physician of Resident #1's worsening pain to her right lower extremity because the facility's process was the nurse notifies the S2 DON and the S2 DON notifies the physician. S3 LPN revealed she has been a nurse at the facility for 3 years and had never called the physician. S3 LPN revealed she didn't know how to notify the physician. S3 LPN stated she went on vacation after 01/19/2023, and when she returned to work on 01/24/2023 or 01/25/2023 not sure of exact date), Resident #1 was in the bed not getting up and continued to have worsening pain to her right lower extremity. Interview on 03/01/2023 at 8:47 a.m. with S11 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S11 CNA revealed Resident #1 was able to walk, dress herself and transfer prior to 01/16/2023. S11 CNA stated she went on her off days, and when she returned to the facility on [DATE] Resident #1 was no longer able to walk. S11 CNA stated Resident #1 complained of right knee pain when she would roll the head of the bed up. S11 CNA stated she reported Resident #1's complaints of knee pain to S3 LPN. Interview on 03/01/2023 at 9:42 a.m. with S4 LPN (who worked the 6:00 a.m. - 6:00 p.m. shift), revealed she provided care for Resident #1 on 01/20/2023. S4 LPN revealed therapy notified her on 01/20/2023 of Resident #1 complaining of dizziness when they rolled the head of her bed up. S4 LPN stated Resident #1's blood pressure was a little low and Resident #1 appeared pale and didn't look right. S4 LPN stated she notified S2 DON and S2 DON told her to raise the head of Resident #1's bed, elevate her feet and monitor her blood pressure. S4 LPN confirmed she did not notify the physician of Resident #1 having dizziness or hypotension. S4 LPN revealed the facility's process was to notify S2 DON of any changes, and S2 DON notifies the physician and receives orders. Interview on 03/01/2023 at 10:19 a.m. with S6 ward clerk revealed on 01/14/2023 Resident #1 ambulated to the nurse's station and stated her right ankle was hurting. S6 ward clerk stated Resident #1 is usually ambulatory with her walker without assistance. S6 ward clerk revealed S3 LPN had to assist Resident #1 back to her room due to right lower extremity pain. Telephone interview on 03/01/2023 at 10:44 a.m. with S7 LPN revealed she worked the 6:00 p.m. - 6:00 a.m. shift, and provided care for Resident #1 on 01/19/2023. S7 LPN stated Resident #1 complained of her knees hurting. S7 LPN stated the CNA asked her to come to Resident #1's room due to Resident #1 was saying she couldn't walk. S7 LPN stated she assessed Resident #1 at that time and found her right leg was swollen, shiny and cooler than the left, with a weaker pedal pulse. S7 LPN confirmed she did not notify the physician of her assessment of Resident #1's right lower extremity. S7 LPN revealed the facility's process was the nurse notifies S2 DON and S2 DON notifies the physician. S7 LPN revealed it had been times in an emergency situation when she S2 DON did not respond to her telephone call, and she would then call the Administrator. S7 LPN stated she notified S2 DON of her assessment of Resident #1's right leg. S7 LPN stated S2 DON said Resident #1 was seen by the physician on 01/17/2023 at the facility, and her pedal pulse was weak then also. Telephone interview on 03/01/2023 at 3:00 p.m. with S12 PTA revealed Resident #1 was receiving therapy due to a functional decline in ADL's. S12 PTA stated Resident #1 complained of right knee pain and revealed she had a tibia fracture years ago which required screws and a plate. S12 PTA stated on 01/26/2023 she was assisting Resident #1 to bed and noticed her right leg was externally rotated. S12 PTA stated she notified nursing staff like she did each time Resident #1 complained of right lower extremity pain. Interview on 03/01/2023 at 4:10 p.m. with S3 LPN revealed on 01/26/2023 she notified S2 DON again of Resident #1 having worsening pain to her right lower extremity, and asked S2 DON if Resident #1 could get an x-ray. S3 LPN revealed S2 DON said she could get an x-ray. S3 LPN confirmed Resident #1 only received Tylenol 500 mg (2 tabs) 1 time for right lower extremity pain between 01/16/2023 through 01/26/2023, and it was documented as ineffective. Telephone interview on 03/02/2023 at 8:15 a.m. with S5 LPN revealed she cared for Resident #1 on the 6:00 p.m. - 6:00 a.m. shift on 01/20/2023. S5 LPN revealed she and S4 LPN went to Resident #1's room to assess her due to complaints of dizziness and low blood pressure. S4 LPN stated Resident #1 appeared to be feeling bad, like she was nauseated. S4 LPN revealed she checked on Resident #1 several times throughout the night, but did not notify the physician. S4 LPN stated the facility's process was the nurse notifies S2 DON, and S2 DON notifies the physician of changes in residents' condition. S4 LPN revealed if she could have, she would have notified the physician. Interview on 03/02/2023 at 8:35 a.m. with Resident #1's physician revealed he treated Resident #1 on 01/17/2023 at the facility for edema to bilateral knees with Lasix (a diuretic), Potassium (electrolyte supplement), and Mobic (NSAID for arthritis). Resident #1's physician stated he was aware Resident #1 was diagnosed with a fracture to her right hip on 01/26/2023. Resident #1's physician stated he had not been notified of Resident #1's right knee pain worsening, not being able to walk, dizziness or hypotension. Resident #1's physician revealed he probably would have ordered an x-ray if he had been notified of Resident #1's worsening pain to her right lower extremity and declining condition. Resident #1's physician revealed the facility does not notify him of changes in his Residents like they should. Resident #1's physician stated he had received calls from the hospital wanting to know why his Resident was in the ER, and he had not been notified they had been sent. Resident #1's physician stated he wanted to know more about his Residents not less. Interview on 03/02/2023 at 9:25 a.m. with S2 DON revealed on 01/16/2023 S3 LPN reported to her Resident #1 was having knee pain. S2 DON revealed she talked to the physician on 01/16/2023, and the physician stated he would see Resident #1 on 01/17/2023 upon rounds at the facility, and she could take Tylenol for pain. S2 DON stated the physician started Resident #1 on Lasix (a diuretic), Mobic (NSAID for arthritis), and Potassium (electrolyte supplement), and after a few days she didn't hear anything about Resident #1 so she assumed the medications were working. S2 DON stated on 01/19/2023 S7 LPN notified her of Resident #1's pedal pulse being faint on the right side. S2 DON stated she informed S7 LPN of Resident #1's pedal pulse being weak on 01/17/2023 when the physician assessed her. S2 DON confirmed she did not notify the physician. S2 DON stated on 01/20/2023 S4 LPN notified her of Resident #1 having dizziness and hypotension and she told S4 LPN to check her vital signs and monitor Resident #1. S2 DON confirmed she did not notify the physician. S2 DON stated she assessed Resident #1's right lower extremity before she had x-rays on 01/26/2023 (did not remember the date or document assessment) and Resident #1's knee was still swollen and still having pain upon range of motion. S2 DON confirmed she did not notify the physician of Resident #1's continued swelling of right knee and pain with range of motion. S2 DON revealed S10 COTA reported to S3 LPN of Resident #1 having increased pain to her right lower extremity and S3 LPN reported to her, and she notified the physician. S2 DON stated the x-ray results from 01/26/2027 revealed Resident #1 had an acute right hip fracture. S2 DON confirmed Resident #1 only received one dose of Tylenol 500 mg (2 tabs) for pain between 01/16/2023 through 01/26/2023 and it was ineffective. S2 DON confirmed the facility's process of physician notification was for the nurse to call her and she notifies the physician. S2 DON stated she does not know if a floor nurse had ever called the physician. Interview on 03/03/2023 at 10:00 a.m. with S1 Administrator revealed on 01/16/2023 S3 LPN reported Resident #1 was having right knee pain. S1 Administrator stated Resident #1 was already receiving therapy, S3 LPN gave Resident #1 Tylenol for the pain, and she was going to see the physician on 01/17/2023. S1 Administrator stated on 01/17/2023 S2 DON tried to get Resident #1 out of her chair, but she couldn't stand, so she was assisted Resident #1 into a wheelchair to go see the physician. S1 Administrator stated the physician put Resident #1 on some medications and from there she didn't know anything until 01/26/2021 when x-rays results revealed Resident #1 had a right hip fracture. S1 Administrator confirmed the nurses should have followed the facility's policy and should have called the physician when there was an issue with a Resident. .

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Notification of Changes (Tag F0580)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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Based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in condition for 1 (#1) of 5 (#1, #2, #3, #4, & #5) residents reviewed for notification of change. The facility failed to timely consult with Resident #1's physician when Resident #1 experienced increased/worsening pain in her right lower extremity and a decline in ADLs due to increased pain, after treatment implemented by the physician was not effective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. Resident #1, a severely cognitively impaired resident who required limited assistance by one person with ambulation, began complaining of pain in her right leg/knee/ankle on 01/16/2023, and became unable to ambulate on 01/17/2023 due to increased pain. Resident #1 was assessed by the physician on 01/17/2023, and Mobic (non-steroidal anti-inflammatory) 7.5 MG PO BID x 30 days, Lasix (a diuretic) 40 MG PO Q Day x 30 days, and Potassium (electrolyte replacement) 10 MEQ PO Q Day x 30 days was prescribed. Resident #1's pain continued to worsen, and Resident #1 continued to decline in ADLs. On 01/19/2023, S7 LPN and S3 LPN reported to S2 DON that Resident #1's pain was not being relieved, and that her right leg was swollen, shiny, and cooler than the left leg. On 01/20/2023, S4 LPN reported to S2 DON that Resident #1 was dizzy, pale, and did not look right. Resident #1's change of condition on 01/19/2023 and 01/20/2023 was not reported to the physician until 01/26/2023. Resident #1 was x-rayed on 01/26/2023, which revealed an acute fracture and dislocation of the femoral neck of the right hip. Resident #1 required surgical intervention of a right bipolar hip arthroplasty on 01/27/2023. This deficient practice continued at a potential for more than minimal harm for all 82 Residents who reside in the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 03/02/2023 at 2:20 p.m. The Immediate Jeopardy was removed on 03/03/2023 at 3:33 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: 1. Root cause analysis nurse failed to notify physician immediately when there was a significant change in resident's condition. 2. NFA Managing Member, NFA and DON reviewed facility policy on Acute Condition Changes and found to be sufficient on 3/2/2023 at 2:45p.m. 3. The nursing staff will follow the clinical protocol to immediately notify the physician of any change of condition or worsening in pain. 4. All nursing staff will be in-serviced by NFA or designee beginning 3/2/2023 at 5:00p.m- 6:30 p.m. on notifying the physician when there is a significant change in residents' condition or worsening in pain and following Clinical Protocol. Nurses will receive a copy of Clinical Protocol for Pain Management and Acute Condition Changes at the time of their in-service. Each nursing staff will be in-serviced prior to beginning of their shift and receive a copy of the clinical protocol for Pain Management and Acute Condition Change with completion by 3/6/2023 at 6:00 p.m. NFA in-serviced CNA's beginning 3/2/2023 5:30pm-6:30pm on reporting any pain or change in residents' condition to the floor nurse, DON and NFA. Each CNA will be will be in-serviced prior to beginning of their shift with completion by 3/6/2023 at 6:00 p.m. Each new hire CNA will be trained during orientation. 33 residents who are currently taking pain medications or have an acute change in condition were reassessed with pain assessment by DON or designee ensuring their pain is relieved by medications beginning 3/2/2023 at 4:00p.m., completing on 3/2/2023 at 8:00p.m., and notification to MD if pain has worsened or not relieved. NFA in-serviced DON on 3/2/2023 at 4:45pm on Clinical Protocol for Pain Management and Acute Condition Changes by reassessing for increase in pain and notifying physician if pain worsens. NFA reiterated during In-service training to DON that per facility policy nurses are to report changes of unrelieved pain or changes in condition to primary care physician. NFA will monitor one nursing meeting weekly x 1 month. NFA will randomly question nursing staff weekly x I month on Clinical protocol for reporting changes in condition and unrelieved pain. 5. In order to monitor performance and assure solutions are sustained the NFA or designee will monitor nurses notes and shift reports for MD notification in change in resident condition 5 days a week for one month and then 3 times a week for or one month. Negative issues will be addressed with the respective employee at the time of occurrence. 6. Completion date 3/6/2023 Findings: Review of the facility's policy titled, Acute Condition Changes-Clinical Protocol revealed in part . 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. 10. The nurse and physician will discuss and evaluate the situation. Monitoring and Follow-Up 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. Review of the medical record for Resident #1 revealed an admit date of 09/02/2021, and diagnoses that included Parkinson's disease, Unspecified abnormalities of gait, Unspecified Dementia, and Pain. Review of Resident #1's significant change MDS with an ARD of 12/28/2022 revealed a BIMS score of 5, which indicated severely impaired cognition, and revealed Resident #1 required limited assistance by one person with bed mobility, transferring, toilet use, and walking. Review of Resident #1's current care plan revealed a problem onset of 01/26/2023 for impaired physical mobility due to right hip fracture/repair of closed right hip fracture with right hip precautions implemented. Approaches included notified S14 MD and new order to send to ER for treatment and evaluation related to x-ray findings. New diagnosis of Osteopenia and Osteoarthritis revealed via x-ray on 01/26/2023. Keep abduction pillow in place while in bed and chair. 02/28/2023-discontinue abduction pillow. 02/09/2023 - seen by Orthopedist, D/C staples, follow back up in 12 weeks, noted knee pain associated with hip fracture, obstructed nerve should resolve. Review of Physical Therapy notes dated 01/19/2023 (no time documented), revealed Resident #1 complained of throbbing pain rated 4 out of 10 to right lower extremity/knee with movement. Review of Occupational Therapy notes dated 01/23/23 and 01/25/2023 (no time documented), revealed Resident #1 reported throbbing, right knee pain of 8 out of 10 with movement, and pain of 3 out of 10 at rest. Review of physical therapy notes dated 01/23/23 (no time documented), revealed Resident #1 complained of throbbing pain of 5 out of 10 with movement, and 3 out of 10 at rest to right lower extremity. In an interview on 02/28/2023 at 1:10 p.m., S9 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift, and stated Resident #1 complained of leg and ankle pain during January 2023 (unsure of date). S9 CNA stated she reported it to S3 LPN, but S3 LPN already knew and would come check on her. In an interview on 02/28/23 at 1:15 p.m., S8 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S8 CNA stated when she left to go on vacation January 2nd or 3rd 2023, Resident #1 was ambulatory with her walker, but when she returned to work on January 16th or 17th 2023, Resident #1 was in the bed. S8 CNA stated she asked her coworkers why was Resident #1 in the bed, and was told she had started on some fluid pills for swelling in her feet and legs. S8 CNA stated when she would change Resident #1's position toward the window (right side), or change her brief, Resident #1 would cry out in pain. S8 CNA stated she reported it to S3 LPN, and stated the nurse would check on her. In an interview on 02/28/2023 at 1:30 p.m., S10 COTA stated Resident #1 had been receiving therapy 3 times per week since 12/21/2022 for functional decline, increased help with ADL's, and balance and safety. S10 COTA stated Resident #1 was ambulatory with a rolling walker, and would walk several times per day. S10 COTA stated therapy noticed Resident #1 had stopped walking as much in the later part of December 2022. S10 COTA stated in January 2023, Resident #1 started complaining of right knee pain, and it got to the point her knee pain was so bad they started treating her in bed because she did not want to get out of bed. S10 COTA stated Resident #1's right knee was swollen and therapy did ESTIM with her to help with the pain. S10 COTA stated at one point Resident #1 had quit walking, and they were just trying to treat her knee pain. S10 COTA stated Resident #1 would verbally say her knee was hurting, and grab and rub it. S10 COTA stated on 01/26/2023 on the morning shift, Resident #1 was trying to get up from a straight back chair in her room when S12 PTA noticed Resident #1's right leg was rotated. S10 COTA stated S12 PTA reported it to the floor nurse and both of them went to report it to S2 DON. S10 COTA stated S2 DON ordered X-rays that revealed a right hip fracture. In an interview on 02/28/2023 at 2:40 p.m., S3 LPN stated she has worked at the facility as a nurse for three years, and has never telephoned the physician. S3 LPN reported the process was to notify S2 DON and S2 DON notified the physician. S3 LPN stated she does not know how to contact the physician. S3 LPN stated Resident #1 was normally ambulatory with her walker, but noted Resident #1 kept saying her knees hurt, and grabbing the rail in the hallway during ambulation. S3 LPN stated she told S2 DON about Resident #1's difficulty walking and knee pain on 01/16/2023 at 11:35 a.m., and S2 DON told her Resident #1 was going to see the physician the next day. S3 LPN stated the physician made rounds on 01/17/2023, and started Resident #1 on new medications. S3 LPN stated within a couple of days Resident #1 was in the bed and not getting up. S3 LPN stated this was not normal because Resident #1 walked all the time. S3 LPN stated on 01/19/2023 at 2:40 p.m. she told S2 DON the new medications were not working, and asked could something different be tried for Resident #1, and S2 DON said ok. In an interview on 03/01/2023 at 8:47 a.m., S11 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S11 CNA stated Resident #1 was able to walk, dress herself, transfer, and toilet herself. S11 CNA stated she went on her off days and came back on 01/19/2023, and Resident #1 was no longer able to walk, transfer, or dress and toilet herself. S11 CNA stated Resident #1 complained of right knee pain when she would raise the head of her bed. In an interview on 03/01/2023 at 9:42 a.m., S4 LPN (who worked the 6:00 a.m. - 6:00 p.m. shift) revealed she cared for Resident #1 on 01/20/2023. S4 LPN stated therapy reported to her when they raised the head of the bed, Resident #1 complained of dizziness. S4 LPN stated Resident #1's blood pressure was a little low, Resident #1 looked pale, and didn't look right. S4 LPN stated she did not notify the doctor, but notified S2 DON on 01/20/2023 instead, who told her to raise Resident #1's head of bed and her feet, and to monitor her blood pressure. S4 LPN stated Resident #1 had bilateral leg edema with black X marks on the top of both feet as if she were being monitored for something. S4 LPN stated Resident #1 complained of knee pain. S4 LPN stated she does not talk to the physician, and stated the nurses report changes to S2 DON who notifies the physician and receives orders. S4 LPN stated when changes that need to be reported occur on the weekend, staff call S2 DON at home. S4 LPN stated sometimes they have to call 2 or 3 times before they reach S2 DON. In an interview on 03/01/23 at 10:44 a.m., S7 LPN revealed she took care of Resident #1 who complained of her knees hurting. S7 LPN stated she worked the 6:00 p.m. - 6:00 a.m. shift, and assessed Resident #1 on 01/19/2023. S7 LPN stated the CNA asked her to come look at Resident #1 because Resident #1 couldn't walk. S7 LPN stated when she assessed Resident #1, she discovered Resident #1's right leg was swollen, shiny, and cooler than her left leg. S7 LPN stated she notified S2 DON of her assessment of Resident #1 soon after. S7 LPN stated she never talked to the physician because the process was for the nurse to notify S2 DON, and S2 DON notifies the doctor. In an interview on 03/01/23 at 3:00 p.m., S12 PTA revealed Resident #1 was receiving therapy due to a functional decline, and had complained of right knee pain. S12 PTA stated Resident #1 had a tibia fracture years ago and had screws and a plate put in, and was aware Resident #1 was recently was prescribed Mobic for knee pain. S12 PTA stated on 01/26/2023 she was assisting Resident #1 to bed and noted her right leg was externally rotated. S12 PTA stated she notified nursing like she did each time a Resident had complaints. S12 PTA stated she did not remember who she notified. In an interview on 03/01/2023 at 4:10 p.m., S3 LPN reported she went to S2 DON on 01/26/2023 at 5:40 p.m., and asked her about obtaining an x-ray because Resident #1 kept complaining of pain. In an interview on 03/02/23 at 8:15 a.m., S5 LPN (worked the 6:00 p.m. - 6:00 a.m. shift), revealed she and S4 LPN went to check on Resident #1 on 01/20/2023 because the day shift nurse said Resident #1 had been dizzy earlier in her shift, and her blood pressure was low. S5 LPN stated Resident #1 seemed to be feeling bad like she was nauseated, so she checked on Resident #1 several times throughout the night. S5 LPN stated she never calls the doctor, but notifies S2 DON of problems, and S2 DON calls the doctor. S5 LPN stated if she could have called the doctor she would have. In a telephone interview on 03/02/2023 at 8:35 a.m., Resident #1's physician revealed he treated Resident #1 on 01/17/2023 for edema to bilateral knees with a diuretic, potassium, and an anti-inflammatory medication. Resident #1's physician stated he was aware Resident #1 was diagnosed with a fracture to her right hip on 01/26/2023. Resident #1's physician stated if he had been notified of Resident #1's decline in ADL's and leg pain, he probably would have ordered an x-ray. Resident #1's physician stated the facility does not notify him like they should, and he wished they would. In an interview on 03/02/2023 at 9:25 a.m., S2 DON reported on 01/19/2023, S7 LPN called her and stated Resident #1's pedal pulse was faint on the right side. S2 DON stated she told S7 LPN that Resident #1's was seen by her physician on 01/17/2023, and her pedal pulse was weak. S2 DON confirmed she did not notify the physician. S2 DON confirmed on 01/20/2023 S4 LPN notified her of Resident #1 having hypotension and dizziness. S2 DON stated she told S4 LPN to check her vital signs and monitor Resident #1. S2 DON confirmed she did not notify the physician. S2 DON stated she assessed Resident #1 before the x-ray was ordered on 01/26/2023, but did not remember the date or time. S2 DON acknowledged Resident #1's knee was still swollen, and Resident #1 was having pain with range of motion on 01/20/2023. S2 DON confirmed she did not notify the physician of Resident #1's continued knee pain and swelling. S2 DON confirmed their facility process for notifying the physician of resident changes in status was for the nurses to notify the DON, and the DON then notifies the physician. S2 DON confirmed Resident #1's physician was not notified of her continued leg pain, swelling, and decline in ADLs until 01/26/2023. In an interview on 03/03/2023 at 10:00 a.m., S1 Administrator revealed on 01/16/2023 S3 LPN stated Resident #1 was having right knee pain. S1 Administrator stated Resident #1 was already receiving therapy and ambulated in therapy on 01/16/23. S1 Administrator reported S3 LPN gave Resident #1 Tylenol on 01/16/2023, and the physician was going to see Resident #1 on 01/17/2023. S1 Administrator stated the physician ordered some medications for Resident #1, and from there she didn't know anything was wrong until the x-rays came back revealing a right hip fracture. S1 Administrator then acknowledged on 01/19/2023 the night CNAs told her Resident #1 was sitting on her roommate's bed with her walker, and Resident #1 could not bear weight when they attempted to assist her up. S1 Administrator stated therapy attends the facility's morning meetings and reports on residents' toleration of therapy, what each resident is doing in therapy, and where they stand with reaching their goals. S1 Administrator confirmed therapy reported Resident #1 was experiencing the same pain. S1 Administrator acknowledged she did not contact Resident #1's physician because she was unaware Resident #1 had continued to decline. S1 Administrator stated the facility nurses should have been aware they could call the physician if they needed to. S1 Administrator stated she was unaware the nurses in the facility were instructed to report all changes to the DON, and were not contacting the physician directly to report significant changes in condition.

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 5 (#1, #2, #3, #4, & #5) sampled residents. The facility failed to: Ensure nursing staff consulted with Resident #1's physician in a timely manner when Resident #1 experienced a significant change in her condition, and pain treatment was ineffective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. Resident #1, a severely cognitively impaired resident who required limited assistance by one person with ambulation, began complaining of pain in her right leg/knee/ankle on 01/16/2023, and became unable to ambulate on 01/17/2023 due to increased pain. Resident #1 was assessed by the physician on 01/17/2023, and treatment was prescribed Resident #1's pain continued to worsen, and Resident #1 continued to decline in ADLs. On 01/19/2023, S7 LPN and S3 LPN reported to S2 DON that Resident #1's pain was not being relieved, and that her right leg was swollen, shiny, and cooler than the left leg. On 01/20/2023, S4 LPN reported to S2 DON that Resident #1 was dizzy, pale, and did not look right. Resident #1's change of condition on 01/19/2023 and 01/20/2023 was not reported to the physician until 01/26/2023. Resident #1 was x-rayed on 01/26/2023, which revealed an acute fracture and dislocation of the femoral neck of the right hip. Resident #1 required surgical intervention of a right bipolar hip arthroplasty on 01/27/2023. This deficient practice continued at a potential for more than minimal harm for all 82 Residents who reside in the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 03/02/2023 at 2:20 p.m. The Immediate Jeopardy was removed on 03/03/2023 at 3:33 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented. The Facility's plan to remove the immediate jeopardy situation included: l. Root cause analysis nursing staff failed to follow facility policy and procedure for notifying the MD of acute change in resident condition 2. Corporate Managing Member, NFA and DON reviewed facility policy on Acute Condition Changes and found to be sufficient on 3/2/2023 at 2:45p.m. 3. Facility will follow the Clinical Protocol to notify the physician in a timely manner of residents Acute Condition Change to receive care and treatment in a timely manner 4. On 3/2/2023 5p.m.-6:30p.m., the NFA in-serviced all nursing staff on notifying the physician of changes in residents' condition. Nurses received a copy of the Clinical Protocol for Acute Condition Changes at the time of in-service. Each nursing staff will be in-serviced prior to beginning of their shift and receive a copy of the clinical protocol for Acute Condition Changes with completion by 3/6/2023 at 6:00 p.m. Nursing staff will not be allowed to work until he or she receives training on the Clinical Protocol for Acute Condition Changes. All new hire nursing staff will be in-serviced during orientation. 5. NFA in-serviced DON on 3/2/2023 at 4:45pm on Clinical Protocol to Provide Pain Management and Acute Condition Changes by reassessing for increase in pain and notifying physician if pain worsens. NFA reiterated during In-service training to DON that per facility policy nurses are to report changes of unrelieved pain or changes in condition to primary care physician. NFA will monitor one nursing meeting weekly x 1 month. NFA will randomly question nursing staff weekly x 1 month on Clinical protocol for reporting changes in condition and unrelieved pain. 6. In order to monitor performance and sustain implemented practice, the facility shall monitor corrective actions by incorporating into regular QA meeting 3 times a week by NFA or QA designee with documentation in QA minutes. DON or designee will complete stand up nursing staff meeting 5 days a week documenting changes in resident conditions and unrelieved pain. The Administrator will review these stand-up nursing meeting x 1 month adding to weekly QA meeting and incorporate finding into Quarterly QAPI meeting including Medical Director. Negative issues will be addressed with the respective employee such as compliance is maintained. 7. In order to monitor performance and assure solutions are sustained Corporate Managing Member will monitor NFA and DON monthly for two months. Negative issues will be addressed with the respective employee at the time of occurrence 8. Completion date 3/6/2023 Findings: Cross Refer to F580. Cross Refer to F697. Review of the facility's policy titled, Acute Condition Changes-Clinical Protocol revealed in part . 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 10. The nurse and physician will discuss and evaluate the situation. In an interview on 03/02/2023 at 9:25 a.m., S2 DON reported on 01/19/2023, S7 LPN called her and stated Resident #1's pedal pulse was faint on the right side. S2 DON stated she told S7 LPN that Resident #1's was seen by her physician on 01/17/2023, and her pedal pulse was weak. S2 DON confirmed she did not notify the physician. S2 DON confirmed on 01/20/2023 S4 LPN notified her of Resident #1 having hypotension and dizziness. S2 DON stated she told S4 LPN to check her vital signs and monitor Resident #1. S2 DON confirmed she did not notify the physician. S2 DON stated she assessed Resident #1 before the x-ray was ordered on 01/26/2023, but did not remember the date. S2 DON acknowledged Resident #1's knee was still swollen, and Resident #1 was having pain with range of motion on 01/20/2023. S2 DON confirmed she did not notify the physician of Resident #1's continued knee pain and swelling. S2 DON confirmed their facility process for notifying the physician of resident changes in status was for the nurses to notify the DON, and the DON then notifies the physician. S2 DON confirmed Resident #1's physician was not notified of her continued leg pain, swelling, and decline in ADLs until 01/26/2023. In an interview on 03/03/2023 at 10:00 a.m., S1 Administrator stated the facility nurses should have been aware they could call the physician if they needed to. S1 Administrator stated she was unaware the nurses in the facility were instructed to report all changes to the DON, and were not contacting the physician directly to report significant changes in condition.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 3 life-threatening violation(s), $99,730 in fines, Payment denial on record. Review inspection reports carefully.
• 48 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $99,730 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.

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About This Facility

What is Colfax Nursing And Rehab, Llc's CMS Rating?

CMS assigns Colfax Nursing and Rehab, LLC an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Colfax Nursing And Rehab, Llc Staffed?

CMS rates Colfax Nursing and Rehab, LLC's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the Louisiana average of 46%. RN turnover specifically is 100%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Colfax Nursing And Rehab, Llc?

State health inspectors documented 48 deficiencies at Colfax Nursing and Rehab, LLC during 2023 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 45 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 Colfax Nursing And Rehab, Llc?

Colfax Nursing and Rehab, LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 140 certified beds and approximately 68 residents (about 49% occupancy), it is a mid-sized facility located in COLFAX, Louisiana.

How Does Colfax Nursing And Rehab, Llc Compare to Other Louisiana Nursing Homes?

Compared to the 100 nursing homes in Louisiana, Colfax Nursing and Rehab, LLC's overall rating (1 stars) is below the state average of 2.4, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Colfax Nursing And Rehab, Llc?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.

Is Colfax Nursing And Rehab, Llc Safe?

Based on CMS inspection data, Colfax Nursing and Rehab, LLC has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Colfax Nursing And Rehab, Llc Stick Around?

Colfax Nursing and Rehab, LLC has a staff turnover rate of 54%, which is 8 percentage points above the Louisiana average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Colfax Nursing And Rehab, Llc Ever Fined?

Colfax Nursing and Rehab, LLC has been fined $99,730 across 1 penalty action. This is above the Louisiana average of $34,076. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Colfax Nursing And Rehab, Llc on Any Federal Watch List?

Colfax Nursing and Rehab, LLC 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.

Facility Details

Beds: 140
Avg. Residents: 68
Occupancy: 49.1%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
3 Immediate Jeopardy citations: -36
48 Deficiencies: -10
Fines ($99,730): -10
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 195430