THE CARE CENTER OF DEQUINCY
For profit - Limited Liability company
80 Beds
RIGHTCARE HEALTH SERVICES
Data: November 2025
Trust Grade
0/100
#253 of 264 in LA
Photo by Care Center of Dequincy
Photo by Care Center of Dequincy
Photo by Care Center of Dequincy
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Care Center of DeQuincy has received a Trust Grade of F, indicating significant concerns about the facility's care and operations. Ranking #253 out of 264 nursing homes in Louisiana places it in the bottom half of facilities in the state, and #9 out of 10 in Calcasieu County means there is only one local option that performs better. Unfortunately, the facility's situation is worsening, with the number of issues doubling from 5 in 2024 to 10 in 2025. Staffing is average here, rated 3/5, with a turnover rate of 47%, which is concerning as it is at the state average. However, the facility faces significant issues, including $146,296 in fines, which is higher than 93% of Louisiana facilities, and it has been reported that residents have suffered physical abuse from one another due to inadequate protections, with instances of biting and skin tears reported. Overall, while there are some average staffing metrics, the serious incidents and low trust grade raise red flags for families considering this home for their loved ones.
- Trust Score
- F
- In Louisiana
- #253/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $146,296 in fines. Higher than 64% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 5%
Review needed
5 → 10 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 10 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: 47%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $146,296
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: RIGHTCARE HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 26 deficiencies on record
2 actual harm
Jan 2025
10 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse for 2...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse for 2 (#3 and #8) of 2 (#3 and #8) sampled residents investigated for abuse.
The facility failed to protect:
1. Resident #8 from physical abuse by Resident #3
2. Resident #3 from physical abuse by Resident #63
This deficient practice resulted in physical harm for Resident #8 on 11/17/2024 at 4:22 p.m. when Resident #3 hit him multiple times. On 11/17/2024 at 4:22 p.m. when Resident #3 hit him multiple times, Resident #8 sustained skin tears to his left forearm and left lower leg.
Findings:
Review of the facility's undated policy titled Abuse Prevention and Investigation revealed, in part, the following: It is the policy of this facility to provide protections .that prohibit and prevent abuse. Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching .
1. Resident #8
Review of Resident #8's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia with Behavior Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Severe Major Depressive Disorder with Psychotic Features, Schizoaffective Disorder, and Cognitive Communication Deficit.
Review of Resident #8's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 12, indicating moderate cognitive impairment. Resident #8 had verbal behavioral symptoms directed toward others.
Review of Resident #8's current comprehensive care plan revealed, in part, the resident has a behavior problem related to diagnosis of schizoaffective disorder initiated 09/01/2024, and the resident has the potential to be physically aggressive due to poor impulse control initiated on 09/29/2024.
Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #8 dated 11/17/2024.
Review of the facility's incident report dated 11/17/2024 at 4:36 p.m. revealed, in part, the following:
Incident Type: Physical Aggression Received
Person Preparing Report: S9RN
Incident Description: Resident #8 backed chair into Resident #3 while waiting to go outside to go smoke. Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to Resident #8's left forearm. Residents separated.
Immediate Action Taken: Residents were separated and placed on 1:1 monitoring
Injuries Observed at the Time of Incident: Skin tear to left lower leg, and skin tear to left forearm
Review of Resident #8's Nurse's Notes revealed, in part, the following:
11/17/2024 at 04:44 p.m. written by S9RN: Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to left forearm. Skin tear to left forearm treated at this time.
Review of Resident #8's Order Summary Report revealed, in part, the following:
11/17/2024 Telephone order: Cleanse skin tear to left lower leg with normal saline, apply antibiotic ointment and a dressing once daily until resolved.
11/17/2024 Telephone order: Cleanse skin tear to left forearm with normal saline, apply antibiotic ointment and a dressing once daily until resolved.
On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed the Incident of Physical Aggression Received reported on 11/17/2024 at 4:36 p.m. was an incident of resident to resident abuse.
2. Resident #3
Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Mild Cognitive Impairment, Generalized Anxiety Disorder, Major Depressive Disorder, Unspecified Intracranial Injury, Bipolar Disorder, and Schizoaffective Disorder.
Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 14, indicating intact cognition.
Review of Resident #3's current Comprehensive Care Plan revealed, in part, the resident has the potential to be physically aggressive due to anger and poor impulse control initiated on 09/12/2024.
Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #3 dated 09/12/2024.
Review of the facility's Incident Report dated 09/12/2024 at 6:46 p.m. revealed, in part, the following:
Incident Type: Physical Aggression Received
Person Preparing Report: S8LPN
Incident Description: Resident #3 and Resident #63 were both going outside to smoke. Resident #3 backed his wheelchair into Resident #63 three times. Resident #63 hit Resident #3 in the face 3 times with his closed fist. The nursing aide separated the residents. Resident #3 stated he backed up on Resident #63 three times. Resident #3 stated he was hit three times in the face by Resident #63.
Immediate Action Taken: Resident #3 was sent to the emergency room for psychiatric evaluation
Injuries: No injuries observed at the time of the incident.
Review of the facility's investigation record for the incident which occurred on 09/12/2024 revealed, in part:
1.
An Incident Communication form dated 09/12/2024 revealed, in part, Resident #63 then hit Resident #3 in the face.
2.
An undated, handwritten note prepared by Resident #63, revealed in part, .after he turned to me I punched him in the face.
On 01/29/2025 at 1:45 p.m., an interview was conducted with S1ADM. He confirmed the Incident of Physical Aggression Received reported on 09/12/2024 at 6:46 p.m. was an incident of resident to resident abuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure the resident was treated with respect and d...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure the resident was treated with respect and dignity as evidenced by the facility failing to keep a resident's urine collection bag covered and private for 1 (Resident #113) out of 1 resident (#113) investigated for dignity.
Findings:
Review of Resident #113's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, acute kidney failure and retention of urine.
Review of Resident #113's most recent admission Minimum Data Set (MDS) dated [DATE], revealed in part, Section H: Bladder and Bowel checked for indwelling catheter.
Review of Resident #113's comprehensive care plan revealed in part, the resident has (foley) catheter with an intervention that read in part, catheter: the resident has 16 FR (French), 10 CC (cubic centimeter) foley. Position catheter bag and tubing below the level of the bladder and away from entrance room door.
On 01/27/2025 at 9:30 a.m., an observation was made of Resident #113 from the hallway as his room door was open, he was resting in bed and his urine collection bag was observed hanging on the left side, at the foot of his bed without a privacy bag or covering. The urine collection bag was visible from the hallway.
On 01/27/2025 at 9:45 a.m., an interview and observation was conducted with S7CNASup (Certified Nursing Assistant Supervisor). An observation was made of Resident #113 from the hallway with S7CNASup as his room door was open, he was resting in bed and his urine collection bag was observed hanging on the left side, at the foot of his bed without a privacy bag or covering. The urine collection bag was visible from the hallway. S7CNASup confirmed the resident's urinary collection bag was visible from the hallway, and did not have a privacy bag over it. S7CNASup further confirmed there should have been a privacy bag over the urine collection bag to ensure the resident's dignity.
On 01/27/2025 at 2:04 p.m., an interview with S2DON (Director of Nursing) who confirmed that when a resident's urinary collection bag was visible from the hallway it should of had a privacy bag it to maintain the resident's dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the discharge status for 1 (Resident # 60) out of 31 sampled r...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the discharge status for 1 (Resident # 60) out of 31 sampled residents.
Findings:
Review of Resident #60's discharge transfer summary on 11/29/2024 revealed he was transferred to another nursing home.
Review of Resident #60's Discharge MDS assessment, with an ARD (Assessment Reference Date) of 11/29/2024 revealed: Section A .Discharge assessment, return not anticipated, planned A2105. Discharge Status. Code 04. Short-Term General Hospital.
On 01/29/2025 at 12:21 p.m., an interview and record review was conducted with S4MDS. She confirmed Resident #60 was discharged from the facility on 11/29/2024 to another nursing home. She reviewed the Discharge MDS, and confirmed the discharge status indicated he was discharged to a short term general hospital, which was coded inaccurately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 2 (Resident #34, Resid...
Read full inspector narrative →
Based on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 2 (Resident #34, Resident #58) out of 5 (Resident #11, Resident #17, Resident #19, Resident # 34, Resident #58) residents reviewed for respiratory care, with the potential to effect 23 residents receiving oxygen therapy.
Findings:
The facility did not provide a policy for storing of oxygen/nebulizer equipment by survey exit.
Resident #34
Review of Resident #34's EMR (Electronic Medical Record) revealed the resident was admitted to facility on 01/02/2024 with diagnosis not limited to Dyspnea, COPD (Chronic Obstructive Pulmonary Disease) and CHF (Congestive Heart Failure).
Review of the physician's orders for Resident #34 revealed an order dated 09/03/2024 - apply O2 (oxygen) 2-4 liters (L) via N/C (nasal cannula) PRN (as needed) to keep oxygen saturation above 90% (percent).
On 01/27/2025 at 9:53 a.m., an observation of Resident #34's O2 concentrator was done. The oxygen storage bag with a date of 01/27/2025 was on floor, with oxygen tubing running through the bag.
On 01/27/2025 at 1:53 p.m., during an observation and interview with S5LPN (Licensed Practical Nurse), she observed and confirmed the oxygen storage bag was on the floor. She confirmed the oxygen tubing storage bag should not be on the floor.
Resident #58
Review of Resident #58's EMR revealed the resident was admitted to facility on 09/24/2024 with diagnosis not limited to Acute and Chronic Respiratory Failure with Hypoxia, COPD and Pneumonia.
Review of the physician's orders for Resident #58 revealed an order dated 10/09/2024 - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) give 1 vial inhale orally every 6 hours as needed for wheezing and 09/24/2024 - Pulmicort Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation) give 1 blister inhale orally two times a day
On 01/27/2025 at 10:00 a.m., an observation of Resident #58's nebulizer machine and nebulizer tubing in a storage bag were on the floor at the head of the resident's bed.
On 01/27/2025 at 11:13 a.m., an interview was conducted with Resident #58. Resident #58 stated that his respiratory equipment should be clean and did not understand why it was stored on the floor and not on a shelf.
On 01/27/2025 at 1:48 p.m., an observation and interview with S5LPN of Resident #58's nebulizer machine and nebulizer tubing. She confirmed the nebulizer machine and nebulizer tubing were on the floor and should not be stored on the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain the most recent recertification of terminal illness and mo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to obtain the most recent recertification of terminal illness and most recent POC (plan of care) for 1 (Resident #26) out of 1 resident (#26) sampled residents reviewed for hospice.
Review of Resident #26's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, personal history of colon polyps and vascular dementia.
Review of Resident #26's Quarterly MDS (Minimum Data Set) dated 01/07/2025 revealed in part, Section O: Special Treatments, Procedures, and Programs checked for Hospice Care.
Review of Resident #26's physician's orders revealed an order entry with a start date of 10/07/2024 read in part, Admit to contracted hospice under the care of physician with Terminal dx (diagnosis) of senile degeneration of brain.
Review of Resident #26's hospice documents in the contracted hospice binder revealed, in part, the most recent certification of terminal illness by the contracted hospice agency's physician was signed on 10/27/2024 for the certification period dated 10/07/2024 to 01/04/2025.
Review of Resident #26's hospice documents in the contracted hospice binder revealed, in part, the most recent POC by the contracted hospice agency's physician was signed on 10/27/2024 for the period dated 10/07/2024 to 01/04/2025.
On 01/29/2025 at 9:34 a.m. a record review and interview was conducted with S2DON (Director of Nursing). Review of Resident #26's hospice documents in the contracted hospice binder was conducted with S2DON who confirmed the most recent certification of terminal illness and POC was for the period dated 10/07/2024 to 01/04/2025. She confirmed there was not an updated recertification of terminal illness and POC in Resident #26's contracted hospice binder and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure alleged violations of abuse were reported immediately, but...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure alleged violations of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (Resident #3, Resident #8 ) of 2 (Resident #3, Resident #8) residents reviewed for Abuse.
Findings:
Review of the facility's policy titled Abuse Prevention and Investigation revealed, in part, the following: It is the policy of this facility to provide protections .that prohibit and prevent abuse. Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching . The facility will report all alleged violations to the Administrator, state agency .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The Administrator will follow up . to report the results of the investigation when final within 5 working days of the incident as required by state agencies.
Resident #3
Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Mild Cognitive Impairment, Generalized Anxiety Disorder, Major Depressive Disorder, Unspecified Intracranial Injury, Bipolar Disorder, and Schizoaffective Disorder.
Review of Resident #3's most recent Quarterly MDS assessment dated [DATE] revealed a BIMS Score of 14, indicating intact cognition.
Review of Resident #3's current Comprehensive Care Plan revealed, in part, the resident has the potential to be physically aggressive due to anger and poor impulse control initiated on 09/12/2024.
Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #3 dated 09/12/2024.
The facility denied reporting any Critical Incident Reports to the Statewide Incident Management System during the last six months.
Review of the facility's Incident Report dated 09/12/2024 at 6:46 p.m. revealed, in part, the following:
Incident Type: Physical Aggression Received
Person Preparing Report: S8LPN
Incident Description: Resident #3 and Resident #63 were both going outside to smoke. Resident #3 backed his wheelchair into Resident #63 three times. Resident #63 hit Resident #3 in the face 3 times with his closed fist. The nursing aide separated the residents. Resident #3 stated he backed up on Resident #63 three times. Resident #3 stated he was hit three times in the face by Resident #63.
Immediate Action Taken: Resident #3 was sent to the emergency room for psychiatric evaluation
Injuries: No injuries observed at the time of the incident
Review of the facility's investigation record for the incident which occurred on 09/12/2024 revealed, in part:
1.
An Incident Communication form dated 09/12/2024 revealed, in part, Resident #63 then hit Resident #3 in the face.
2.
An undated, handwritten note prepared by Resident #63, revealed in part, .after he turned to me I punched him in the face
On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed no Critical Incident Reports have been created during the last six months. He confirmed the Incident of Physical Aggression Received reported on 09/12/2024 at 6:46 p.m. was an incident of resident to resident abuse. He confirmed the incident of abuse was not reported immediately, or within 2 hours after the allegation was made to the State Survey Agency, but should have been.
Resident #8
Review of Resident #8's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia with Behavior Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Severe Major Depressive Disorder with Psychotic Features, Schizoaffective Disorder, and Cognitive Communication Deficit
Review of Resident #8's most recent Quarterly MDS assessment dated [DATE] revealed a BIMS Score of 12, indicating moderate cognitive impairment.
Review of Resident #8's current Comprehensive Care Plan revealed, in part, the resident has a behavior problem related to schizoaffective disorder initiated 09/01/2024, and the resident has the potential to be physically aggressive due to poor impulse control initiated on 09/29/2024.
Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #8 dated 11/17/2024.
Review of the facility's Incident Report dated 11/17/2024 at 4:36 p.m. revealed, in part, the following:
Incident Type: Physical Aggression Received
Person Preparing Report: S9RN
Incident Description: Resident #8 backed chair into Resident #3 while waiting to go outside to go smoke. Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to left forearm. Residents separated.
Immediate Action Taken: Residents were separated and placed on 1:1 monitoring
Injuries Observed at the Time of Incident: Resident #8 had a skin tear to left lower leg and left forearm
Review of Resident #8's Nurse's Notes revealed, in part, the following:
11/17/2024 at 4:44 p.m. written by S9RN: Resident #8 was struck multiple times by another resident resulting in a skin tear to left forearm.
On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed no Critical Incident Reports have been created during the last six months. He confirmed the Incident of Physical Aggression Received reported on 11/17/2024 at 4:36 p.m. was an incident of resident to resident abuse. He confirmed the incident of abuse was not reported immediately, or within 2 hours after the allegation was made to the State Survey Agency, but should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to initiate an investigation of an alleged violation of abuse for 1 (Resident #8) of 2 (Resident #3, Resident #8) sampled residents.
Findings...
Read full inspector narrative →
Based on record review and interviews, the facility failed to initiate an investigation of an alleged violation of abuse for 1 (Resident #8) of 2 (Resident #3, Resident #8) sampled residents.
Findings:
Review of the facility's undated policy titled Abuse Prevention and Investigation revealed, in part, the following: It is the policy of this facility to provide protections .that prohibit and prevent abuse. Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching . An immediate investigation is warranted when suspicion of abuse or reports of abuse occur. Investigations include identifying and interviewing all involved persons, determining if abuse occurred, determining the extent and cause of the abuse, and providing complete and thorough documentation of the investigation.
Review of the facility's Incidents by Incident Type record for the last 120 days revealed, in part, one incident of Physical Aggression Received for Resident #8 dated 11/17/2024.
Review of Resident #8's Nurse's Notes revealed, in part, the following:
11/17/2024 at 4:44 p.m. written by S9RN: Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to left forearm. Skin tear to left forearm treated at this time.
On 01/28/2025 at 10:08 a.m. S1ADM stated he was responsible for investigation of all incidents. S1ADM stated he was responsible for creating Critical Incident Reports. S1ADM was asked to provide a copy of the incident report involving Resident #8 which occurred on 11/17/2024.
On 01/28/2025 at 10:37 a.m. S1ADM was asked to also provide documentation of the investigation of the 11/17/2024 incident.
On 01/28/2025 at 10:41 a.m. S2DON provided copy of incident report. No documentation of investigation was provided.
Review of the facility's incident report dated 11/17/2024 at 4:36 p.m. revealed, in part, the following:
Incident Type: Physical Aggression Received
Person Preparing Report: S9RN
Incident Description: Resident #8 backed chair into Resident #3 while waiting to go outside to go smoke. Resident #8 was struck multiple times by Resident #3 resulting in a skin tear to Resident #8's left forearm. Residents separated.
Immediate Action Taken: Residents were separated and placed on 1:1 monitoring
Injuries Observed at the Time of Incident: Skin tear to left lower leg, and skin tear to left forearm
On 01/28/2025 at 12:33 p.m. S1ADM stated he had no documentation of investigation of the incident involving Resident #8 which occurred on 11/17/2024.
On 01/29/2025 at 1:45 p.m. an interview was conducted with S1ADM. He confirmed the Incident of Physical Aggression Received reported on 11/17/2024 at 4:36 p.m. was an incident of resident to resident abuse. S1ADM confirmed an investigation of the abuse was not conducted or documented, but should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure sch...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure schedule IV controlled medications were stored in a locked, permanently affixed compartment and/or a single unit package drug distribution system for 1 (Room A) of 1 medication storage room reviewed.
Findings:
On 01/27/2025, a review of the facility's policy titled, Medications - Controlled Substances with a last review date of 01/2025, read in part, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use or controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposer. The policy also indicated how controlled medications are to be stored: Patient-specific controlled substances (e.g. narcotic/epidural infusions, tablets, etc.) are stored under double lock until administered to the patient.
On 01/27/2025 at 12:54 p.m., an observation was conducted of medication storage in Room A with S2DON (Director of Nursing). Upon entering into Room A, a black refrigerator was noted and was unlocked. S2DON stated medications were stored in the black refrigerator. A black safe box was noted inside the refrigerator and was unlocked. Medications observed inside of the unlocked black safe box were:
1. Valium suppository 10 mg (milligram) PR (per rectum) - Quantity was 2
2. diazePAM Rectal Gel 10 mg PR - Quantity was 3
An interview was conducted with S2DON at this time. S2DON confirmed the black medication refrigerator and black safe box were unlocked. S2DON further confirmed the medications stored in the black safe box were schedule IV controlled medications that should have been double locked and were not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure that the recipes for pureed foods were followed by the S6DC (Dietary Cook) failing to follow the recipes when preparing...
Read full inspector narrative →
Based on observation, record review and interview, the facility failed to ensure that the recipes for pureed foods were followed by the S6DC (Dietary Cook) failing to follow the recipes when preparing pureed foods. This deficient practice had the potential to affect the six residents in the facility who received a pureed diet.
Findings:
On 01/28/2025, a review of the facility's policy titled, Use of Recipes with no revision date, read in part, .Policy: Recipes are to be used when preparing menu items. Procedure: #3) Cooks are expected to use and follow the recipes provided.
On 01/27/2025 at 10:20 a.m., an observation was conducted of S6DC as she prepared pureed white beans with ham. S6DC placed an undetermined amount of white beans with ham using a large scoop with no marked measurements. S3DM (Dietary Manager) stopped S6DC from beginning the puree process and poured the white beans with ham back in the original large pot. S3DM then measured out 7 servings of white beans with ham using a 6oz (ounce) spoodle into the blender. S6DC then began the puree process adding 4 scoops of powdered food thickener. S6DC transferred the puree white beans with ham to a pan on the steam table and washed the blender. S6DC then began the puree process for cornbread muffins. S6DC placed 7 cornbread muffins into the blender, added an 8oz carton of thickened milk and pureed until smooth. S6DC was observed preparing both items without using a recipe. S6DC subsequently interviewed. S6DC confirmed she does not follow recipes; stated she just adds water, juice, milk, or thickener as needed.
On 01/27/2025 at 12:45 a.m., an interview was conducted with the S3DM. S3DM confirmed that the dietary staff had not been following recipes when preparing puree foods since the rotation of the menu's and could not recall when that was. She provided the recipes for this day's noon meal and stated; I'm not going to lie, I just printed these and made this binder. S3DM confirmed the dietary staff should be following recipes when preparing puree foods.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on review of the facility's Quality Assurance and Performance Improvement (QAPI) Program and interview, the facility failed to take actions aimed at performance improvement and after implementin...
Read full inspector narrative →
Based on review of the facility's Quality Assurance and Performance Improvement (QAPI) Program and interview, the facility failed to take actions aimed at performance improvement and after implementing those actions, measure its success and track performance. This was evidenced by lack of evidence of:
1. Measuring or tracking success of actions implemented; and
2. collection and analysis of data;
This deficient practice had the potential to affect a census of 61 residents.
Findings:
On 01/29/2025, a review of the facility's undated policy titled, Quality Assurance and Performance Improvement (QAPI) Program, with a review date of 01/2025, revealed the following in part: Each facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. 2. c. Develop and implement appropriate plans of action to correct identified quality deficiencies.
On 01/29/2025 at 2:30 p.m., a review of the QAPI program and an interview was conducted with S2DON (Director of Nursing). There was no documented evidence that the actions implemented were measured or performance of the action plans were tracked from July 01, 2024 through January 12, 2025. There was also no evidence of data collection and analysis. S2DON confirmed there was no documented evidence of data collection, analysis of data, monitoring, or performance tracking being conducted from July 01, 2024 to January 12, 2025.
Jan 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records observed during a medication pass. The facility had a total census of 65...
Read full inspector narrative →
Based on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records observed during a medication pass. The facility had a total census of 65 residents.
Findings:
On 01/23/2024 at 8:40 a.m., while walking down Hall B, a medication cart was observed against the wall with a computer on top of the cart. Upon getting to medication cart, the electronic medical record was open with a list of resident's names visible.
On 01/23/2024 at 8:45 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed the computer was not locked by privacy screen and a list of resident names was visible on the computer. She stated the nurse should have initiated the privacy screen before walking away from the computer.
On 01/23/2024 at 9:10 a.m., an interview was conducted with S6LPN. She confirmed she forgot to use the privacy screen when she walked away from her computer earlier to give a resident medication. She stated the computer should be placed on privacy screen before walking away.
On 01/24/2024 at 10:45 a.m., during an interview with S1DON (Director of Nursing), she confirmed the computer privacy screen should be initiated prior to leaving the computer unattended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status of 1 (#1) out of 33 sampled residents, by failing to ensure that the resident's fall status was coded.
Findings:
Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part: Parkinson's Disease, Abnormal Posture, Acute Diastolic Congestive Heart Failure, Unspecified Dementia with Other Behavioral Disturbances and History of Falling.
A review of Resident #1's clinical record revealed a progress note written on 10/10/2023 that read in part . Resident found lying on the floor.
A review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE], read in part: Section J1800: Falls since admit/reentry/prior assessment: any falls - No. In section J1900A: Falls since admit/reentry/prior assessment: no injury was left blank.
On 01/24/2024 at 11:16 a.m., a review of Resident #1's clinical record and interview was conducted with S4LPNMDS (Licensed Practical Nurse, Minimum Data Set). She confirmed Resident #1 had a fall on 10/10/2023. S4LPNMDS reviewed the Quarterly MDS assessment with an Assessment Reference Date (ARD) of 12/13/2023. She confirmed Section J1800 for falls since admit/reentry/prior assessment was coded as no and J1900A had No injury left blank. She stated J1800 should have been coded as Yes to reflect Resident #1 had 1 fall with no injury since prior assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure residents who need respiratory care were pro...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards for 1 (#20) of 1 residents investigated for respiratory care out of a total of 33 sampled residents, by failing to ensure that the resident's oxygen tubing was labeled stored in a sanitary manner when not in use.
Findings:
A review of the facility's policy titled Oxygen Administration read in part: Purpose. The purpose of this procedure is to provide guidelines for oxygen administration and storage of oxygen cylinders. 18. Tubing, cannulas and mask should be dated and replaced weekly unless otherwise ordered.
Resident #20 was admitted to the facility on [DATE] with diagnoses including: Shortness of breath, Chronic Obstructive Pulmonary Disease and Asthma.
A review of the physician's orders revealed an order written on 07/08/2022 for O2 (oxygen) per (delivered by) NC (nasal cannula) at 2 l/min (liters per minute) prn (as needed) SOB (shortness of breath).
On 01/22/2024 at 10:05 a.m., Resident #20 was receiving oxygen per NC at 2 liters. An observation of the oxygen tubing revealed the tubing and humidifier were not labeled with a date.
On 01/22/2024 at 11:18 a.m., a second observation of Resident #20's oxygen tubing revealed the tubing still did not contain a date of initiation.
On 01/23/2024 at 8:30 a.m., an observation was made of Resident #20 lying in bed with eyes closed. Further observation revealed an oxygen concentrator to the left side of the bed with NC and oxygen tubing rolled-up and under concentrator handle, with no storage bag in use.
On 01/23/2024 at 8:53 a.m., an observation of the oxygen concentrator with S3LPN was conducted. S3LPN confirmed oxygen tubing and humidifier had no date or labeling and was resting under the handle of the oxygen concentrator, with no storage bag in use. She stated the oxygen tubing should have been labeled with the date and stored in a bag when not in use.
On 01/23/2024 at 10:06 a.m., an interview was conducted with S2ADON. S2ADON confirmed oxygen tubing should be dated and stored in a bag when the tubing was not in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure its medication error rate was not 5 percent o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure its medication error rate was not 5 percent or greater, as evidenced by a calculated medication error rate of 72 percent.
Findings:
Review of a facility document titled, Medications - Administering, read in part: Policy Statement - medications shall administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders.
Resident #10
Resident #10 was admitted to the facility on [DATE] with diagnoses in part: Epilepsy, Hemiplegia, Unspecified Psychosis, Alcohol Abuse, Major Depressive Disorder and Hypertension.
Review of Resident #10's January 2024 physician's orders revealed in part:
Escitalopram 10 mg (milligrams) orally (po) daily
Bupropion HCL XL 300 mg po daily
Divalproex Sod ER 500 mg po twice a day (BID)
Depakote EC 125 mg po BID
Lisinopril-HCTZ (Hydrochlorothiazide) 20-12.5 mg po daily
Lisinopril 20 mg po every night at bed time (QHS)
Vitamin D3 1,000 unit's po daily
Review of Resident #10's eMAR (Electronic Medication Administration Record) revealed the following medications were scheduled for administered at 8:00 a.m. on 01/23/2024:
Lisinopril-HCTZ 20-12.5 mg po daily
Depakote Na DR 500mg po BID
Escitalopram 10mg po daily
Vitamin D3 25 mcg (1,000 units) po daily
Depakote 125 mg po BID
Wellbutrin XL 300 mg po daily
Review of Resident #10's administration record for January 2024 revealed:
10:02 a.m.,01/23/2024 (scheduled: 8:00 a.m., 01/23/2024; Lisinopril-HCTZ 20-12.5 mg tablet)
Pre Admin (administration) Blood Pressure - Generic 162/70
//01/23/2024 10:02 a.m.
Resident #36
Resident #36 was admitted to the facility on [DATE] with diagnoses in part: Limited activity d/t disability, Muscle Weakness, Atrial Fibrillation, Major Depressive Disorder, Tremors, Bipolar Disorder, Fibromyalgia, Congenital Scoliosis, Schizophrenia, and Anxiety.
Review of Resident #36's physician orders dated January 2024 read in part:
Eliquis 2.5 mg po BID
Keppra 500mg po BID
K+ CL ER (Potassium Chloride extended release) 20 MEQ (Milli equivalent) po daily
Digoxin 0.125 mg po daily
Review of Resident #36's administration record for January 2024 revealed:
10:12 a.m.,01/22/2024 10:12 a.m., (scheduled: 8:00 a.m., 01/22/2024; Digoxin 0.125 mg)
Pre Admin pulse: 60
//01/22/2024 10:12 a.m.
Resident #70:
Resident #70 was admitted to the facility on [DATE] with diagnoses in part: Alzheimer's disease, Hypothyroidism, and Type 2 diabetes mellitus.
Review of Resident #70's physician orders for January 2024 read in part:
Levothyroxine 50 mcg one tab before breakfast daily.
Review of Resident #70's eMAR (Electronic Medication Administration Record) revealed the following medication was administered at 8:25 a.m., on 01/09/2024:
Levothyroxine 50 mcg one tab before breakfast daily due at 6:00 a.m.
Resident #43
Resident #43 was admitted to the facility on 03//06/2023 with diagnoses in part: Epilepsy, Tremors, Tachycardia and Alcohol use.
Review of Resident #66's physician orders dated January 2024 read in part:
Vitamin D3 400 units give 2 tabs po daily
Keppra ER 750 mg give 2 tabs daily
Review of Resident #43's January 2024 eMAR (Electronic Medication Administration Record) revealed the following medication were scheduled for administered at 8:00 a.m.:
Vitamin D3 400 units give 2 tabs po daily
Keppra ER 750 mg give 2 tabs daily
Resident #59
Resident #59 was admitted to the facility on [DATE] with diagnoses in part: Major Depressive Disorder, Diabetes Mellitus type 2, Heart Failure, Epilepsy, Bradycardia and Hypertension.
Review of Resident #59's physician orders dated January 2024 read in part:
Metformin 1000mg BID po
Metoprolol Tar 25mg BID po
Fluoxetine 20mg po Daily
Eliquis 5mg po BID
Levetiracetam 100mg/ml 5 ml BID po
Potassium/Phosphorous supplement powder 2 packets in 6 ounces H2O (water) QID (four times a day)
Review of Resident #59's eMAR (Electronic Medication Administration Record) revealed the following medication were scheduled to be administered at 8:00 a.m.:
Metformin 1000mg BID po
Metoprolol Tar 25mg BID po
Fluoxetine 20mg po Daily
Eliquis 5mg po BID
Levetiracetam 100mg/ml 5 ml (milliliters) BID po
Potassium/Phosphorous supplement powder 2 packets in 6 ounces H2O (water) QID (four times a day)
On 01/22/2024 at 9:55 a.m., an observation of medication pass and interview was conducted with S7LPN. S7LPN confirmed she was still trying to pass her 8:00 a.m. medications to residents, and still had several resident that needed their 8:00 a.m. medications. S7LPN confirmed she was aware that medications should be given within one hour before to one hour after scheduled administration times and she was late giving 8:00 a.m. medications to Resident's #36 and Resident #59.
On 01/23/2024 at 9:10 a.m., an observation of medication pass and interview was conducted with S6LPN. S6LPN confirmed she had not finished with her 8:00 a.m. medication administration, having several more medications to give to residents. S6LPN confirmed she was aware that medication should be given within one hour before to one hour after scheduled administration times and she was late giving her 8:00 a.m. medications to Resident #43.
On 01/23/2024 at 9:40 a.m., an observation of medication pass and interview with S5LPN. S5LPN stated that she was late with finishing her medication administration to residents for 8:00 a.m. She confirmed medication that was due at 8:00 a.m., should be given one hour before to one hour after the scheduled time. She confirmed the medication given to Resident #10 were considered late because it was greater than one hour of administration time of 8:00 a.m.
On 01/24/2024 at 10:45 a.m., an interview was conducted with S1DON, she confirmed scheduled medications should be given within one hour before to one hour after scheduled administration time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure medications were stored properly for routine medications, medication refrigerator temperature logs were up to date, disposal of expi...
Read full inspector narrative →
Based on observations and interviews, the facility failed to ensure medications were stored properly for routine medications, medication refrigerator temperature logs were up to date, disposal of expired medications and schedule II-V medications being maintained in separately locked, permanently affixed compartments. The deficiency had the potential to affect a census of 65.
Findings:
Review of the facility's policy titled, Medication - Controlled Substances read in part: 2. Storage and Security: b. areas without automated dispensing systems utilize a substantially-constructed storage unit with two locks and a paper system for 24 hour recording of controlled substance use.
Review of the facility's policy titled, Medications - Storage read in part: Policy statement: the facility shall store all drugs and biologicals in a safe secure and orderly manner. 4. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such shall be returned to the dispensing pharmacy or destroyed. 7. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.
A policy for refrigerator temperature log was not provided to surveyor by time of exit from survey.
On 01/23/2024 at 9:35 a.m., an observation of Hall A medication cart, in the hallway, the medication cart was observed not locked at main key lock.
On 01/23/2024 at 9:40 a.m., an interview was conducted with S5LPN, she confirmed she had forgot to lock medication cart before she had walked away from the cart. S5LPN stated the cart should be locked before stepping away from the cart.
On 01/24/2024 at 10:05 a.m., a review of the facility medication storage room with S6LPN was conducted. Review of the temperature log book revealed January 2024 with no temperature documented on 01/15/2024, 01/16/2024, 01/19/2024, 01/20/2024 and 01/21/2024.
Further review of the temperature logs from October 2023 to December 2023 revealed November 2023 temperature log did not have a temperature logged on 11/26/2023, 11/27/23 and 11/28/2023. December 2023 temperature log did not have a temperature logged on 12/01/2023 and 12/03/2023. S6LPN confirmed the temperature logs were not completed for November 2023, December 2023, and January 2024.
On 01/24/2024 at 10:35 a.m., an interview was conducted with S6LPN, who confirmed the following medications were found in the resident storage bin and were expired with the following dates of expiration:
Resident #6 - a) Medroxyprogesterone injectable 150mg per ml with an expiration date of 08/17/2023
b) Sertraline 100mg issued 12/27/2022 with an expiration date 12/27/2023 (#6 pills)
c) Divalproex DR 125mg capsule issued 12/01/2022 with an expiration date 11/26/2023 (#10 pills)
Resident #12 - Fluticasone Propionate 50mcg/spray nasal inhaler issued 01/24/2022 and expiration date 01/09/2023
Resident #20 - a) Atrovent HFA 17mcg/inhalation issued 01/09/2023 and expiration date 01/04/2024
b) Atrovent HFA 17mcg/inhalation issued not available and expiration date 11/03/2023
c) Atrovent HFA 17mcg/inhalation issued 07/17/2023 and expiration date 01/08/2024
Resident #47 - Xulane patch 150/35mcg/day with an expiration date of 10/23/2023
S6LPN stated medications are checked for expiration regularly by a nurse.
On 01/24/2024 at 10:45 a.m., an interview was conducted with S1DON, she confirmed the medication storage room is checked for expired medication, usually on a weekly basis and medications are placed in the cubicle in the medication storage room to be destroyed or discarded by the DON. S1DON stated the controlled medications are kept in a drawer in her desk, with a key lock. She stated that she is the only person with a key to drawer. She stated the controlled medication, for disposal, are not kept under double lock and key at all times. S1DON also confirmed the medication cart should be locked when the nurse is present at the cart; and the medication refrigerator temperature should be documented daily on the temperature log.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#1) of 7 sampled residents. This was evidenced when facility failed to follow the physician's orders for fall mat to the right side of the bed, between the bed and the bathroom for Resident #1.
Findings:
Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cognitive Communication Deficit, Dysphagia, ESRD (End Stage Renal Disease), Major Depressive Disorder, Sepsis, Heart Failure, Atelectasis, and Type 2 DM (Diabetes Mellitus).
Review of the resident's care plan revealed the resident was at risk for falls due to history of falling on 05/12/2023, 10/04/2023, and 10/15/2023. The care plan included an intervention for fall mat to right side of bed between bed and bathroom.
Review of the resident's physician's orders revealed in part: Fall mat to the right side of bed between the bed and the bathroom.
On 10/23/2023 at 11:00 a.m., an observation was made of Resident #1 lying in bed in his room. No fall mat was observed in his room on the right side of the bed between the bed and bathroom.
On 10/23/2023 at 2:00 p.m., another observation was conducted of Resident #1's room. No fall mat was observed in his room on the right side of the bed between the bed and bathroom.
On 10/23/2023 at 2:15 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse). She reviewed the resident's chart and confirmed orders for a fall mat. She observed the resident's room and confirmed no fall mat and should have been there per physician orders.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide appropriate, treatment and care to prevent ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide appropriate, treatment and care to prevent urinary tract infections for residents who had indwelling urinary catheters for 2 (#6, #7) out of 7 sampled residents as evidenced by:
1. Failing to follow the physician orders for changing the suprapubic catheter q (every) month for Resident #6 and;
2. Failing to ensure a split gauze dressing was applied to the resident's suprapubic catheter; failing to ensure the catheter drainage bag was not on the floor; and failing to replace a soiled catheter stabilization device for Resident #7.
Findings:
Review of the facility's policy titled Indwelling Urinary Catheters read in part .8. Monthly changing of indwelling urinary catheters is often the accepted standard in a long term care setting .11. Bag contact with the floor must be avoided.
Resident #6
Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Palsy, Neuromuscular Dysfunction of Bladder.
Review of the resident's care plan revealed the resident was at risk for infections due to indwelling catheter (suprapubic). The care plan included an intervention for change q month on the 23rd and PRN (as needed) leakage/occlusion/dislodgement.
Review of the resident's physician's orders dated 12/09/2022 revealed in part: suprapubic catheter 22 french r/t (related to) neurogenic bladder change q month on the 23rd and PRN leakage/ occlusion/dislodgement.
On 10/23/2023 at 10:30 a.m., an observation and interview was conducted with Resident #6. The resident stated she just had a bath. She looked clean and was dressed appropriately. Her suprapubic catheter was observed with a moderate amount of sediment in the tubing and in the bag. The suprapubic catheter was secured to her thigh. There was no date, time or initials of when it was changed. When the resident was asked about the catheter, she stated it had been over a month since her catheter was changed.
10/23/2023 at 11:23 a.m., an interview was conducted with S3TN (treatment nurse). She stated she was unsure when the last time the suprapubic catheter was changed due to the bag having no date on it. S3TN reviewed the resident's TAR (treatment administration record) and stated there was no evidence of when the suprapubic catheter was changed.
Resident #7
Resident #7 was admitted to the facility on [DATE] with diagnoses including Limitation of Activities Due to Disability, Other Neuromuscular Dysfunction of Bladder, and Urinary Tract Infection.
Review of Resident #7's October 2023 Physician's Orders revealed an order dated 07/14/2023 that read: Suprapubic Catheter Site - Clean with wound cleanser, pat dry, and apply split gauze daily.
Review of Resident #7's plan of care revealed an intervention for catheter care every shift.
On 10/23/2023 at 4:00 p.m., an observation was made of Resident #7 in his room. The resident was lying in bed on his back with his left leg partially exposed. A catheter stabilization device was observed on his left leg. The white adhesive portion of the device had brown and tan stains, and there was no clamp on device to stabilize the catheter tubing. The drainage bag was on the floor. Resident #7 stated that he did not place the drainage bag on the floor and could not change his position on his own.
On 10/23/2023 at 4:08 p.m., an observation of Resident #7 and interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN stated the resident has a suprapubic catheter. She proceeded to remove the resident's blanket and exposed the resident's catheter site. There was no split gauze on the site. S4LPN also observed the resident's catheter stabilization device and confirmed it was dirty, had no clamp to stabilize the catheter, and should have been replaced. S4LPN stated there was no split gauze on the catheter insertion site, and there should have been. S4LPN also confirmed that the catheter drainage bag should not have been on the floor.
On 10/23/2023 at 4:50 p.m., S6CNA (Certified Nursing Assistant ) stated Resident #7 hadn't had a split gauze dressing on his catheter insertion site since she began her shift at 6:00 a.m.
On 10/23/2023 at 4:56 p.m., an interview was conducted with S5ADONIP (Assistant Director of Nursing/Infection Preventionist). She stated that she usually cleaned and applied the resident's split gauze dressing, but any floor nurse could have applied the split gauze. She confirmed Resident #7 should have had split gauze on his catheter insertion site per the physician orders; the catheter stabilization device should have been changed; and the catheter drainage bag should not have been on the floor.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement a comprehensive person-centered care plan by failing to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement a comprehensive person-centered care plan by failing to notify the physician of refusal of treatment for 1 (#1) resident of 5 (#1, #2, #3, #4, #5) sampled residents.
Findings:
A review of the facility's policy for a Change in a Resident's Condition or Status revealed the following, in part: Protocol for notifying attending Physician of Changes in resident's medical/mental condition. f) Refusal of treatment or medications (i.e., two or more consecutive times).
Resident #1 admitted to the facility on [DATE] with diagnoses that included the following, in part: Alcoholic Cirrhosis of Liver without Ascites, Homelessness, Chronic Viral Hepatitis C, Nicotine Dependence Cigarettes, Cocaine Use in Remission, Alcohol Abuse with Alcohol-induced Anxiety Disorder, Alcoholic Hepatic Failure without Coma.
Review of Resident #1's MDS (Minimum Data Set) Quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. On 07/26/2023, Resident #1 discharged from the facility for an inpatient psychiatric hospitalization.
A review of Resident #1's Care Plan dated 06/02/2023 read, in part: Refuses medications. Interventions included, in part: Administer medications as ordered.
A review of Resident #1's Physician Orders for July 2023 included, in part:
Promod 30 milliliters(ml) by mouth (PO) every day (QD)
Xifaxan 550 milligrams(mg) 1 PO twice a day (BID)
Eliquis 5 mg 1 PO BID- Ordered 7/10/23 Start date 7/11/23
Vitamin D2 400 unit tablet give 2 tabs (to equal 800 IU) PO QD
Levothyroxine 50 micrograms (mcg) 1 PO daily
Pantoprazole Sodium Delayed Release 40 mg 1 PO daily
Metoprolol tartrate 50mg 1 PO BID (ordered 7/10/23, start 7/11/23, discontinue date 8/14/23)
Folic Acid 400 mcg give 1 tablet PO daily (order 2/17/23; discontinue 8/14/23)
Zinc sulfate 220 mg give 1 po bid (order 3/10/23; discontinue 8/14/23)
Vitamin C 500mg five 1 po bid (order 3/10/23; discontinue 8/14/23)
Thiamine 100 mg 1 po TID (Order 2/17/23; discontinue 8/14/23
Lactulose 20 gram/30 ml solution give 45 ml PO BID (order 2/17/23; discontinue 8/14/23
A review of Resident #1's Medication Administration Record (MAR) for July 2023 revealed Resident #1 refused medications per Physician Orders a total of 24 days out of 25 days.
A review of Resident #1's Nurse's notes dated 07/01/2023 through 07/31/2023 revealed the physician was not notified of Resident #1's refusal of medications.
On 08/14/2023 at 3:35 p.m., Resident #1's MAR for July 2023 was reviewed with S2DON who confirmed that Resident #1 had refused medications. S2DON confirmed the physician was not notified of Resident #1's refusal of medication and 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to provide adequate supervision of residents while smo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to provide adequate supervision of residents while smoking which resulted in elopement of 1 (#1) out of 5 (#1, #2, #3, #4,#5) sampled residents investigated for elopement. The deficient practice had the potential to affect 33 residents who smoked out of a total census of 64 residents.
Findings:
A review of the facility's Smoking Policy revealed, in part:
This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents.
1)
Residents who smoke will be assessed for safety awareness and for willingness and ability to follow the facility's safety rules for smoking upon admission, and thereafter as needed but at least quarterly.
5)
Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan.
Resident #1 admitted to the facility on [DATE] with diagnoses that included the following, in part: Alcoholic Cirrhosis of Liver without Ascites, Homelessness, Chronic Viral Hepatitis C, Nicotine Dependence Cigarettes, Cocaine Use in Remission, Alcohol Abuse with Alcohol-induced Anxiety Disorder, and Alcoholic Hepatic Failure without Coma.
Review of Resident #1's MDS (Minimum Data Set) Quarterly assessment dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment and disorganized thinking present that fluctuated. Further review of the MDS revealed Resident #1 did not have behaviors or wandering. Resident #1 was independent for transfers and locomotion with a wheelchair.
A review of Resident #1's Care Plan revealed the following in part:
On 02/08/2023 a plan was started for the diagnosis of history of alcohol abuse with alcohol-induced anxiety disorder, history of cocaine use, history of nicotine dependence (cigarettes). The interventions included in part, the following: Monitor for signs/symptoms, notify physician for any complications.
A review of Resident #1's clinical record revealed a Smoking Assessment was completed on 03/01/2023 and he was assessed to be a safe smoker.
On 08/14/20233, a review of Resident #1's Incident Report and Investigation revealed that on 07/25/2023 at 10:32 a.m., Resident #1 eloped while smoking in the supervised designated smoking area outside. Further review revealed that there was one S3SUN that supervised the residents' during the smoke break. At 12:04 p.m. the resident was not in his room, facility initiated possible elopement search of premises. He was found at 12:15 p.m. at a local grocery store under a tree drinking a beer in his wheelchair. Resident #1 was brought back to the facility after refusing care at the emergency room. Resident #1 was assessed with no injuries noted. Interventions were initiated for Resident #1 that included: He was placed on census checks every fifteen minutes for the next twenty four hours, one to one when outside to smokes, and an elopement alert bracelet was placed on his ankle.
On 08/15/2023 at 2:55 p.m., a review of the camera footage was viewed with S1ADM (Administrator). The footage revealed that on 07/25/2023 Resident #1 was on the patio with 16 other residents and S3SUN was on the patio to supervise residents while smoking for safety and elopement risk. S3SUN was seen distributing and lighting residents' cigarettes. Residents were seen continuously being escorted to the patio at varying intervals by staff. The footage revealed at 10:33 a.m. Resident #1 turned his head toward S3SUN and other residents, then rolled himself toward the driveway out of the camera's view.
On 08/15/23 at 11:18 a.m., an interview was conducted with S3SUN who confirmed that on 07/25/2023 at 10:30a.m., she supervised the residents for smoking and recalled that she lit Resident #1's cigarette, then continued to light the other resident's cigarettes. S3SUN stated that she was not aware that Resident #1 had eloped.
On 08/15/23 at 2:45 p.m., an interview was conducted with S2DON (Director of Nursing) who stated the aide or staff member assigned to supervise residents while smoking was responsible to ensure that the residents did not elope.
On 08/15/2023 at 3:50 p.m., an interview was conducted with S1ADM who confirmed aide or staff member assigned to supervise residents while smoking was responsible to ensure that the residents did not elope. A review of the plan of correction with S1ADM was completed. S1ADM who confirmed that the plan of correction she implemented included the following: In-services were completed with all staff on the Elopement policy, maintenance to check residents with Wander guards and the alarm system, and residents were assessed for elopement risk and smoking safety. A second staff/aide assigned to monitor residents while they are smoking, including monitor residents going out to smoke and then returning inside and document. Both aides will observe for residents' safety and monitor for elopement risk. S1ADM stated when Resident #1 is outside smoking he will be monitored one to one and the aide will not leave resident. She stated this procedure will remain in place.
Mar 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews; the facility failed to protect the resident's right to be free from physical and psychos...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews; the facility failed to protect the resident's right to be free from physical and psychosocial abuse from other residents for 3 (#1, #2, and #3) out of 5 (#1-#5) sampled residents. The facility failed to protect Resident #1, Resident #2 and Resident #3 from being bit by Resident #5.
This deficient practice resulted in:
1. Physical and psychosocial harm for Resident #2, on 01/20/2023 at 11:47 a.m., when Resident #5 bit her on the right ankle causing redness and discomfort. Resident #2 voiced being fearful of Resident #5 and being bit by him again.
2. Physical and psychosocial harm for Resident #3, on 02/21/2023 at 1:45 p.m., when Resident #5 bit her on the hand that caused a skin tear. Resident #3 required preventive antibiotics and a TDAP (Tetanus, Diphtheria, and Whooping Cough) vaccine. Resident #3 was observed tearful and upset following the incident. Resident #3's son had to report to facility to assist in comforting her after the incident.
3. Physical harm for Resident #1, on 12/17/2022 at 3:30 p.m., when Resident #5 bit her on her right forearm causing several bite marks with 2 puncture sites.
Findings:
A review of the facility's Abuse Prevention and Investigation Policy statement read in part: Residents have the right to be free from .physical abuse. Residents will not be subjected to abuse by anyone.
Resident #5
Review of Resident #5's clinical record revealed an admit date of 11/08/2022 with diagnoses of Severe Intellectual Disabilities, Fetal Alcohol Syndrome, Bipolar, and Impulse Disorder.
Review of Resident #5's MDS (Minimum Data Set) dated 11/27/2022 revealed a BIMS (Brief Interview for Mental Status) score of 00 which indicated he was rarely understood.
Review of Resident #5's care plan revealed he was care planned for behaviors that included socially inappropriate/disruptive behavior and child-like behaviors (grabbing, biting, playing, running, jumping). Interventions included talk in calm voice, remove from public when behavior unacceptable, monitor behaviors, elicit input from family, medications for behaviors and diversional activities. Interventions for physically aggressive behaviors listed the following: 12/17/22 bit peer- placed on 1:1 (supervision) with staff at this time; 1/20/23 bit peer- redirected, staff to observe for adverse behaviors and redirect; and 2/21/23 bit peer- placed on 1:1.
Resident #2
Review of Resident #2's clinical record revealed an admit date of 08/08/2022 with diagnoses of Encephalopathy, Seizures, Essential Tremor, Anoxic Brain Injury, Adjustment Disorder with Mixed Anxiety and Depression, Viral Hepatitis, and Stimulant Abuse.
Resident #2's MDS Quarterly assessment dated [DATE] revealed she had a BIMS score of 14, indicating she was cognitively intact.
Resident #2's care plan revealed she was independent in her locomotion, transferred with no assistive devices utilized, and monitored for skin integrity related to bite from peer (Resident #5) on 01/20/2023.
A review of Resident #2's investigation report dated 01/20/2023 at 11:47 a.m. completed by S1ADM revealed in part, Resident #2 was sitting on the couch in the front lobby when Resident #5 was moving back and forth in front of her. Resident #5 was noted to be playing childlike, clapping his hands and moving to and from his wheelchair. Resident #5 looks at Resident #2 and puts his face down on her leg. Resident #2 stated Ouch, he is biting me. S5LPN was in the lobby at the time, but had her back to residents. The treatment nurse assessed Resident #2 and provided an ice pack and bandage to a reddened area on her right ankle. Resident #5 was removed from the lobby and placed on 1:1 supervision for 24 hours and to have extra supervision when in the front lobby.
A review of Resident #2's nursing progress note dated 01/20/2023 at 11:47 a.m. written by S5LPN, revealed that the resident was seated on one the couches in the main lobby area when another resident (Resident #5) rolled up to her in his wheelchair and bit her right lower leg. She was assessed for a slight bite mark to lower extremity with no broken skin.
On 03/14/2023 at 11:55 a.m., an interview was conducted with Resident #2. She recalled the biting incident involving Resident #5. She stated she was just sitting on the couch and he came up to her and bit her on her ankle. She stated she has did not want Resident #5 near her because she was fearful of him biting her again.
On 03/14/2023 at 11:40 a.m., an interview was conducted with S6SpeechTherapist. She stated she had witnessed the biting incident between Resident #2 and Resident #5. She stated Resident #2 had finished eating her lunch and sat down on the couch in the front lobby area. Once Resident #5 finished his lunch, he wheeled himself in his wheelchair to the front lobby area. When he passed by Resident #2, he bent over and bit her on her foot.
During an interview on 03/14/2023 at 12:40 p.m. S5LPN, confirmed she was in the front lobby when Resident #5 bit Resident #2 on her ankle. She verbalized that she was at her medication cart and had her back turned to the residents. She heard Resident #2 holler ouch, he (Resident #5) is biting me and went over to check on her. She stated the Resident #2 had red area to her ankle.
On 03/14/2023 at 12:15 p.m., an interview conducted with S3 Treatment Nurse confirmed she had assessed Resident #2 for injuries after Resident #5 bit her on the ankle. Resident #2 had a small reddened area to her right ankle and was provided an ice pack for discomfort.
During an interview on 03/15/2023 at 3:00 p.m. with S1ADM and S2DON, they confirmed that on 01/20/2023, Resident #2 was bit on her ankle by Resident #5. They acknowledged that Resident #2 had a reddened area to her ankle with no skin breakage, and was provided an ice pack for pain. They stated that Resident #5 was placed on 1:1 supervision for 24 hours after he bit Resident #2's ankle on 01/20/2023.
Resident #3
A review of Resident #3's clinical record revealed an admit date of 04/13/2021 with diagnosis of Anxiety, Depression, Hypertension, Dementia, Osteoporosis, Bilateral Hearing Loss, and Cataracts.
Resident #3's MDS Quarterly assessment dated for 02/09/2023 revealed she had a BIMS score of 3, indicating she was severely cognitively impaired.
Resident #3's care plan revealed she required supervision with locomotion and transfers with use of rolling walker. Further review revealed she was monitored for skin integrity related to a bite from peer (Resident #5) on 02/21/2023, including administration of preventive antibiotics, daily wound care until resolution on 03/02/2023.
A review of Resident #3's investigation report dated 02/21/2023 at 2:00 p.m. completed by S1ADM revealed in part, Resident #5 was in the front lobby with other residents and sat down next to Resident #3. Resident #5 put his head on Resident #3's shoulder and then tried to put his head in her lap where her hand was placed. Resident #5 then bit Resident #3 on the hand.
A review of Resident #3's nursing progress notes dated 02/21/2023 at 1:45 p.m. written by S4LPN revealed multiple staff heard Resident #3. Resident was sitting on the couch and Resident #5 bit her on right wrist causing a skin tear of 1.2 cm (centimeters) x 0.8 cm. Resident was tearful. Resident #3's son was notified and was asked to come spend time with mother and calm her. Resident #3's physician was notified and ordered TDAP vaccine and Keflex 250 milligrams (an antibiotic used to treat infections) three times daily for 7 days for preventative infection from bite wound.
A review of Resident #3's physician's orders for 02/21/2022 listed an order for Keflex 250 mg by mouth three times a day for 7 days for prevention from infection from bite wound; and TDAP booster give 0.5 ml (milliliters) IM (intramuscular) for 1 dose.
A review of Resident #3's electronic medication administration record for 02/2023 to 03/2023 revealed Resident was administered Keflex 250 mg three times daily for 7 days and received an intramuscular injection to the right deltoid (arm muscle) of TDAP booster 0.5 ml on 02/22/2023. Daily wound care for the skin tear was provided from 02/21/2023 until resolution on 03/02/2023.
On 03/15/2023 at 9:30 a.m., a telephone interview was conducted with Resident #3's son. He voiced the facility called to inform him of Resident #5 biting his mother on the hand that caused a skin tear. His mother was crying and upset. He stated he came to the facility to sit and talk with her to comfort her. He verbalized that he was concerned that his mother may be bitten again by Resident #5 and that she would be fearful of Resident #5 if she didn't have dementia and could recall the incident.
On 03/15/2023 at 11:00 a.m., during an interview with S4LPN, she confirmed Resident #3 was sitting on the couch in main lobby area. Resident #5 sat next to her and put his head on her shoulder, then immediately put his head on her lap and bit her on the hand. It happened in just a few seconds of him sitting down next to her. Resident #3 was visibly upset and crying. Resident #3's son was called and said he would come to the facility to see about his mother and help calm her down. She stated Resident #3 had a skin tear on her right hand that required treatment.
During an interview on 03/15/2023 at 3:00 p.m. with S1ADM and S2DON, they confirmed that on 02/21/2023 Resident #5 bit Resident #2 on her hand. They acknowledged she sustained a skin tear requiring treatment, was placed on preventive antibiotic treatment for 7 days and received a TDAP vaccine. S2DON confirmed that Resident #2's son was notified of his mother being visibly upset and came to the facility to help calm her. She voiced he stayed for an hour with his mother. They reported that Resident #5 was placed on 1:1 supervision within arm's length of staff at all times after he bit Resident #3's hand on 02/21/2023. They stated that Resident #5 has remained on 1:1 supervsion since he bit Resident #3's hand.
Resident #1
Review of Resident #1's clinical record revealed an admit date on 09/09/2020 with diagnoses of Schizoaffective disorder, Bipolar, PVD (Peripheral Vascular Disease), Osteoporosis, Anoxic Brain Damage, Depression, Seizures, and Impulse disorder.
Review of Resident #1's MDS (Minimum Data Set) Quarterly Assessment, dated 11/27/2022, revealed she had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact.
Resident #'s 1 care plan revealed she required total assistance from staff for transfers, but was able to perform locomotion with her wheelchair independently. Further review, revealed she was monitored for skin integrity related to bite from peer (Resident #5) on 12/17/2022, including daily wound care until resolution on 12/27/2022.
A review of an incident reported dated 12/17/2022 at 3:30 p.m. and completed by S1ADM, revealed Resident #1 reported another resident (Resident #5) had bit her on her arm and then told nurse not to worry about it. Resident #5 was playing with Resident #1's wheelchair, and rubbing his head and face on her back and arm. Staff encouraged Resident #1 to not let Resident #5 do those things due to him not being able to understand or communicate. Residents were in the front lobby area for 45 minutes before Resident #5 moved away. Resident #1 looked at her arm and told the nurse Resident #5 had bitten her but it was no big deal.
A review of Resident #1's nursing progress notes dated 12/17/2022 at 3:30 pm written by S4LPN revealed that Resident #1 reported that Resident #5 had bit her arm. Look, he bit me, but it's no big deal She had several bites to right forearm with 2 puncture sites.
Resident #1 was discharged from the facility on 02/14/2023 and was unavailable for an interview.
On 03/14/2023 at 12:15 p.m., during an interview conducted with S3 Treatment Nurse, she confirmed she treated Resident #1's right forearm for a bite mark with a puncture site. She stated she cleaned area, applied triple antibiotic ointment daily until wound resolved on 12/27/2022.
On 03/15/2023 at 11:00 a.m., an interview was conducted with S4LPN. She confirmed she was working on 12/17/2022 when Resident #5 bit Resident #1. Resident #5 was playing with Resident #1's arms and hands. She instructed Resident #1 not to let him play with her. Resident #1 voiced later to her that Resident #5 had bitten her on the arm.
During an interview on 03/15/2023 at 3:00 p.m. with S1ADM and S2DON, they confirmed that on 12/17/2022 Resident #5 had bitten Resident #1. Resident #5 had been rubbing his face on her arm and back. Resident #1 was told numerous times not to let him do that to her. Resident #1 showed her arm to the nurse and told her Resident #5 had bitten her. S2DON acknowledged Resident #1 had a bite mark with skin puncture to her right forearm.They stated that Resident #5 was placed on 1:1 supervision for 24 hours after he bit Resident #1's arm on 12/17/2022.
Jan 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents' personal funds were available during non-banking hours. This failed practice had the potential to affect any resident who...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure residents' personal funds were available during non-banking hours. This failed practice had the potential to affect any resident who deposited funds in the residents' trust fund
Findings:
A review of the facility policy Resident Personal Funds revealed in part, provide access to funds weekdays (Monday through Friday, excluding holidays) during business hours.
An interview was conducted on 01/09/2023 at 10:32 a.m., with Resident #32. He stated he could not get funds from petty cash, as his funds were not available in the account. He stated his funds were not available because the new person in charge of funds, had not transferred the funds.
On 01/11/2023 at 11:05 a.m., an interview was conducted with S4BOM (Business office Manager), she reported the residents are only able to request and receive their money out of their petty cash funds from S2SSD (Social Service Director). She reported there is no access for resident funds when the SSD is not available because she is the only one with access to the resident funds.
On 01/11/2023 at 02:05 p.m., during an interview S2SSD reported the resident's do not have access to personal funds at any given time. She confirmed she is the person responsible for giving resident's petty cash money upon request. She reported when she is not at the facility the DON (Director of Nursing) and/or Administrator have access to dispense petty cash funds to residents. S2SSD confirmed there is no one in facility, outside of business hours, readily available to be able dispense petty cash upon request.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide quarterly statements for resident personal funds for 1 (#32) resident out of 1 resident (#32) reviewed for personal funds.
Finding...
Read full inspector narrative →
Based on interview and record review, the facility failed to provide quarterly statements for resident personal funds for 1 (#32) resident out of 1 resident (#32) reviewed for personal funds.
Findings:
Resident #32's MDS (Minimum Data Set), dated 09/22/2022, revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact.
Review of Resident #32's demographic information sheet revealed Resident #32's sister, (Responsible Party), is his responsible party.
Review of the facility's policy titled Resident Personal Fund revealed, in part, the following:
.The resident and or his Responsible Party shall be given a quarterly statement detailing activity in the Resident Trust Fund Account. Statements are mailed out by the 20th of the month following the end of the quarter. A copy of the individual statements will be kept in a file with the Administrator's and bookkeeper's signature showing the date they were mailed.
On 01/09/23 at 10:32 a.m., an interview was conducted with Resident #32, he stated he had never received a statement of funds from the facility.
On 01/11/23 at 11:05 a.m., an interview was conducted with S4BOM (Business office Manager). She reported residents who are their own RP receive their own quarterly statements and if they have an RP, the RP will receive the quarterly statement. She confirmed Resident #32's sister is his RP, therefore, the statements are mailed to the RP.
During an interview on 1/11/2023 at 11:25 a.m., Resident #32's responsible party, stated the resident had funds at the facility but she did not receive quarterly statements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated tr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for 2 (#40, #263) out of 2 (#40, #263) residents investigated for hospitalizations.
Findings:
Resident #40.
Resident #40 was admitted on [DATE] with a diagnosis of Lennox-Gastaut Syndrome (severe complex epilepsy).
A review of Resident #40's medical record revealed Resident #40 was transferred to the hospital on [DATE] and 11/25/22.
A review of the Emergency transfer log for the months of November 2022 and December 2022 revealed the Ombudsman was not notified of Resident #40's transfer to the hospital.
On 01/11/23 at 12:33 p.m., an interview was conducted with S2SSD (Social Services Director) who confirmed her responsibility for performing the task of notifying the Ombudsman of facility initiated hospital transfers. She confirmed that the Ombudsman was not notified of either of the residents' transfers.
Resident #263.
Resident #263 admitted to the facility on [DATE] with diagnoses of Unspecified Brain Damage due to birth injury, Frontal Lobe and Executive Function Deficit and cerebral edema due to birth injury.
A review of Resident #263's medical record revealed the resident was transferred to the hospital on [DATE].
A review of the facility's Emergency transfer log for December 2022 through January 11, 2023 revealed Resident #263's name was not on the log to notify the Ombudsman of discharges.
On 01/11/23 at 12:36 p.m., an interview was conducted with S2SSD. Requested policy for Ombudsman notification of hospitalization. S2SSD stated she was not able to locate a policy. S2SSD confirmed the ombudsman was not notified of Resident #263's discharge on [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that a resident's enteral feeding was properly...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#43) out of 1 (#43) residents investigated for tube feeding. This deficient practice had the potential to affect the 4 residents in the facility who received continuous tube feedings.
Findings:
Review of the facility's policy titled Tube Feeding, Nasogastric/Gastric revealed in part . complete the label on ready-to-hang container; label the bag with the resident's name, date, time, formula ordered and amount to be given.
A review of Resident #43's clinical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of dementia, dysphagia, aphasia, and mild protein-calorie malnutrition.
A review of Resident #43's current physician orders revealed a diet order for Enteral feed (tube feeding) of Isosource (formula) 1.2 at 55 ml/hr. (milliliters per hour) continuously with 150 ml H2O (water) auto-flush every 4 hours via kangaroo pump.
On 01/09/2023 at 09:30 a.m., an observation of Resident #43's disposable tube feeding bag, revealed the bag was not labeled with a name, date, rate or time initiated.
On 01/10/2023 at 10:10 a.m., an observation was made of Resident #43's disposable tube feeding bag. The bag had a label that read Isosource 1.2 The tube feeding was infusing via Kangaroo pump at 55 ml/hr with a flush of 150 ml every 4 hours. There was no name, rate, date or time on the disposable bag.
On 01/10/2023 at 12:55 p.m., an observation and interview was conducted with S3LPN (Licensed Practical Nurse). She confirmed the tube feeding bag of Isosource 1.2 was infusing at 55 ml/hr, for Resident #43. She also confirmed the disposable tube feeding bag did not have a label with a date, rate or resident name on bag. She confirmed the bag should be labeled with resident's name, rate of infusion and date and time that the bag was hung.
On 01/10/2023 at 01:00 p.m., an interview was conducted with S1DON (Director of Nursing), she confirmed when a resident is receiving a tube feeding, the disposable tube feeding bag should have a label with the resident's name, rate of infusion, date, and time that the infusion was started.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on interview and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the developmen...
Read full inspector narrative →
Based on interview and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable disease and infections. The facility failed to maintain a water management program to prevent the growth of Legionella and other waterborne pathogens in the building's water system. This failed practice had the potential to affect a census of 59.
Findings:
Review of a policy (no date), titled Water Management Program, read in part: It is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems .1. A water management team has been established to develop and implement the facility's water management program 2. Maintains documentation that describes the facility' water system. A copy is kept in the water management program binder. 3. A risk assessment will be conducted by the water management team annually. 12. The facility will conduct an annual review of the water management program.
On 01/11/2023 at 4:01 p.m., S1DON stated she assumed the role of facility IP (Infection Preventionist) in August 2022 but had not completed IP training. She verified that the facility had no cases of Legionella and deferred to the Administrator for policy and testing.
On 01/11/2023 at 4:50 p.m. an interview and policy review was conducted with S5ADM, who was hired in June 2022. She stated the city's water company does water testing for the facility, but the facility must submit a request to have them come to the facility to test. She reported that she had not submitted a request form for water testing. S5ADM denied knowledge of having a water management team and was not aware of the location of a water management program binder. She was unable to provide any documentation of a water risk assessment or annual water testing. She verbalized a folder from the previous administrator only contained request forms for water testing and did not contain any of the results from prior testing.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on record review and interview, the provider failed to ensure that the staff responsible for the Infection Control Program was qualified by having completed specialized training in infection pre...
Read full inspector narrative →
Based on record review and interview, the provider failed to ensure that the staff responsible for the Infection Control Program was qualified by having completed specialized training in infection prevention and control. The facility census was 59.
Findings:
A review of the facility's Infection Prevention and Control Program Policy indicated that a designated Infection Preventionist or infection control nurse will serve to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The provider's policy failed to indicate the Infection Preventionist required certification in specialized training of infection prevention and control.
During an interview with S1DON on 01/11/2023 at 4:01 p.m., she verified she assumed the role of facility Infection Preventionist since August 2022. S1DON stated she was aware that, in addition to her Registered Nurse licensure, she was required to have specific training and certification in infection control. S1DON confirmed she had not completed the specialized infection prevention and control training required to be certified as the Infection Preventionist.
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 safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 2 harm violation(s), $146,296 in fines. Review inspection reports carefully.
- • 26 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $146,296 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 a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is The Of Dequincy's CMS Rating?
CMS assigns THE CARE CENTER OF DEQUINCY 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 The Of Dequincy Staffed?
CMS rates THE CARE CENTER OF DEQUINCY's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the Louisiana average of 46%.
What Have Inspectors Found at The Of Dequincy?
State health inspectors documented 26 deficiencies at THE CARE CENTER OF DEQUINCY during 2023 to 2025. These included: 2 that caused actual resident harm and 24 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Of Dequincy?
THE CARE CENTER OF DEQUINCY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by RIGHTCARE HEALTH SERVICES, a chain that manages multiple nursing homes. With 80 certified beds and approximately 60 residents (about 75% occupancy), it is a smaller facility located in DEQUINCY, Louisiana.
How Does The Of Dequincy Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, THE CARE CENTER OF DEQUINCY's overall rating (1 stars) is below the state average of 2.4, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Of Dequincy?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is The Of Dequincy Safe?
Based on CMS inspection data, THE CARE CENTER OF DEQUINCY has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). 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 The Of Dequincy Stick Around?
THE CARE CENTER OF DEQUINCY has a staff turnover rate of 47%, which is about average for Louisiana nursing homes (state average: 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 The Of Dequincy Ever Fined?
THE CARE CENTER OF DEQUINCY has been fined $146,296 across 2 penalty actions. This is 4.2x the Louisiana average of $34,542. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is The Of Dequincy on Any Federal Watch List?
THE CARE CENTER OF DEQUINCY 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.