Camelot Leisure Living
For profit - Limited Liability company
91 Beds
PARAMOUNT HEALTHCARE CONSULTANTS
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
1/100
#187 of 264 in LA
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Camelot Leisure Living has received a Trust Grade of F, indicating significant concerns about the care provided at this facility. They rank #187 out of 264 nursing homes in Louisiana, placing them in the bottom half of facilities across the state, and they are the only option in Concordia County. Unfortunately, the trends are worsening, with reported issues increasing from 9 in 2024 to 19 in 2025. Staffing is rated at 2 out of 5 stars, which is below average, and they have a 47% turnover rate, aligning with the state average, suggesting that staff may not stay long enough to build strong relationships with residents. Additionally, fines totaling $78,891 are quite concerning, as this is higher than 80% of Louisiana facilities, pointing to ongoing compliance issues. Several critical incidents highlight serious problems, including a failure to maintain a clean and sanitary kitchen, risking foodborne illnesses for all residents, and a situation where a staff member used bleach to wash dishes intended for food preparation, posing significant health risks. There was also a serious case of resident-to-resident abuse where one resident physically harmed another, leading to injuries that required emergency medical attention. While the facility has some aspects to improve upon, families should carefully consider these significant weaknesses when researching options for their loved ones.
- Trust Score
- F
- In Louisiana
- #187/264
- 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
- $78,891 in fines. Higher than 60% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 42 deficiencies on record. Higher than average. Multiple issues found across inspections.
1/100
Bottom 30%
Review needed
9 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 19 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: $78,891
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: PARAMOUNT HEALTHCARE CONSULTANTS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 42 deficiencies on record
2 life-threatening 1 actual harm
Jul 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure prompt resolution of an allegation of not providing proper Ileostomy care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Res...
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Based on interview and record review the facility failed to ensure prompt resolution of an allegation of not providing proper Ileostomy care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to initiate a grievance for Resident #1.Findings: Review of the Facility's Policy titled Filing/Grievances/Complaints with a revision date of 01/22/2025 revealed in part.Policy Statement: Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made.Policy Interpretation and Implementation:3. Grievances and/or complaints may be submitted orally or in writing.5. Upon receipt of written grievance and/or complaint, the social services director will investigate the allegation and submit a written report of such findings to the administrator within 24 hours of receiving the grievance and/or complaint.7. The resident, or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the administrator, or his or her designee, within 3 working days of the filing of the grievance or complaint with the facility.Review of Resident #1's medical record revealed an admit date of 04/20/2022 with diagnoses which included in part.Type 2 Diabetes Mellitus, Moderate Protein-Calorie Malnutrition, Gastrostomy Status, Ileostomy Status, Pain Unspecified, and Unspecified Dementia.Review of Resident #1's Quarterly MDS with ARD of 05/27/2025 revealed Resident #1 had a BIMS score of 99 indicating the resident was unable to complete the interview. Resident #1's MDS revealed she required partial to moderate assistance with toileting, bathing, eating, and personal hygiene.Review of Resident #1's Care Plan with a Target date of 07/22/2025 revealed in part.Alteration in Gastrointestinal Status related to Ileostomy with interventions that included provide treatment as ordered, change Ileostomy appliance (wafer and bag) every Tuesday and Thursday and PRN dislodgement.Telephone interview on 07/14/2025 at 7:57 a.m. with Resident #1's daughter revealed she had complained to the DON on three separate occasions (unable to remember dates) of her mother's (Resident#1) Ileostomy bag leaking and her mother having feces on her. Responsible Party revealed she visited her mother daily and on several visits her mother would have feces on her and a towel would be stuffed around the Ileostomy bag to catch the feces. Responsible Party stated the DON had assured her the matter would be taken care of, but it had not been.Review of the facility's Grievance Log revealed no grievances for Resident #1.Review of the facility's form titled Hand in Hand Program read in part.Date: 04/02/2025Any concerns or issues to be addressed: RP has a concern: says that the Nurse isn't changing Resident #1's Colostomy bag in a timely manner.Action taken to resolve the issue: I will notify the ADON and DON.Person contacted about what was done to resolve: BlankHand in Hand Rep signature: BlankAdministrator signature issue resolved: Signed by AdministratorInterview on 07/15/2025 at 9:16 a.m. with S7 [NAME] Clerk revealed Hands in Hands was a weekly call that she made to all resident's family members to help identify any concerns or complaints. S7 [NAME] Clerk stated Resident #1's RP had voiced many complaints mostly about nursing and those complaints had been given to S1 ADON and S8 DON.Interview on 07/15/2025 at 2:00 p.m. with S3 Administrator and S1 ADON stated department heads decide what is considered a grievance. S3 Administrator and S1 ADON confirmed the Hand in Hand tool did not replace a grievance. S3 Administrator and S1 ADON confirmed the facility had no grievances/investigations or resolutions to any grievances on Resident #1.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop a person-centered care plan for 1 (Resident #2) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to develop a...
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Based on interview and record review, the facility failed to develop a person-centered care plan for 1 (Resident #2) of 3 (Residents #1, #2, and #3) sampled residents. The facility failed to develop a care plan related to feeding assistance for Resident #2.On 07/16/2025 at 10:39 a.m., review of facility policy titled, Care Plans, Comprehensive Person- Centered, with revision date of 01/15/25, revealed in part. A Comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. A comprehensive, person-centered care plan will. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.On 07/16/2025 at 10:40 a.m., review of facility policy titled, Activities of Daily Living (ADLs), Supporting, with revision date of 01/15/25, revealed in part. Appropriate care and services will be provided to residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with. dining (meals and snacks).A review of Resident # 2's medical record revealed an admission date of 05/28/2025, with diagnoses that included in part. Dysphagia following Unspecified Cerebrovascular Disease, Senile Degeneration of Brain Not elsewhere Specified, Anorexia, Moderate Protein Calorie Malnutrition, and Other Sequelae of Non-traumatic Intracerebral Hemorrhage. Review of Resident #2's admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 06/09/2025, revealed Resident #2 was rarely/never understood with an altered level of consciousness that was continuously present. Resident #2 required moderate assistance with eating and was dependent for personal hygiene, mobility, and transfers. On 07/14/2025 at 12:00 p.m., review of grievance filed by Resident #2's family member on 06/23/2025 revealed in part. Date Incident Occurred: 06/20/2025Description: Family member reported that the resident's lunch tray was on the bedside table, left over her mom in bed. Family member reported the tray had tumbled over in her bed next to residents head and no aide was in the room.Findings of Investigation: Findings were that the tray was left in the room over the resident.On 07/14/2025 at 12:30 p.m., review of Resident #2's care plan revealed that the comprehensive care plan did not reflect the level of feeding assistance Resident #2 required. During an interview on 07/15/2025 at 10:00 a.m., S2 MDS Nurse confirmed Resident #2 required staff assistance to be fed. Resident #2's care plan was reviewed with S2 MDS Nurse and S1 ADON at this time. S2 MDS Nurse confirmed Resident #2's level of assistance required for feeding was not care planned 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
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
Based on Observation, interview and record review the facility failed to ensure that a resident who required Ileostomy services received such care consistent with professional standards of practice fo...
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Based on Observation, interview and record review the facility failed to ensure that a resident who required Ileostomy services received such care consistent with professional standards of practice for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents by failing to change Resident #1's ileostomy bag as needed.Findings: Review of the Facility's Policy titled Colostomy/Ileostomy Care with a review date of 01/25/2025 revealed in part.Purpose: The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter.Documentation: The following information should be recorded in the resident's medical record:1. The date and time the colostomy/ileostomy care was provided.2. The name and title of the individual (s) who provided the colostomy/ileostomy care.6. The signature and title of the person recording the data.Reporting: Report other information in accordance with facility's policy and professional standards of practice.Review of Resident #1's medical record revealed an admit date of 04/20/2022 with diagnoses which included in part.Type 2 Diabetes Mellitus, Moderate Protein-Calorie Malnutrition, Gastrostomy Status, Ileostomy Status, Pain Unspecified, and Unspecified Dementia.Review of Resident #1's Quarterly MDS with ARD of 05/27/2025 revealed Resident #1 had a BIMS score of 99 indicating the resident was unable to complete the interview. Resident #1's MDS revealed she required partial to moderate assistance with toileting, bathing, eating, and personal hygiene.Review of Resident #1's Care Plan with a Target date of 07/22/2025 revealed in part.Alteration in Gastrointestinal Status related to Ileostomy with interventions that included provide treatment as ordered, change Ileostomy appliance (wafer and bag) every Tuesday and Thursday and PRN dislodgement. Review of Resident #1's July 2025 Medication Administration Record revealed in part. Burp/Empty Colostomy-change as needed six times a day related to encounter for attention to Ileostomy.Telephone interview on 07/14/2025 at 7:57 a.m. with Resident #1's daughter revealed she had complained to the DON on three separate occasions (unable to remember dates) of her mother's (Resident#1) Ileostomy bag leaking and her mother having feces on her. Resident #1's Responsible Party stated she visited her mother daily and on several visits her mother would have feces on her and a towel would be stuffed around the Ileostomy bag to catch the feces. Resident #1's Responsible Party revealed her mother had to wait for long periods of time before a nurse could provide Ileostomy care for her.Observation on 07/14/2025 at 11:30 a.m. with S4 CNA in attendance revealed Resident #1 lying in bed. Resident #1 had loose feces on her skin which had leaked from her Ileostomy bag. S4 CNA stated the towel had been placed around the Ileostomy bag to catch the feces. S4 CNA stated that she had informed S5 RN/ADON Treatment Nurse a little after 10:00 a.m. that Resident #1's Ileostomy bag needed to be changed and that S5 RN/ADON Treatment Nurse replied it would be a minute (a while) before she would be able to change Resident #1's Ileostomy bag.Interview on 07/15/2025 at 8:20 a.m. with S1 ADON confirmed the following orders for Resident #1: Burp/Empty Colostomy-change as needed six times a day related to encounter for attention to Ileostomy. S1 ADON revealed it was the treatment nurse's and floor nurse's responsibility to provide Ileostomy care for Resident #1. S1 ADON revealed if the treatment nurse or floor nurse is busy they should notify another nurse to provide ileostomy care for Resident #1. S1 ADON revealed Resident #1's RP had complained of certain staff not changing Resident #1's Ileostomy bag.Interview on 07/15/2025 at 9:48 a.m. with S5 RN/ADON Treatment Nurse revealed she did not provide Ileostomy care to Resident #1 on 07/14/2025. S5 RN/ADON Treatment Nurse stated S6 LPN provided Ileostomy care for Resident #1 on 07/14/2025.Interview on 07/15/2025 at 11:10 a.m. with S9 Bookkeeper revealed S6 LPN clocked in to work at 11:16 a.m.Telephone Interview on 07/16/2025 at 8:09 a.m. with S6 LPN revealed it was after 2:00 p.m. on 07/14/2025 when she provided Ileostomy care for Resident #1. S6 CNA stated she had not been informed that Resident #1 needed Ileostomy care prior to that.Interview on 07/16/2025 at 9:38 a.m. with S5 RN/ADON Treatment Nurse confirmed she had not reported to S6 CNA on 07/14/2025 that Resident #1 needed Ileostomy care.
Feb 2025
16 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Food Safety
(Tag F0812)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serv...
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Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to effect all 64 residents who resided in the facility. The facility failed to ensure:
1.
Staff used approved chemicals/sanitizers during dishwashing;
2.
Food items in the refrigerators were labeled and dated;
3.
Maintenance of a clean freezer, in a safe operating condition, and food stored appropriately;
4.
Food items in the pantry were labeled with an open date, stored in a sealed container, and expired foods were not available for use;
5.
Food items in hot-warmer were covered and labeled until ready for serving;
6.
Maintenance of a clean and sanitary kitchen at all times;
7.
Staff are wearing hair restraints including beard restraints to prevent hair from contacting food;
8.
Staff are practicing effective hand hygiene and glove usage during food preparation activities; and
9.
Staff monitor food and refrigerator temperatures.
This deficient practice resulted in an immediate jeopardy situation on 02/17/2025 at 12:17 p.m. when S3 Dietary [NAME] was observed using a bucket that contained a Clorox/Bleach solution for dishwashing of the blender during pureed meal preparation. S3 Dietary [NAME] was alerted by the survey team to dispose of meats/beef patties on two occasions during meal preparation. S3 Dietary [NAME] stated this was how she washed dishes normally to save time. Surveyors observed S3 Dietary [NAME] continue to prepare the meats in the same blender and then S3 Dietary [NAME] placed the meat on the serving/steam line for meal plating/serving. S1 Administrator intervened and the meats were disposed of properly on 02/17/2025 at 12:20 p.m.
S1 Administrator was notified of the Immediate Jeopardy on 02/17/2025 at 5:07 p.m.
The Immediate Jeopardy was removed on 02/19/2025 at 1:29 p.m. as confirmed by onsite verification through observation and interview the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Review of an undated facility policy on 02/17/2025 at 2:32 p.m. titled, Dishwashing in Three Compartment Sink revealed in part .utensils and dishes washed by hand will be cleaned and sanitized .
Review of a facility policy on 02/17/2025 at 2:32 p.m. titled, Food Storage with a revision date of 06/2003 revealed in part .food storage area shall be maintained in a clean, safe, and sanitary manner. 1. Food storage shall be clean at all times .2. All packaged food or food items stored shall be kept clean .5. All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, or other surfaces that facilitate thorough cleaning .8. The dietary manager, or his/her designee, will check refrigerators and freezers daily for proper temperatures. Records of such information are maintained .
Review of an undated facility policy on 02/17/2025 at 2:32 p.m. titled, Food Preparation and Service revealed in part .Food will be maintained at proper temperatures during service and transported in a sanitary manner .
Review of an undated facility policy on 02/17/2025 at 2:32 p.m. titled, Sanitation and Food Handling revealed in part .sanitary conditions will be maintained in the storage, preparation and distribution of food .personnel will observe personal cleanliness and exercise satisfactory food handing techniques .8. Employees must wash their hands: d. after touching other parts of the body .F. when going from a soiled job to a clean job .H. when returning to the kitchen for any reason .
Usage of Chemicals
1. On 02/17/2025 at 12:17 p.m., S3 Dietary [NAME] was observed preparing pureed meals with the kitchen blender. After blending the white rice, she walked across the kitchen to the 3-compartment sink and cleaned/sanitized the blender to continue with meal preparation. Observed S3 Dietary [NAME] prepare spinach. After blending the spinach, S3 Dietary [NAME] was observed washing the blender with a rag she obtained from a red bucket near her blending station. S3 Dietary [NAME] stated the red bucket contained a Clorox/Bleach solution and she used the rag to wash her blender. She stated that this was her normal routine and she uses the Clorox/Bleach solution for most of her dishwashing to save time from walking across the kitchen to the 3-compartment sink. Surveyor observed S3 Dietary [NAME] put 6-8 beef patties into the same blender and began to blend the beef patties. S3 Dietary [NAME] was alerted by the survey team on two different occasions to dispose of the beef patties due to the usage of Clorox/Bleach solution during dishwashing. S3 Dietary [NAME] stated, I am going to do it anyways! Surveyor observed S3 Dietary [NAME] continue to blend the beef patties in the same blender and then S3 Dietary [NAME] placed the blended beef patties onto the serving/steam line for meal plating/serving. S1 Administrator was nearby in the Dietary Manager's office and was alerted by the survey team of the above findings.
In an interview on 02/17/2025 at 12:18 p.m., S1 Administrator stated the Clorox/Bleach solution in the red buckets (3 total buckets) were for cleaning of the kitchen countertops and shelving (not for dishwashing).
In an observation of and interview with S1 Administrator at 02/17/2025 at 12:20 p.m., S1 Administrator counseled S3 Dietary [NAME] that the Clorox/Bleach solution was not for dishwashing and stated it should only be used for surface level disinfecting. S3 Dietary [NAME] confirmed she did use the Clorox/Bleach solution to wash the blender. S1 Administrator instructed S3 Dietary [NAME] to remove the pureed beef patties from the serving/steam line and dispose of them properly. Surveyor observed S3 Dietary [NAME] dispose of pureed beef patties. Surveyor observed S1 Administrator properly clean and sanitize the blender in the 3-compartment sink. S1 Administrator instructed S3 Dietary [NAME] to prepare a new batch of pureed beef patties.
In an interview on 02/17/2025 at 8:40 a.m., S4 Maintenance Supervisor revealed he was helping S1 Administrator manage the kitchen and dietary staff due to the Dietary Manager being out on FMLA since 07/2024. At this time, a tour of the kitchen was conducted with S4 Maintenance Supervisor and revealed the following:
Reach-In Refrigerator:
2. Two bowls of unlabeled and undated peaches.
Two bowls of unlabeled and undated pureed fruit cocktails.
One bowl of unlabeled and undated assorted fruit (oranges/pears/peaches).
Three opened gallon jug pitchers of unlabeled and undated red liquid.
Walk-In Freezer:
3. Observed freezer door was unable to be closed properly due to the frost build-up. Observed increased production of frost throughout walk-in freezer. Upon entrance of the walk-in freezer, observation of multiple cardboard boxes of food items covered with frost and unable to view item labels due to the excessive amounts of frost. Observed excessive frost accumulated on the freezer ceiling, walls, doorway, and flooring. Observed several boxes of food items stored directly on the walk- in freezer floor.
During the tour, S4 Maintenance Supervisor stated that the walk-in freezer door was fixed/replaced recently and the frost accumulation is due to the staff not closing the freezer door properly.
No documentation of walk-in freezer door repairs provided from S1 Administrator during the survey, as requested multiple times on 02/17/2025 and 02/18/2025.
Dry Pantry:
4. One undated, open to air, 50-pound bag of white rice.
One undated, open to air, box of Quaker oats
One undated, open to air, bag of corn flakes
One opened and undated squeeze bottle of grape jelly with an expiration date of 12/21/2024.
Hot Foods Warmer:
5. Two large baking pans of uncovered and undated assorted cakes
Kitchen Cleanliness:
6. During kitchen tour, Surveyor observed dried brown grease stains on the kitchen floors; sticky floors, food particles on several areas of the kitchen floor, kitchen shelving, equipment, and counter tops; accumulation of dust and crumbs on sealed containers throughout the kitchen, meal prep area, and dry pantry area; dust, debris, and stains on the dishwashing station equipment, brown splatter marks on walls behind stove area; used foil observed in the stove from previous meals. Surveyor observed the inside of the stove contained baked on food accumulation on the walls, racks, and glass door, as well as an accumulation of dust, crumbs, and food stains on the clean dish rack.
S4 Maintenance Supervisor confirmed all the above findings during kitchen tour.
Hair Restraints:
7. In an observation of and interview in the kitchen area of S11 Dietary [NAME] on 02/17/2025 at 12:03 p.m., revealed S11 Dietary [NAME] had long curly beard/facial hair and no usage of a beard net. S11 Dietary [NAME] confirmed he does not wear a beard net and was unaware to wear a beard net since he was hired 4 months ago.
In an observation of and interview in the kitchen area with S12 Dietary Aide on 02/17/2025 at 12:05 p.m., revealed S12 Dietary Aide had a curly beard/facial hair and no usage of a beard net. S12 Dietary Aide confirmed he does not wear a beard net and was unaware to wear a beard net since he was hired 1 year ago.
In an observation of S11 Dietary [NAME] on 02/17/2025 at 12:30 p.m., revealed him walking throughout the kitchen and meal prep area with no beard net.
Hand Hygiene:
8. On 02/17/2025 at 12:35 p.m., observed S12 Dietary Aide with gloves on assist with lunch meal plating. Surveyor observed S12 Dietary Aide with the same gloves begin to organize the clean plates, sort through the resident meal tickets, adjust clothing/pants, put hands on his hips, touch the lower bottom shelving behind him, and push the serving cart out of the kitchen/prep area into the resident dining area. Surveyor observed S12 Dietary Aide return from dining area with same gloves on. He then touched clean utensils, and grabbed a slice of cornbread with his gloved hand. No hand hygiene or change of gloves observed throughout all of the above tasks.
Temperature Logs:
9. On 02/17/2025 at 12:26 p.m., observed S4 Maintenance Supervisor plate the lunch meal. Surveyor observed that S4 Maintenance had not measured the temperature of each food item and logged the temperatures prior to serving lunch.
On 02/17/2025 at 12:40 p.m., a review of Food Temperature Logs revealed missing temperature logs for the following dates:
02/07/2025-lunch
02/08/2025-lunch
02/09/2025-breakfast-lunch-dinner
02/10/2025-breakfast-lunch-dinner
02/11/2025 breakfast-lunch
02/12/2025 breakfast-lunch
02/13/2025-breakfast-lunch
02/14/2025 breakfast-lunch
02/15/2025 breakfast-lunch-dinner
02/16/2025 breakfast-lunch-dinner
On 02/17/2025 at 12:40 p.m., a review of Refrigerator Temperature Record revealed missing temperature logs for the following dates:
02/10/2025
02/11/2025
02/12/2025
02/13/2025
02/14/2025
02/15/2025
02/16/2025
In an interview on 02/17/2025 at 12:45 p.m., S3 Dietary [NAME] stated the kitchen staff were supposed to monitor and log the food temperatures prior to serving meals and monitor/log the refrigerator/freezer temperature logs on each shift. S3 Dietary [NAME] confirmed the above dates were not logged; therefore, the temperatures were not checked.
In an interview on 02/17/2025 at 2:15 p.m., S4 Maintenance Supervisor confirmed he should have checked with S3 Dietary [NAME] to see if she measured food temperatures prior to serving lunch today, but he did not. S4 Maintenance Supervisor confirmed temperatures for food items should be taken prior to food being served to ensure the proper food temperature.
In an interview on 02/17/2025 at 2:20 p.m., S1 Administrator confirmed that the dietary staff should perform temperature checks and log all temperatures for each meal (breakfast, lunch, and dinner) prior to serving/plating the foods. S1 Administrator confirmed the above missing temperatures were not monitored or documented but should have been.
In an interview on 02/18/2025 at 2:25 p.m., S13 RD revealed she had been the facility RD since September 2024 and had the same concerns as the above survey findings. S13 RD stated when she first toured the kitchen in September 2024, she told the dietary staff not to use Clorox/Bleach and stated it would only be appropriate if they used a capful of Clorox/Bleach. However, the dietary staff were just free-pouring the Clorox/Bleach in the red buckets. S13 RD stated since September 2024, the walk-in freezer has always had excessive frost build-up. S13 RD confirmed the dietary staff should have worn beard nets when they have facial hair and always practice proper hand hygiene/gloving throughout their shift, especially when handling foods and food items.
Plan of Removal :
All 65 residents have the potential for illness or serious harm from the alleged deficiency F812.
On 02/17/2025 a cook used bleach to sanitize a food processor. Immediately the administrator called the dietary consultant to come in 02/18/2025 and in-service and train the dietary staff to ensure regulatory compliance. After review of policy and procedures they did not require updating. The continuing education of current and new dietary staff will be done by the administrator, the administrator's designee, or the dietary consultant at monthly in-services. The administrator removed all bleach from dietary, and the facility on 02/17/2025.
On 02/17/2025 the administrator immediately verbally in-serviced dietary staff present that bleach is not used to sanitize equipment, pots & pans, and cutlery. The 3 compartment sink was explained and how to check the proper level of sanitizer. On 02/17/2025 the administrator called the dietary consultant to come 02/18/2025 to in-service and train dietary staff on sanitary conditions in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance. On 02/18/2025 the administrator called 2 off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer. All dietary staff have been in-serviced as of 02/18/2025. Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at monthly in-services for all dietary staff.
The kitchen will be audited randomly to ensure there is no bleach in the kitchen, the audits will be done bi-weekly for the next 3 weeks and then weekly to monitor the kitchen that no bleach is present. This monitoring will be included in the current QAPI being done in the kitchen and reported quarterly in the QA meeting, the Administrator and Maintenance Supervisor will complete the random audits and weekly audits. Any dietary staff not following policies and procedures given in-services will be given written warnings up to and including termination.
Correction Date: 02/19/2025 at 1:29 p.m.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observation, record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-bei...
Read full inspector narrative →
Based on observation, record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficient practice had the potential to effect all 64 residents who resided in the facility. The facility failed to ensure the dietary department was practicing professional standards for food services.
This deficient practice resulted in an immediate jeopardy situation on 02/17/2025 at 12:17 p.m. when S3 Dietary [NAME] was observed using a Clorox/Bleach solution for dishwashing of the blender, used during pureed meal preparation. S3 Dietary [NAME] stated this was how she washed dishes normally to save time. S3 Dietary [NAME] was advised by Surveyor to dispose of meats/beef patties on two occasions during meal preparation. Surveyor observed S3 Dietary [NAME] continue to prepare the meats in the same blender and then S3 Dietary [NAME] placed the meat on the serving/steam line for meal plating/serving. S1 Administrator intervened and the meats were disposed of properly on 02/17/2025 at 12:20 p.m.
The deficient practice continued at a potential for more than minimal harm for all 64 residents who resided in the facility.
S1 Administrator was notified of the Immediate Jeopardy on 02/17/2025 at 5:07 p.m.
The Immediate Jeopardy was removed on 02/19/2025 at 1:29 p.m. as confirmed by onsite verification through observation and interview the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Cross Reference F812
Review of a facility policy on 02/20/2025 at 1:15 p.m. titled, Dietary Staff Competency with a date of 01/15/2025 revealed in part .Purpose: All dietary staff will be trained according to policy. 1. Provide all dietary employees with training upon hire and as needed. 2. Staff should be made aware of all safety precautions, nursing home policies, and necessary in-services regarding dietary equipment and meal services. 3. Dietary Supervisor will provide in-services to dietary staff as needed .
Review of an undated facility policy on 02/20/2025 at 1:15 p.m. titled, Dietary Competency revealed in part .the Dining Services Manager will review each skill, observe staff demonstration, and sign each item on this list annually with each evaluation. The completed form will be placed in the employee file competencies included in part .Skill: purpose, emergency preparedness, food storage and handling, procedures, handwashing, food preparation, meal services, safety procedures, sanitary procedures, proper temperatures and recordings, storage, washing dishes, trash containers, operation, cleaning, and safety .
In an interview on 02/17/2025 at 8:40 a.m., S4 Maintenance Supervisor revealed the dietary manager had been out for several months so he had been helping S1 Administrator oversee the kitchen and dietary staff.
In an observation of and interview in the kitchen area of S11 Dietary [NAME] on 02/17/2025 at 12:03 p.m., revealed S11 Dietary [NAME] had long curly goatee/facial hair and no usage of a beard net. S11 Dietary [NAME] confirmed he does not wear a beard net and he had not been made aware that he needed to wear a beard net since he was hired 4 months ago. S11 Dietary [NAME] stated no one has ever spoke to him about covering his beard/goatee hair. S11 Dietary [NAME] stated that no one has properly trained him. S11 Dietary [NAME] revealed that he was 'self-taught' and stated, To be completely honest, it's a s!@# show every day in this kitchen! S11 Dietary [NAME] stated that S1 Administrator nor S4 Maintenance Supervisor had ever trained him. S11 Dietary [NAME] stated he did not feel comfortable asking them for help because they do not listen and do not help the kitchen staff. S11 Dietary [NAME] stated that S14 Part-Time Dietary Manager comes weekly but had never taught him anything regarding his duties. S11 Dietary [NAME] reported that he worked by himself sometimes and often had little to no help.
In an interview and observation on 02/17/2025 at 12:13 p.m., S3 Dietary [NAME] was observed preparing pureed meals in the kitchen blender. S3 Dietary [NAME] was observed free-pouring and unmeasured amount of powdered thickener. S3 Dietary [NAME] revealed this was how she normally prepares her pureed meals and she just eye-balls it. S3 Dietary [NAME] stated no one had taught her differently.
In an interview on 02/17/2025 at 1:33 p.m., S3 Dietary [NAME] stated prior to today, she was unaware she was not to use Clorox/Bleach for dishwashing.
Review of facility dietary staff personnel files revealed there was no documentation indicating dietary staff had received training upon hire. Findings included in part .
S1 Administrator was hired on 09/01/2024 with no documentation of dietary staff competencies or duties check-off.
S3 Dietary [NAME] was hired on 12/11/2024 with no documentation of dietary cook competencies or duties check-off.
S4 Maintenance Supervisor was hired on 10/29/2001 with no documentation of dietary staff competencies or duties check-off.
S11 Dietary [NAME] was hired on 11/22/2024 with no documentation of dietary cook competencies or duties check-off.
S12 Dietary Aide was hired on 05/09/2024 with no documentation of dietary aide competencies or duties check-off.
In an interview on 02/18/2025 at 2:25 p.m., S13 RD stated there was no current Dietary Manager overseeing the kitchen and that S1 Administrator was overseeing the kitchen daily. S13 RD stated she was made aware today that the kitchen staff had never received training and had never had competency check offs completed.
In an interview on 02/17/2025 at 9:26 a.m., S1 Administrator revealed the dietary manager had been out since July 2024 due to an injury. S1 Administrator stated he completed his self-serve certification and was ultimately responsible for managing the kitchen and dietary staff. S1 Administrator stated recently corporate had allowed him to hire S14 Part-Time Dietary Manager who came once a week to assist in the kitchen. S1 Administrator stated S13 RD monitored the kitchen monthly. S1 Administrator confirmed that he was responsible for daily duties, hiring/firing of dietary staff, education, and daily monitoring.
Plan of Removal:
All 65 residents have the potential for illness or serious harm from the alleged deficiency F835.
The dietary staff allegedly was not properly trained on dishwashing practices. After a review of policies and procedures they did not require updating. The training of new dietary staff will be done on hire, and continuing education will be provided at monthly in-services for all dietary staff to improve the knowledge, and basic skills of the dietary staff to ensure regulatory compliance. The training and continuing education of current and new dietary staff will be done by the administrator, the administrator's designee, or the dietary consultant.
On 02/17/2025 the administrator immediately verbally in-serviced dietary staff present not to use bleach to sanitize equipment and instructed staff how to use the 3 compartment sink and check for the proper amount of sanitizer. On 02/17/2025 the administrator called the dietary consultant to come 02/18/2025 to in-service and train dietary staff on sanitation in the kitchen and how to set up and check the sanitizer in the 3 compartment sink to ensure regulatory compliance. On 02/18/2025 the administrator called 2 off duty dietary staff to verbally in-service them about not using bleach, and how to setup the 3 compartment sink and check the sanitizer. All dietary staff have been in-serviced as of 02/18/2025. Continuing education will be provided by the administrator, the administrator's designee, or the dietary consultant at monthly in-services for all dietary staff.
The training of each new hire in dietary will be monitored using a check list to orient them to the kitchen and dietary policies and procedures, and all dietary staff will receive monthly in-servicing training. The administrator will monitor the training of new dietary staff and the monthly in-services, both will be ongoing. The dietary consultant will monitor the administrator to ensure new hire training and monthly in-servicing is taking place during their monthly visit. This monitoring will be included in the current QAPI being done in the kitchen and reported quarterly in the QA meeting.
Correction Date: 02/19/2025 at 1:29 p.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Resident #19
Review of Resident #19's medical records revealed an admit date of 03/26/2024 with diagnoses that included: Dysarthria following Unspecified Cerebrovascular Disease, Hypoparathyroidism, U...
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Resident #19
Review of Resident #19's medical records revealed an admit date of 03/26/2024 with diagnoses that included: Dysarthria following Unspecified Cerebrovascular Disease, Hypoparathyroidism, Unspecified Cognitive Communication Deficit, Type 2 Diabetes Mellitus without complications, Major Depressive Disorder, Cerebral Infarction, and Dysphagia.
Review of Resident #19's Quarterly MDS with ARD of 12/24/2024 revealed a BIMS of 13 indicating intact cognition. Resident #19 required partial to moderate assistance with personal hygiene.
Observation and interview on 02/17/25 at 10:18 a.m. with Resident #19 revealed long facial hair to her chin and neck area. Resident #19 stated she did not like the long hair on her face, and had asked staff to shave her, but was told they are afraid to cut her.
Observation and interview on 02/18/2025 at 11:20 a.m. with Resident #19 revealed long facial hair to her chin and neck area. Resident #19 stated she had been cleaned up this morning, but no one had shaved her. Resident #19 stated she would like to be shaved.
Interview on 02/18/2025 at 11:29 a.m. with S10 LPN confirmed Resident #19's hair on her chin and neck are was long and needed to be shave, but had not been.
Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#32 and #19) of 2 Residents reviewed for dignity. The facility failed to ensure:
1. Resident #32, who was seated at a table with another Resident, was served his meal at the same time; and
2. Resident #19 was free from facial hair.
Findings:
Review of the facility's policy titled Quality of Life- Dignity dated 01/15/2025 read in part . Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individually. 1. Residents shall be treated with dignity and respect at all times. 3. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).
Resident #32
Observation on 02/18/2025 at 11:58 a.m. revealed all residents seated in the dining room with the exception of Resident #32 had been served their lunch meal tray.
Interview on 02/18/2025 at 11:58 a.m. with S15 CNA revealed Resident #32 had not been served lunch, because the kitchen did not prepare his tray. S15 CNA stated they had requested Resident #32's lunch tray several times from the kitchen, but were still waiting.
Interview on 02/18/2025 at 12:05 p.m. with Resident #32 revealed he had been seated at table in dining room since 11:50 a.m., and had not received his lunch tray. Observation revealed Resident #32 was seated at the same table as a female resident, who had received her lunch tray, and was eating her meal. Resident #32 stated he was tired of waiting, and the kitchen always served his meal late.
Observation on 02/18/2025 at 12:10 p.m. revealed S5 ADON presented to the kitchen and requested Resident #32's lunch tray. Kitchen staff replied they were working to prepare Resident #32's tray.
Observation on 02/18/2025 at 12:14 p.m. revealed S5 ADON received Resident #32's tray from the kitchen staff and served Resident #32 his tray.
Interview on 02/18/2025 at 12:14 p.m. with S5 ADON revealed Resident #32 should not have had to wait that long to be served. S5 ADON confirmed all residents seated together at a table should be served at the same time, but had not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for 1 (#72) of 3 (#49, #71, and...
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Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for 1 (#72) of 3 (#49, #71, and #72) closed records reviewed.
Findings:
Record Review on 02/20/2025 of the facility's policy dated 01/15/2025 titled Change in Resident's Condition or Status read in part Policy statement: Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, residents rights, etc.) Policy: 1.The nurse will notify the resident's Physician or physician on call when they there has been a (an):
a.
Accident or incident involving the resident
d. Significant change in resident's physical/emotional/mental condition.
Review of Resident #72's medical record revealed an admit date of 12/06/2024 with diagnoses that included: Heart Failure, Coronary Angioplasty Implant and Graft, Essential Hypertension, Type 2 Diabetes Mellitus, and Dementia.
Review of Resident #72's nurse's notes read in part .
12/21/2024 at 12:10 p.m. S22 CNA called for assistance and stated Resident was fine one minute and talking then he began to twitch and became unresponsive. S21 Charge Nurse was notified and stated, He does this, he's been sent out for it before, but nothing was found wrong. It is because of his blood pressure. He does not need to be sent out to the hospital. He'll be fine. B/P 92/69, P 63, R16, O2 97. Resident came around/alert. S21 Charge Nurse feeding Resident #72. Resident responding/talking. Resident experienced syncope episode. Monitoring continued.
Interview on 02/19/2025 at 4:16 p.m. with S2 DON revealed she was not made aware of the episode that occurred with Resident #72 on 12/21/204.
Telephone interview on 02/19/2025 at 4:55 p.m. with S19 MD revealed he could not recall if he was notified of incident with Resident #72 on 12/21/2024, and could not say if he would have sent Resident #72 out for evaluation or not.
Interview on 02/19/2025 at 4:45 p.m. with S20 LPN revealed she was the nurse that cared for Resident #72 on 12/21/2024. S20 LPN stated she was notified by S22 CNA that Resident #72 had a change in condition. S20 LPN stated she observed Resident #72 in bed with his eyes closed, and he was not responding to verbal stimuli, but was breathing. S20 LPN stated she notified S21 Charge Nurse and he was able to get a response from Resident #72 after a sternal rub. S20 LPN stated S21 Charge Nurse told her that Resident #72 had done this before, and that he did not need to be sent out to the hospital. S20 LPN stated that she did not notify the physician of the change in condition for Resident #72 on 12/21/2024.
Interview on 02/20/2025 at 9:00 a.m. with S21 Charge Nurse revealed he was the charge nurse at the facility on 12/21/2024 and 12/22/2024. S21 Charge Nurse stated that he was notified by S20 LPN on 12/21/2024 that resident #72 was unresponsive. S21 Charge Nurse stated he went into the room and preformed a sternal rub and Resident #72 responded. S21 Charge Nurse stated he did not call the physician because resident #72 was responsive and he felt that Resident #72 was at his baseline.
Interview on 02/20/2025 at 9:29 a.m. with S22 CNA stated she went to change Resident #72 on 12/21/2024 and he was not moving, so she notified the nursing staff. S22 CNA stated after S21 Charge Nurse performed a sternal rub, Resident #72 became responsive. S22 CNA stated she was told that Resident #72 had had these episodes before. S22 CNA stated Resident #72 was sleepy, not eating, and was not acting like his normal self that day.
Interview on 02/20/2025 at 11:05 a.m. with S2 DON revealed she could not confirm if the physician should have been called or not because S21 Charge Nurse made an assessment and determined that Resident #72 was at his baseline.
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 observation, interview, and record review, the facility failed to ensure the security and confidentiality of medical records.
Findings:
On 02/20/2025, review of the facility's policy entitled...
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Based on observation, interview, and record review, the facility failed to ensure the security and confidentiality of medical records.
Findings:
On 02/20/2025, review of the facility's policy entitled Electronic Medical Records dated 12/23/2024 revealed, in part .computer screens with resident's information will be placed in privacy mode or covered when the employee is not present.
Observation on 02/19/2025 at 9:02 a.m. revealed Cart A in Hall A with the electronic medical record (EMR) screen open and visible. There was no employee present. The surveyor remained with Cart A until a staff member approached Cart A. The staff member identified herself as S7LPN.
An interview on 02/19/2025 at 9:15 a.m. with S7LPN confirmed she was currently using Cart A to provide medications to residents on Hall A. S7LPN confirmed the computer screen with resident's information was not closed when she was away from the medication cart, but should have been.
An interview 02/19/2025 at 9:40 a.m. with S6ADON confirmed computer screens with resident information should be closed and not visible when staff was not present.
An interview on 02/19/25 at 10:09 a.m. with S5ADON confirmed computer screens with resident information should be closed and not visible when staff was not present.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment upon dischar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment upon discharge for 1 (Resident #28) of 1 resident sampled for Resident Assessment.
Findings:
Record review revealed Resident #28 was admitted on [DATE] and discharged on 12/14/2024.
Review of Resident #28's MDS record revealed no Discharge MDS assessment.
An interview on 02/19/2025 at 1:00 p.m. with S6ADON confirmed she was responsible for completion of MDS assessments. S6ADON confirmed she did not complete a Discharge MDS assessment when Resident #28 was discharged , but should have.
An interview on 02/19/2025 at 2:52 p.m. with S6ADON revealed she had submitted a Discharge MDS assessment for Resident #28. She provided a CMS Submission Report dated 02/19/2025 at 3:46 p.m. which revealed, in part .Target date of 12/14/2024 .assessment completed late, more than 14 days after the Assessment Reference Date (ARD).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to complete a significant change MDS within 14 calendar days after determining there was a significant change in residents status for 1 (#7) of...
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Based on record review and interview the facility failed to complete a significant change MDS within 14 calendar days after determining there was a significant change in residents status for 1 (#7) of 35 sampled resident's. Findings:
Record Review of the facility's current policy titled MDS dated 01/15/2025 read in part . Our facility will complete, conduct, and submit resident assessments in accordance with current federal and state submission timeframes.
Record Review of Resident #7's medical record revealed an admission date of 03/25/2019. Resident #7 had diagnoses that included in part . Parkinson's Disease, Unspecified Psychosis, and Depression.
Record Review of a MDS State Optional Assessment with ARD of 12/17/2024 revealed Resident #7's BIMS was not assessed, due to being rarely understood. Resident #7 was dependent on staff with 2 person physical assistance required for Bed Mobility, Transfers, and Toileting, and 1 person physical assistance required for Eating.
Record Review of Resident #7's paper chart revealed a written order dated 02/03/2025: Admit resident to hospice services.
Record Review of Resident #7's Care Plan with target review date of 03/17/2025 revealed Resident had a psychosocial well-being problem related to anxiety with and intervention of: Hospice to visit resident. - Initiation date of 02/05/2025.
Record Review of Resident #7's MDS assessments revealed no evidence that a significant change MDS had been completed, or was in progress, following her admission to hospice on 02/03/2025.
Interview on 02/19/2025 at 1:23 p.m. with S6 ADON revealed she was responsible for resident care plan revisions and MDS assessments. S6 ADON revealed Resident # 7 was currently on hospice as of 02/03/2025. S6 ADON confirmed a Significant Change MDS had not been completed yet for Resident #7, and should have been within 14 days of her admission to hospice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide services that meet professional standards of q...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide services that meet professional standards of quality. The facility failed to revise the care plan interventions to prevent development of a wound for 1 (Resident #43) of 3 residents (Resident #10, Resident #43, and Resident #223) sampled for skin conditions.
Findings:
Review of the facility's policy entitled Care Plans, Comprehensive Person-Centered dated 01/15/2025 revealed, in part, the Interdisciplinary Team (IDT) develops and implements a comprehensive, person-centered care plan for each resident. The care plan will describe the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
Record review revealed Resident #43 was admitted on [DATE] with diagnoses including, in part, Hemiplegia and Hemiparesis following a Cerebral Infarction.
Review of Resident #43's Quarterly MDS with ARD of 12/31/2024 revealed, in part, the resident had limited ROM to the upper and lower extremities on one side. The resident was dependent for eating, all hygiene, dressing, and transfers. Resident #43's primary diagnosis was Cerebrovascular accident (CVA) with Hemiplegia. Resident #43 was at risk for development of pressure injuries. Resident #43 was not receiving any therapies or treatments.
Review of Resident #43's current physician orders revealed, in part, an order dated 05/01/2023 for the nurse to ensure nail care is performed daily.
Review of Resident #43's 02/2025 Treatment Administration Record revealed, in part, daily documentation of nail care being ensured.
Review of Resident #43's current Care Plan revealed, in part, risk for impaired skin integrity and need for preventative measures related to contractures and impaired mobility initiated on 03/09/2021. Interventions included, in part, assess skin over bony prominences, and skin checks per facility policy initiated on 04/05/2021. Resident #43 was not care-planned for use of a hand roll or other pressure relieving device related to contracture of hand.
Review of Resident #43's progress notes revealed no documentation of current skin impairment.
Observation of Resident #43 on 02/18/2025 at 12:06 p.m. revealed contracted right hand with no hand roll or other pressure prevention device.
Observation of Resident #43 on 02/19/2025 at 09:02 a.m. accompanied by S7 LPN revealed purple discoloration to right palm where 5th digit presses into palm. Dark red substance crusted to right palm and between 3rd, 4th, and 5th digits of the right hand. Resident #43 resisted further examination. S7 LPN stated she did not think Resident #43 was care-planned for a hand roll.
Observation of Resident #43 on 02/19/2025 at 9:40 a.m. accompanied by S6 ADON, S8 LPN, and S5ADON revealed an open wound with reddish-pink drainage to the palm of resident's contracted right hand, where 5th digit pressed into palm. A dry, dark red substance was noted to the resident's palm and between the 3rd, 4th, and 5th digits of the right hand. S6 ADON confirmed Resident #43 did not have an order for a hand roll. She stated the facility attempted to use a hand roll in the past, but were unable because of how tightly Resident #43's right hand was clenched.
An interview was conducted 02/19/2025 at 11:26 a.m. with S9 NP who confirmed there was a wound to Resident #43's right palm.
Review of Progress Note dated 02/19/2025 at 09:15 p.m. per S9 NP revealed, in part, .due to right hand/fingers contracted, appears fingernail has caused skin tear to palm of hand.
Review of Physician's Telephone Order for Resident #43 dated 02/19/2025 revealed an order to cleanse skin tear to palm of right hand with wound cleanser, pat dry, apply triple antibiotic ointment, apply rolled gauze to right hand as tolerated every day, Occupational Therapy (OT) to screen, and consult wound care.
Review of Incident/Accident Reporting Form for Resident #43 dated 02/19/2025 revealed, in part, .on 02/19/2025 at 9:20 a.m. S6 ADON observed a skin tear to resident's right palm under resident's pinky finger .resident has contractures to right hand unable to apply hand roll. On 02/19/2025 at 11:20 a.m. S6 ADON noted, in part, the NP stated .appears to be a skin tear from .clenching hand.
Review of Multidisciplinary Screen Form dated 02/19/2025 completed by OT revealed NP recommendation to place a 4x4 gauze under the 5th digit to prevent skin breakdown.
Observation of Resident #43 on 02/20/2025 at 10:15 a.m. revealed a folded gauze to contracted right hand, between the 5th digit and the palm.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interviews and record review the facility failed to ensure the resident's environment remained as free of accidents/ hazards as possible for 1 (#13) resident reviewed for acciden...
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Based on observation, interviews and record review the facility failed to ensure the resident's environment remained as free of accidents/ hazards as possible for 1 (#13) resident reviewed for accidents. The facility failed to repair a crack in the parking lot's concrete which resulted in a fall for Resident #13. Total sample size was 35.
Findings:
Review of Resident #13's medical record revealed an admit date of 09/29/2023 with diagnoses which included in part .Chronic Systolic (Congestive) Heart Failure, Pain Unspecified, Cognitive Communication Deficit, Unspecified Lack of Coordination, and Muscle Weakness.
Review of Resident #13's Quarterly MDS with ARD of 12/29/2024 revealed Resident #13 had a BIMS score of 9 indicating moderate cognitive impairment. Resident #13 required supervision or touching assistance for walking 10 feet and partial/moderate assistance for walking 150 feet. The MDS indicated Resident #13's ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor) should not be attempted due to a medical condition or safety concerns.
Review of Resident #13's Care Plan with a target date of 04/15/2025 revealed in part .Resident is at risk for impaired vision with approaches that included: Keep environment free of small objects and clutter. Actual falls related to impaired balance, and unsteady gait with approaches that included in part .transfer per wheelchair to van, Physical Therapy to screen and staff education.
Interview on 02/17/2025 at 9:15 a.m. with Resident #13 revealed she had fallen outside in the facility's parking lot.
Review of an incident report dated 02/13/2025 at 9:10 a.m. by S6 ADON revealed in part .S25 CNA reported that Resident #13 had fallen outside in the parking lot. Resident #13 was ambulating per walker and stepped in a pot hole. I observed Resident #13 sitting on her knees in the parking lot over a pot hole. There was water in the pot hole. Redness noted to bilateral knees. Resident complained of 3/10 pain. Resident was assisted into a wheelchair out of the water.
Review of a nurse's progress note dated 02/13/2025 at 9:12 a.m. revealed MD notified, new orders noted to send Resident to the emergency room for evaluation and treatment (X-Rays).
Interview on 02/18/2025 at 12:59 p.m. with S2 DON revealed on 02/13/2025 at 9:10 a.m. S25 CNA and S26 CNA/Transportation were taking Resident #13 and another resident to a scheduled doctor's appointment. S2 DON revealed Resident #13 was ambulating to the nursing home van with a rolling walker. S2 DON revealed there was an uneven area of concrete in the parking lot filled with rain water, close to where the van was parked. S2 DON revealed Resident #13's rolling walker went into the uneven (cracked concrete) and fell to her knees. S2 DON revealed Resident #13 had redness to bilateral knees and was sent to the hospital for evaluation. S2 DON revealed Resident #2 had no injuries.
Observation on 02/18/2025 at 1:05 p.m. of the facility's front parking lot with S2 DON revealed a large area of cracked concrete which had created a hole. S2 DON confirmed at present the cracked uneven concrete in the front parking lot had not been repaired and was unsafe.
Interview on 02/19/2025 at 11:03 a.m. with S1 Administrator revealed the cracked uneven area of the front parking lot of the facility had been repaired that morning (02/19/2025). S1 Administrator confirmed he and maintenance were responsible for checking the parking lot for any disrepair or hazards.
Interview on 02/19/2025 at 11:15 a.m. with S4 Maintenance Supervisor revealed all employees were responsible for ensuring the parking lot was safe.
Interview on 02/19/2025 at 2:39 p.m. with S25 CNA revealed on 02/13/2025 she was in the front parking lot of the facility when Resident #13 had fallen. S25 CNA revealed when she turned around Resident #13 was on her knees on the ground. S25 CNA revealed an employee had fallen in the same hole previously.
Interview on 02/19/2025 at 2:49 p.m. with S26 CNA/Transportation revealed on 02/13/2025 he was assisting Resident #13 to the van in the front parking lot. S26 CNA/Transportation revealed Resident #13 stepped in a crack in the concrete and fell to her left knee then to her right knee.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and ...
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Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 64.
Findings:
Observation on 02/17/2025 at 12:30 p.m. revealed a form for Daily Nursing Census dated 02/17/2025 was posted on a bulletin board near the nurse's station. Daily staffing hours required, and daily staffing hours provided were not posted on the form.
Observation on 02/18/2025 at 9:51 a.m. revealed a form for Daily Nursing Census dated 02/18/2025 was posted on a bulletin board near the nurse's station. Daily staffing hours required, and daily staffing hours provided were not posted on the form.
Observation on 02/18/2025 at 12:49 p.m. revealed forms for Daily Nursing Census dated 02/10/2025- 02/18/2025 did not have daily staffing hours required and daily staffing hours provided documented on the forms.
Interview on 02/18/2025 at 12:55 p.m. with S2 DON to review 02/10/2025- 02/18/2025 Daily Nursing Census forms, S2 DON confirmed the facility did not post daily nursing hours required and daily nursing hours provided, only the total amount of nurses and CNA's scheduled for each shift. S2 DON confirmed the facility kept up with daily hours provided and required, but confirmed the facility did not post that information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 64 residents who resided in the f...
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Based on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 64 residents who resided in the facility.
Findings:
Review of a facility policy on 02/17/2025 at 2:32 p.m. titled, Garbage and Rubbish Disposal with an unknown original date and a revised date of 06/2023 revealed in part .Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters .5. Garbage and rubbish containing food wastes shall be stored so as to be inaccessible to vermin .8. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area .
Observation on 02/17/2025 at 8:50 a.m. of the facility dumpster area accompanied by S4 Maintenance Supervisor revealed there were two facility dumpsters. Both dumpster's top lids were opened and both dumpster's side door was opened.
Observed several bags of trash piled in both dumpsters. One dumpster's top lid was unable to close properly due to being broken completely off. Observed litter such as used gloves, paper products/trash, and metal pieces of a mechanical lift near the dumpster on the grounds.
S4 Maintenance Supervisor confirmed the above findings during the tour of the dumpster area. S4 Maintenance Supervisor confirmed that the dumpster lids/doors should remain closed at all times, the dumpster area should be clean, and the trash should be picked up.
In an interview on 02/17/2025 at 9:26 a.m., S1 Administrator stated he was unaware of the broken top lid on the dumpster. S1 Administrator confirmed the facility dumpsters should remain closed at all times when not in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 3 (Resident #10, Resident #17 and Resident #273) of 35 resi...
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Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 3 (Resident #10, Resident #17 and Resident #273) of 35 residents reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly changed, labeled and stored.
Findings:
Review of a Facility Policy titled Oxygen Administration with a revision date of 12/02/2024, revealed in part .
All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures.
Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and PRN. All tubing and bottles are to be labeled each week when changed. When the tubing I not being used, it should be stored properly in a zip lock bag. Humidifiers are not required but are permitted with oxygen flow of 1-2 LPM.
Resident #273
Review of Resident #273's medical record revealed an admit date of 02/06/2025 with diagnoses that included: Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Type 2 Diabetes Mellitus, and Human Immunodeficiency Virus.
Review of Resident #273's Medication Administration Record dated 02/2025 revealed in part .Budesonide inhalation Suspension 0.5 MG/2ML (breathing treatment) 1 inhalation two times a day related to Chronic Obstructive Pulmonary Disease. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (breathing treatment) 1 inhalation three times a day related to Chronic Obstructive Pulmonary Disease.
Review of Resident #273's care plan with a target date of 05/08/2025 revealed in part .Impaired Gas Exchange related to Chronic Obstructive Pulmonary Disease with approaches that included: Administer medications as ordered, Administer oxygen therapy as ordered.
Observation and interview on 02/17/2025 at 9:57 a.m. revealed Resident #273 sitting in a recliner in her room. A nebulizer mask was lying uncovered on top of Resident #273's refrigerator. Resident #273 revealed she received breathing treatments via the nebulizer mask.
Observation and interview on 02/17/2025 at 10:00 a.m. with S24 LPN revealed Resident #273 received breathing treatments via the nebulizer mask. S24 LPN confirmed Resident #273's nebulizer mask was lying on top of her refrigerator uncovered, and it shouldn't have been.
Resident #10
Review of Resident #10's medical record revealed an admission date of 11/17/2020 with diagnoses that included in part . Dementia, Unspecified Severity, without Behavioral Disturbance, (Congestive) Heart Failure, Acute Respiratory Failure with Hypoxia, Dyspnea, and Shortness of Breath .
Review of Resident #10's Modification of Quarterly and State Optional MDS with ARD of 11/12/2024 revealed a BIMS score of 14, which indicated cognition was intact, and resident received oxygen therapy. Resident #10 required total dependence with one person physical assist for bed mobility and required total dependence with two persons physical assist for transfers.
Review of Resident #10's current physician orders revealed in part . -Change oxygen and nebulizer tubing weekly on Thursday every night shift with a start date of 01/30/2025 . -Oxygen per nasal cannula at 3LPM continuously every twelve hours related to acute respiratory failure with hypoxia with a start date of 09/01/2024 .
Review of Resident #10's care plan with an initial date of 08/20/2024 revealed in part .a focus of altered respiratory status/difficulty breathing with interventions included change oxygen and nebulizer tubing weekly on Thursday, provide oxygen as ordered-oxygen per nasal cannula at 3LPM continuously with an initiated date of 08/20/2024.
Observation and interview on 02/17/2025 at 10:50 a.m., revealed Resident #10 with oxygen in progress at 3 LPM, no humidified bottle attached to the oxygen and no date on the oxygen tubing. Resident stated she wears her oxygen at all times.
Observation and interview on 02/18/2025 at 12:10 p.m., revealed Resident #10's oxygen in progress with no humidifier bottle attached and undated oxygen tubing. Observed an unopened, bagged humidifier bottle on the bedside table, not in use.
Observation and interview on 02/18/2025 at 12:39 p.m. with S24 LPN stated Resident #10 had orders for continuous oxygen and sometimes she had a humidifier bottle and sometimes she does not. S24 LPN stated that the facility staff change out the oxygen tubing, label, and date the tubing and humidifier bottles when ordered. S24 LPN was not sure if Resident #10 required humidified oxygen. S24 LPN confirmed Resident #10 did not have a humidifier bottle for her continues oxygen and the oxygen tubing was not dated.
In an interview on 02/19/2025 at 9:35 a.m., S2 DON revealed that oxygen/nebulizer tubing should be labeled and stored in a bag when not in use. The nursing staff change the nebulizer/oxygen tubing and label bags weekly on Thursdays. S2 DON stated that residents with oxygen orders of less than 2 liters per minute do not require a humidifier bottle for oxygen usage. S2 DON confirmed residents with orders oxygen therapy of 2 liters per minute or above required a humidifier bottle during oxygen therapy.
In an interview on 02/19/2025 at 1:45 p.m., S2 DON confirmed Resident #10 should've had a humidifier bottle attached to her oxygen.
Resident #17
Review of Resident #17's medical record revealed an admission date of 04/14/2024 with diagnoses that included in part .Persistent Asthma with (Acute) Exacerbation, Anxiety Disorder, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, and Acute Respiratory Failure with Hypercapnia .
Review of Resident #17's Quarterly and State Optional MDS with ARD of 01/07/2025 revealed a BIMS score of 15, which indicated cognition was intact, and resident received oxygen therapy. Resident #17 required total dependence with one person physical assist for bed mobility and required total dependence with two persons physical assist for transfers.
Review of Resident #17's current physician orders revealed in part . -Change oxygen and nebulizer tubing weekly on Thursday every night shift with a start date of 01/30/2025 . -Oxygen per nasal cannula at 2LPM continuously every twelve hours related to severe persistent asthma with acute exacerbation with a start date of 09/03/2024 . -Ipratropium-Albuterol Nebulization Solution 0.5-2.5(3)mg/3ml dose inhale orally four times a day related to severe persistent asthma with acute exacerbation with a start date of 09/03/2024 .
Review of Resident #17's care plan with an initial date of 01/18/2025 and a next review date of 04/18/2025 revealed in part .a focus of impaired gas exchange related to ineffective air clearance with interventions included administer oxygen therapy as ordered and provide breathing treatment as ordered with an initiated date of 01/18/2025 .
On 02/17/2025 at 10:15 a.m., observed Resident #17's oxygen tubing on the resident's bedroom floor, un-bagged, and unlabeled. Observed Resident #17's nebulizer mask placed directly on the bedside dresser drawer, un-bagged, and undated.
In an interview and observation on 02/17/2025 at 10:20 a.m., S10 LPN confirmed Resident #17's oxygen tubing and nebulizer mask should be in a bag and that both the nebulizer and oxygen items should be stored/labeled correctly and was not.
In an interview on 02/19/2025 at 9:35 a.m., S2 DON revealed that nursing staff are ordered to change the nebulizer/oxygen tubing and bags weekly on Thursdays. S2 DON confirmed that all oxygen and nebulizer tubing should be labeled and stored in a bag when not in use.
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, interview, and record review the facility failed to ensure drugs were stored in accordance with currently accepted professional principles by:
1.
Failing to ensure an insulin vi...
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Based on observation, interview, and record review the facility failed to ensure drugs were stored in accordance with currently accepted professional principles by:
1.
Failing to ensure an insulin vial was labeled with the date it was opened;
2.
Failing to maintain accurate and complete documentation for medications in the emergency kit;
3.
Having a loose pill in 1 (Cart A) of 1 medication cart checked for safe and secure storage;
4.
Failing to ensure expired medications were not available for use;
5.
Failing to document administration of controlled substances;
6.
Failing to ensure a narcotic record included the strength of the medication; and
7.
Failing to discard a controlled substance when it was discontinued.
Findings:
Review of the facility's policy entitled Insulin Administration dated 01/15/2025 revealed, in part .if opening a new vial, record the expiration date and time on the vial, and follow the manufacturer's recommendations for expiration after opening. Lantus insulin vials expire 28 days after opening.
Review of the facility's undated policy entitled Emergency Medication Kit revealed, in part .when an emergency or stat medication is needed, the nurse breaks the container's seal and removes the prescribed medication. The nurse records the name of the medication, strength, quantity taken, date, the name of the resident, name of the physician, and the nurse's signature. A new seal is placed on the kit after the replacement medication has been added.
Review of the facility's policy entitled Administering Oral Medications revised on 01/15/2025 revealed, in part .select the drug from the unit dose drawer or stock supply. Check the label on the medication and confirm the medication name and dose with the medication administration record. Check the expiration date on the medication. Expired medication should be turned in to your supervisor for medication destruction.
Review of the facility's policy provided on 02/19/2025 at 1:44 p.m. and entitled Controlled Substances dated 01/15/2025 revealed, in part .a resident's controlled substance record must include the name and strength of the medication, the number on hand, the time of administration, and the signature of the nurse administering the medication.
Review of the facility's policy provided on 02/19/2025 at 3:06 p.m. and entitled Controlled Substances dated 01/15/2025 revealed, in part .the DON shall investigate any discrepancies in narcotics reconciliation. When a controlled substance is discontinued, the nurse will bring the medication to the DON. The controlled medication will be placed into a locked closet until the medication is destroyed.
#1
Observation of the medication storage room on 02/19/2025 at 11:50 a.m. with oversight from S5 ADON revealed an opened undated vial of Lantus in the medication refrigerator. An interview was conducted with S5 ADON at this time. She confirmed vials of insulin should be labeled with the date they are opened and discarded 28 days after opening. S5 ADON confirmed the Lantus was not labeled with the date it was opened, but should have been.
#2
Observation of the facility's emergency kit (E-Kit) revealed the box was locked with seal/tag #0138033. Review of the facility's E-Kit Log dated February 2025 revealed, in part, the current tag # was #0138086/1143910 applied on 02/18/2025 by S2 DON. Further review of the E-Kit Log revealed documentation of the strength of the medication, quantity taken or added, and the name of the physician were not included on the log. An entry dated 02/12/2025 did not include the name of the medication removed. An interview was conducted with S5 ADON at this time who confirmed the tag # on the E-Kit should match the most recent tag # on the E-Kit Log. S5 ADON confirmed the tag on the E-Kit does not match the tag # documented on the E-Kit Log, but should. In interview was conducted with S2 DON at this time who confirmed she did document tag #0138086/1143910 on 02/18/2025 on the E-Kit log. S2 DON confirmed the tag on the E-Kit was not the same tag # documented on the E-Kit Log, but should be.
#3
Observation of Cart A on 02/19/2025 at 12:20 p.m. with oversight from S7 LPN and S5 ADON revealed half of an unidentified loose yellow tablet in the bottom of the 2nd drawer of the cart. An interview was conducted with S7 LPN at this time who confirmed there was half of an unidentified loose tablet in bottom of the 2nd drawer of the medication cart, but should not have been.
#4
Further observation of Cart A revealed one bottle of Latanoprost Ophthalmic Solution 0.005% with an open date of 10/29/2024, one bottle of Dorzolamide Ophthalmic Solution 2% with an open date of 11/30/2024, and one opened bottle of Brimonidine tartrate Ophthalmic Solution 0.2% without an open date. An interview was conducted with S5 ADON at this time who confirmed eye drops should be labeled with the date they are opened and discarded 28 days after opening. S5 ADON confirmed the Latanoprost Ophthalmic Solution 0.005% and Dorzolamide Ophthalmic Solution 2% were not discarded 28 days after opening, but should have been. S5 ADON confirmed the Brimonidine tartrate Ophthalmic Solution 0.2% was not labeled with the open date, but should have been.
#5
Observation of the Cart A narcotic storage drawer with oversight from S7 LPN and S5 ADON revealed one blister pack for Resident #55 containing 13 tablets of Lorazepam 0.5mg. Review of the narcotic record revealed one record for Resident #55 dated 02/21/2024 indicating 13 Lorazepam 0.5mg tablets remaining, and one record for Resident #55 dated 08/01/2024 indicating 13 Lorazepam 0.5mg tablets remaining. An interview was conducted with S5 ADON at this time who confirmed there were two narcotic records for Resident #55, indicating a total of 26 tablets of Lorazepam 0.5mg. S5 ADON confirmed there were 13 tablets of Lorazepam 0.5mg for Resident #55 and the narcotic record was incorrect for Resident #55.
Further observation revealed one blister pack for Resident #41 containing 19 Norco 5/325mg tablets. The narcotic record for Resident #41 revealed 20 Norco 5/325mg tablets remaining. One blister pack was observed for Resident #67 containing 39 Norco 5/325mg tablets. The narcotic record for Resident #67 revealed there were 40 Norco 5/325mg tablets remaining. An interview was conducted with S7 LPN at this time who revealed she had provided one Norco 5/325mg tablet to Resident #41 and one Norco 5/325mg tablet to Resident #67 this am. S7 LPN confirmed she did not document the narcotic medications on the narcotic record when they were administered, but should have.
#6
The narcotic record for Resident #67 stated the name of the medication, Zolpidem, but did not include the strength. S5 ADON confirmed the strength of the medication should be documented on the narcotic record.
#7
An interview with S5 ADON on 02/19/2025 at 2:09 p.m. revealed the Lorazepam had been previously discontinued for Resident #55. She did not know the date the Lorazepam had been discontinued. S5 ADON confirmed when controlled substances were discontinued, they should be removed from the cart and the DON was responsible for returning them to the pharmacy. S5 ADON confirmed the Lorazepam for Resident #55 should not have been in Cart A.
An interview was conducted on 02/19/2025 at 4:48 p.m. with S2 DON who confirmed the discontinued Lorazepam for Resident #55 should have been removed from Cart A, but was not.
Review of Resident #55's current Order Summary Report revealed no current order for Lorazepam.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26
Review of Resident #26's medical records revealed an admit date of 02/26/2016 with a readmission date of 12/14/2021...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26
Review of Resident #26's medical records revealed an admit date of 02/26/2016 with a readmission date of 12/14/2021. Resident #26 had diagnoses that included: Protein Calorie Malnutrition, Cognitive Communication Deficit, and Depressive Episodes.
Review of Resident #26's Quarterly MDS with ARD 02/11/2025 revealed BIMS was not conducted because resident is rarely or never understood, and a mechanically altered diet was used for nutritional approach.
Interview on 02/17/2025 on 2:35 p.m. with Resident #26's RP (responsible party) revealed that lunch had been consistently late for the past 6 weeks. RP stated lunch was served between 12:30 p.m. to 2:00 p.m.
Observation on 02/19/2025 at 12:40 p.m. revealed Resident #26 was observed sitting in room in wheelchair. Lunch tray had not been delivered yet.
Interview on 02/19/2025 at 12:42 a.m. with S23 RN revealed that lunch was being served a little later recently, and the halls was served lunch around 1:00 p.m. daily.
Observation on 02/19/2025 at 1:04 p.m. revealed Resident #26's lunch tray was served to her in her room.
Based on observations, interviews, and record review, the facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition services. The facility failed to ensure meals were served timely according to the meal times posted. This deficient practice had the potential to affect the 62 residents that received meals from the facility kitchen. Findings:
Review of the facility's Meal Times revealed the following in part:
Dining Room: Breakfast 07:30 a.m., Lunch 11:30 a.m., and Supper 4:30p.m.
Hall Trays (Cart): Breakfast 7:45 a.m., Lunch 12:00 p.m , and Supper 5:00p.m.
Review of the facility's policy titled Frequency of Meals dated 06/2003 read in part . 1. At least three meals or their equivalent are served daily, at regular times.
Observation on 02/17/2025 at 12:35 p.m. revealed kitchen staff began to serve lunch to residents in the dining room. Observation revealed the lunch meal service began 1 hour and 5 minutes past the posted lunch meal service time.
Resident #32
Interview on 02/17/2025 at 1:45 p.m. with Resident #32 revealed the facility served lunch late, almost daily, around 1:00 p.m., or 1:30 p.m.
Review of Resident #32's medical record revealed he was admitted to the facility on [DATE]. Resident #32 had diagnoses that included in part . Type 2 Diabetes Mellitus, Heart Failure, Hypertensive Heart Disease, Generalized Edema, Chronic Obstructive Pulmonary Disease, and Primary Generalized Osteoarthritis.
Review of Resident #32's Annual MDS with ARD of 01/21/2025 revealed Resident had BIMS of 15, which indicated his cognition was intact.
Interview on 02/18/2025 at 11:58 a.m. with S15 CNA, S16, CNA, S17 CNA, and S18 CNA who were present in the dining room during lunch meal service revealed CNA's stated lunch meal service was almost always served late. S15 CNA stated residents often waited a long time for lunch, and were almost always served between 1:00p.m. - 1:30p.m.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 11 (#6, #7, #10, #12, #15, #26, #30, #...
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Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 11 (#6, #7, #10, #12, #15, #26, #30, #45, #55, #61, and #224) of 11 Residents who were ordered and served pureed diets. Findings:
Record Review of the facility's current, undated policy titled Standardized Recipes read in part . Standardized recipes shall be developed and used in preparation of foods.
Record Review of the facility's current, undated Cook Job Description read in part . Responsibilities: Follows menu and recipes to prepare food.
Record Review of the facility's approved 2024 Fall/Winter Lunch Menu revealed the facility was on Week: 3, Day: Monday: Red beans and Sausage, Steamed Rice, Club Spinach, Cornbread, Caramel Sour Cream Cake for Dessert, and Beverage/Water. Alternate Menu item: Beef Patty (hamburger steak).
Record Review of the facility's approved recipe for Pureed steamed rice read in part . Ingredients: Serving size 15: 11.25 ½ cups Seamed Rice, 1 cup and 1 tablespoon of Whole Milk, and ½ cup and 1 tablespoon of Soft Margarine. Instructions: Prepare rice according to regular recipe. 2. Place food in processor, process until smooth adding 1.5 tablespoon of milk and 2.5 tablespoons of margarine per portion.
Record Review of the facility's approved recipe for Pureed club spinach read in part . Ingredients: Serving size 15: 3 pounds of frozen chopped spinach, 9 ½ oz. shredded cheddar mild cheese, 4 ¼ oz. bread crumbs, 2 tablespoon, 1 /1/4 teaspoon of soft margarine, 1 ¾ cup of water or stock, 3 tablespoon and 2 ½ teaspoons of food thickener. Instructions: Steam and drain spinach. Place a layer in greased pan. 2. Cover spinach with cheese. 3. Combine crumbs and margarine, sprinkle equal quantity over cheese in each pan. 4. Bake at 325F for 30 minutes or until internal temperature of 165F or higher for 15 seconds. 5. Prepare slurry (water or stock and food thickener) 6. Process until smooth using 1 oz. of slurry per portion.
Record Review of the facility's approved recipe for Pureed hamburger steak read in part . Ingredients: Serving size 15: 15-6 oz. hamburger steak with 3 oz. of onion gravy, 1 ¾ cup and 2 tablespoon Stock beef/soup base, and 3 tablespoon, and 2 ½ teaspoons of food thickener bulk. Instructions: Prepare hamburger steak according to regular recipe. 2. Prepare slurry (stock beef/soup, and food thickener). 3. Process until smooth adding 1 oz. slurry per portion.
Observation on 02/17/2025 at 12:03 p.m. revealed S3 Dietary [NAME] prepared puree meal items: steamed rice, and spinach. S3 Dietary [NAME] was observed placing an unmeasured amount of rice into the blender with no other ingredients, and pureed the rice. S3 Dietary [NAME] then placed the prepared pureed rice onto the steamtable for serving. S3 Dietary cook was then observed preparing pureed spinach. S3 Dietary cook placed an unmeasured amount of spinach and placed in the blender, and added an unmeasured amount of food thickener to the blender as she pureed the spinach. S3 Dietary cook placed the prepared pureed spinach onto the steam table for serving. S3 Dietary [NAME] stated she did not refer to recipes when she prepared pureed food items, and stated she added an unmeasured amount of food thickener due to doing it by sight.
Observation on 02/17/2025 at 12:38 p.m. revealed S3 Dietary [NAME] prepared puree meal item: Beef Patty/Hamburger steak. S3 Dietary [NAME] was observed placing 6 hamburger patties into the blender, adding an unmeasured amount of water into the blender, and an unmeasured amount of food thickener to the blender. S3 Dietary [NAME] placed the prepared pureed beef patties onto the steam table for serving. Observation revealed S4 Maintenance Supervisor served the prepared pureed food items to residents who received pureed diets.
Interview on 02/17/2025 at 12:38 p.m. with S3 Dietary [NAME] revealed she did not refer to recipes when she prepared the above puree meal items, and did not know if using water when preparing puree food items was appropriate. S3 Dietary [NAME] confirmed she had not been trained on referring to recipes when she prepared meals.
Interview on 02/17/2025 at 2:20 p.m. with S4 Maintenance Supervisor, who was the acting dietary manager, confirmed dietary cooks were to refer to recipes when preparing meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
Review of Resident #17's medical record revealed an admission date of 04/14/2024 with diagnoses that included in pa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
Review of Resident #17's medical record revealed an admission date of 04/14/2024 with diagnoses that included in part .Persistent Asthma With (Acute) Exacerbation, Anxiety Disorder, Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, and Acute Respiratory Failure with Hypercapnia .
Review of Resident #17's Quarterly and State Optional MDS with ARD of 01/07/2025 revealed a BIMS score of 15, which indicated cognition was intact, and resident received oxygen therapy. Resident #17 required total dependence with one person physical assist for bed mobility and required total dependence with two persons physical assist for transfers.
Review of Resident #17's current physician orders revealed in part . -Change oxygen and nebulizer tubing weekly on Thursday every night shift with a start date of 01/30/2025 . -Oxygen per nasal cannula at 2LPM continuously every twelve hours related to severe persistent asthma with acute exacerbation with a start date of 09/03/2024 .
Review of Resident #17's care plan with an initial date of 01/18/2025 and a next review date of 04/18/2025 revealed in part .a focus of impaired gas exchange with interventions that included administer oxygen therapy as ordered .
On 02/17/2025 at 10:15 a.m., observed Resident #17's oxygen tubing/nasal prongs directly on the resident's bedroom floor.
In an interview and observation on 02/17/2025 at 10:20 a.m., S10 LPN confirmed Resident #17's oxygen tubing was directly on the floor and should have been stored in a labeled bag and was not.
In an interview on 02/19/2025 at 9:35 a.m., S2 DON revealed that nursing staff are ordered to change/label/store the oxygen tubing in bags weekly on Thursdays. S2 DON confirmed that all oxygen tubing should be labeled and stored in a bag when not in use.
Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by:
1.
failing to ensure staff decontaminated reusable medical equipment between residents,
2.
failing to ensure staff washed their hands or applied an alcohol-based hand rub before and after direct contact with residents,
3.
failing to ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #9) of 1 resident sampled for Dialysis,
4.
failing to ensure oxygen was properly stored in a sanitary manner that prevented the transmission of infection.
Findings:
Review of the facility's policy entitled Cleaning and Disinfection of Resident-Care Items and Equipment dated 01/13/2025 revealed, in part .Reusable resident care equipment will be decontaminated between residents.
Review of the facility's undated policy entitled Infection Control Guidelines for All Nursing Procedures revealed, in part . Employees must wash their hands before and after direct contact with residents. If hands are not visibly soiled, use an alcohol-based hand rub before and after direct contact with residents, after contact with a resident's intact skin, and after contact with medical equipment in the immediate vicinity of a resident.
Observation on 02/18/2025 from 8:15 a.m. until 9:20 a.m. revealed S10LPN using a wrist blood pressure (BP) cuff and an arm BP cuff to monitor the blood pressures of multiple residents. The BP cuffs were not decontaminated between uses on different residents. S10LPN did not wash her hands or apply hand sanitizer before or after direct contact with the residents.
An interview on 02/18/2025 at 9:20 a.m. with S10LPN confirmed she did not decontaminate the wrist BP cuff or the arm BP cuff between uses on residents, but should have. S10LPN confirmed she did not wash her hands or use hand sanitizer before or after direct contact with the residents.
Observation on 02/19/2025 at 9:02 a.m. revealed S7LPN used a wrist BP cuff to monitor the blood pressure of a resident. S7LPN then placed the wrist BP cuff onto Cart A without decontaminating the cuff. S7LPN then continued with dispensing of medications without washing her hands or using hand sanitizer.
An interview on 02/19/2025 at 9:15 a.m. with S7LPN confirmed she did not decontaminate the wrist BP cuff after using the cuff on a resident, but should have. S7LPN confirmed she did not always decontaminate the BP cuff after use, but did so when she thought about it. S7LPN confirmed she did not wash her hands or use hand sanitizer before or after direct contact with a resident, but should have.
An interview on 02/19/2025 at 9:40 a.m. with S6ADON confirmed blood pressure cuffs should be decontaminated between uses on residents. S6ADON confirmed staff should wash hands or use hand sanitizer before and after direct contact with residents.
An interview on 02/19/2025 at 10:09 a.m. with S5ADON confirmed blood pressure cuffs should be decontaminated between uses on residents. S5ADON confirmed staff should wash hands or use hand sanitizer before and after direct contact with residents.
Resident #9
Record review revealed Resident #9 was admitted on [DATE] with diagnoses including, in part .End Stage Renal Disease (ESRD).
Review of Resident #9's Quarterly MDS with ARD of 01/04/2025 revealed, in part .BIMS score of 12 with indication for Dialysis.
Review of current physician orders for Resident #9 revealed and order dated 01/21/2025 for Dialysis on Tuesday, Thursday and Saturday related to ESRD. An order dated 01/15/2025 revealed EBP to be used during resident high contact activities related to ESRD.
An observation on 02/18/2025 at 11:56 a.m. revealed no EBP sign on Resident #9's door and no EBP equipment outside Resident #9's room.
An observation on 02/18/2025 at 3:00 p.m. revealed no EBP sign on Resident #9's door and no EBP equipment outside Resident #9's room.
An observation on 02/19/2025 at 10:04 a.m. revealed no EBP sign on Resident #9's door and no EBP equipment outside Resident #9's room.
An interview was conducted with S5ADON on 02/19/2025 at 10:09 a.m. S5ADON confirmed EBP were not in place or maintained for Resident #9, but should have been. S5ADON confirmed residents receiving dialysis should have EBP in place.
Dec 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure an allegation of sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the sexual abuse w...
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Based on record review and interview the facility failed to ensure an allegation of sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the sexual abuse was reported for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) sampled residents. The facility also failed to report a fracture of unknown origin for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents.
Findings:
Review of the facility's undated policy titled Abuse Investigation and Reporting revealed in part .
Policy Statement
All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
Resident #1
Review of Resident #1's medical record revealed an admit date of 10/17/2024 with diagnoses that included in part . Pain Unspecified, Anxiety Disorder Unspecified, Depression Unspecified, Bipolar Disorder Unspecified, and Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue.
Review of Resident #1's admission MDS with an ARD of 11/11/2024 revealed Resident #1 had a BIMS score of 13 indicating intact cognition.
Review of a nurse progress note dated 11/16/2024 at 8:30 p.m. read in part .a deputy from the sheriff's office was at the facility inquiring about Resident #1. The deputy wanted to know if Resident #1 was a Resident at the facility. The deputy was informed Resident #1 had been sent to a behavioral hospital. The deputy revealed the family had made a complaint regarding Resident #1.
Interview on 12/17/2024 at 2:00 p.m. with S1 Administrator revealed on 11/18/2024 he called the sheriff's department to inquire about a visit from a police officer at the facility on 11/16/2024 regarding a complaint for Resident #1. S1 Administrator revealed he spoke with an officer and was informed Resident #1's family had alleged sexual abuse of Resident #1 while at the facility. S1 Administrator confirmed the facility had not reported the allegation of sexual abuse for Resident #1, but should have.
Resident #2
Review of Resident #2's medical record revealed an admit date of 03/25/2019 with diagnoses that included in part .Parkinson's Disease, Age related Osteoporosis with current Pathological Fracture of Left Lower Leg, Disorder of Bone Density and Structure Unspecified, Other Specified Disorders of Bone Density Multiple and Structure Multiple Sites, and Pain Unspecified.
Review of Resident #2's Quarterly MDS with an ARD of 10/07/2024 revealed Resident #2 had a BIMS score of 0 indicating severe cognitive impairment. The MDS revealed resident #2 required extensive assistance with bed mobility, transfers, and toileting.
Interview on 12/17/2024 at 10:27 a.m. with S2 DON revealed in part . on 12/05/2025 at 4:35 a.m. S3 LPN was called to Resident #2's room by S4 CNA due to bruising and edema to Resident #2's left foot. S2 DON revealed Resident #2's physician was contacted and given orders to obtain X-rays. S2 DON revealed X-ray results showed Resident #2 had a fracture to the distal Tibia. S2 DON revealed Resident #2 was transferred to the hospital and X-rays were obtained which showed Resident #2 had a fracture of the Tibia and Fibula, and Diffuse Osteopenia.
Review of a hospital X-ray report for Resident #2 dated 12/05/2025 revealed in part .Minimally displaced distal fracture of the Tibia and Fibula. Diffuse Osteopenia.
Interview on 12/17/2024 at 2:17 p.m. with S1 Administrator confirmed the facility did not report to the State Survey Agency of Resident #2 having a fracture of unknown origin.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to thoroughly investigate and allegation of sexual abuse for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) of 4 ...
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Based on interview and record review the facility failed to thoroughly investigate and allegation of sexual abuse for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) of 4 sampled residents.
Findings:
Review of the facility's undated policy titled Abuse Investigation and Reporting revealed in part .
Policy Statement
All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.
Review of Resident #1's medical record revealed an admit date of 10/17/2024 with diagnoses that included: Pain Unspecified, Anxiety Disorder Unspecified, Depression Unspecified, Bipolar Disorder Unspecified, and Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue.
Review of Resident #1's admission MDS with an ARD of 11/11/2024 revealed Resident #2 had a BIMS score of 13 indicating intact cognition.
Review of the facility's SIMS reports revealed no evidence of alleged Sexual Abuse involving Resident #1.
Review of a nurse progress note dated 11/16/2024 at 8:30 p.m. read in part .a deputy from the sheriff's office was a the facility inquiring about Resident #1. The deputy wanted to know if Resident #1 was a Resident at the facility. The deputy was informed Resident #1 had been sent to a behavioral hospital. The deputy revealed the family had made a complaint regarding Resident #1.
Interview on 12/17/2024 at 2:00 p.m. with S1 Administrator revealed on 11/18/2024 he called the sheriff's department to inquire about a visit from a police officer at the facility on 11/16/2024 regarding a complaint for Resident #1. S1 Administrator revealed he spoke with an officer and was informed Resident #1's family had alleged sexual abuse of Resident #1 while at the facility. S1 Administrator confirmed the facility had not investigated the allegation of sexual abuse for Resident #1, but should have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to develop a comprehensive care plan with appropriate interventions after a fall for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident ...
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Based on record review and interview, the facility failed to develop a comprehensive care plan with appropriate interventions after a fall for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents.
Findings:
Review of Resident #1's medical record revealed an admit date of 10/17/2024 with diagnoses that included in part . Pain Unspecified, Anxiety Disorder Unspecified, Depression Unspecified, Bipolar Disorder Unspecified, and Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue.
Review of Resident #1's admission MDS with an ARD of 11/11/2024 revealed Resident #1 had a BIMS score of 13 indicating intact cognition. The MDS revealed Resident #1 required limited assistance with bed mobility and eating, and extensive assistance with transfers and toilet use.
Review of Resident #1's Care Plan with a review date of 02/12/2025 revealed in part .11/12/2024 Fall Actual from wheelchair with interventions that included: Refer to inpatient Behavioral Unit, Return to facility from Emergency Room-not a danger to self at this time.
Observation of video surveillance on 12/16/2024 at 9:45 a.m. with S1 Administrator and S2 DON revealed on 11/12/2024 at 10:00 a.m. Resident #1 was sitting in the dayroom and fell face first out of her wheelchair onto the floor. Resident #1 had a nose bleed, and was transferred to the hospital.
Review of Resident #1's Care Plan revealed no intervention for fall which occurred on 11/12/2024.
Interview on 12/17/2024 at 8:40 a.m. with S2 DON confirmed there were no fall interventions put into place after Resident #1 fell out of her wheelchair on 11/12/2024 and it should have been.
Jan 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 reside...
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Based on record review and interview the facility failed to ensure a resident's right to formulate an advanced directive was properly reflected in the resident's medical record for 1 (#38) of 1 resident reviewed for advance directives. The facility failed to ensure all medical records regarding code status consistently reflected the resident's wishes to be a DNR (Do Not Resuscitate). The total sample size was 32.
Findings:
Review of the facility's policy titled Advance Directives read in part .
The Director of Nursing Services or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care.
Review of Resident # 38's Electronic Medical Record revealed an admit date of 01/11/2023 with diagnoses that included: Chronic Kidney Disease, Type 1 Diabetes Mellitus, Atrial Fibrillation, End Stage Renal Disease, and Congestive Heart Failure.
Review of Resident #38's Face Sheet revealed the code status as Full Code.
Review of Resident #38's 01/2024 Physician's Orders revealed the code status as Full Code.
Review for Resident #38's Care Plan with the review date of 04/03/2024 revealed the code status as DNR.
An interview on 01/10/2024 at 1:53 p.m. with S3 LPN revealed Resident #38 had recently changed to DNR status after going on hospice services. S3 LPN stated she would check for code status on the physician orders and the resident's dashboard.
An interview on 01/10/2024 at 9:10 a.m. with S1 DON confirmed Resident #38's advance directives were not updated on the Physician orders or the face sheet in the hard chart to reflect Resident #38's wishes, but should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner to residents or his or her responsible parties for 2 (Resident #164 and R...
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Based on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner to residents or his or her responsible parties for 2 (Resident #164 and Resident #165) of 3 (Resident #2, Resident #164 and Resident #165) residents reviewed for Beneficiary Notification. The facility failed to issue NOMNC at least two days prior to the end of Medicare Part A coverage to allow the right to appeal the discharge.
Findings:
#164
Review of Resident #164's Beneficiary Notification Review revealed in part .Resident #164's Medicare covered Part A services started on 12/04/2023 and his last Medicare Part A covered day was 12/06/2023.
Review of Resident #164's NOMNC revealed Resident #164's last covered day of Medicare Part A service was 12/06/2023. Review revealed Resident #164's representative signed the NOMNC on 12/05/2023 to acknowledge she received and understood the notice.
#165
Review of Resident #165's Beneficiary Notification Review revealed in part .Resident #165's Medicare covered Part A services started on 06/02/2023 and her last Medicare Part A covered day was 06/16/2023.
Review of Resident #165's NOMNC revealed Resident #165's last covered day of Medicare Part A service was 06/16/2023. Review also revealed Resident #165's representative signed the NOMNC on 06/15/2023 to acknowledge she received and understood the notice.
Interview on 01/10/2024 at 12:32 p.m. with S8 Admissions/Marketing Director stated she and Social Services were currently responsible for issuing NOMNC's to the resident/and or resident representative when the facility initiated a Medicare Part A discharge. S8 Admissions/Marketing Director confirmed notices had not been issued at least two days prior to the Medicare Part A discharge as required, to Residents #164 and #165 or their representatives as indicated and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #53) of 1 sampled residents with MDS record over ...
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Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #53) of 1 sampled residents with MDS record over 120 days old.
Findings:
Review of an MDS transcription report revealed an entry assessment for Resident #53 with an ARD of 04/06/2023 and a discharge assessment with an ARD of 10/24/2023 had been transmitted on 01/09/2023.
Interview on 01/10/2024 at 9:19 a.m. with S2 ADON revealed she was responsible for transmitting MDS Assessments. S2 ADON confirmed Resident #53's MDS Assessments had not been transmitted timely and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews the facility failed to implement a comprehensive person-centered care plan for 1 (#33) of 32 sampled residents. The facility failed to ensure Reside...
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Based on observations, record review and interviews the facility failed to implement a comprehensive person-centered care plan for 1 (#33) of 32 sampled residents. The facility failed to ensure Resident #33 was provided a hand roll as directed in the plan of care.
Findings:
Review of Resident #33's medical records revealed an admit date of 02/28/2020 with diagnoses that included: Essential HTN, Unspecified Dementia, Anxiety Disorders, Dysphagia, Primary Osteoarthritis, and Hyperlipidemia.
Review of Resident #33's annual MDS with an ARD of 12/26/2023 revealed a BIMS score of 0, indicating severe cognitive impairment. Resident #33 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, and bathing.
Review of Resident #33's Care Plan with a review date of 03/26/2024 revealed in part .Resident requires assistance with hand roll to right hand contracture. Assist with the correct application of braces/splints, assist with the application according to scheduled wearing time, and monitor skin under the devices for irritation or breakdown.
An observation on 01/08/2024 at 11:24 a.m. revealed Resident #33 sitting up in a wheelchair in the dining room. Resident #33's right was contracted with no hand roll observed.
An observation on 01/09/2024 at 11:12 a.m. revealed Resident #33 with no hand roll in place to right hand contracture.
An interview on 01/09/2024 at 11:35 a.m. with S6 CNA revealed she was unsure if Resident #33 was supposed to have a hand roll to her right hand. S6 CNA stated she had never observed Resident #33 with a hand roll to her right hand.
An interview on 01/09/2024 at 11:50 a.m. with S7 LPN confirmed Resident #33 did not have a hand roll in place to right hand contracture, but it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Resident #33
Review of Resident #33's medical records revealed an admit date of 02/28/2020 with diagnoses that included: Essential HTN, Unspecified Dementia, Anxiety Disorders, Dysphagia, Primary Oste...
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Resident #33
Review of Resident #33's medical records revealed an admit date of 02/28/2020 with diagnoses that included: Essential HTN, Unspecified Dementia, Anxiety Disorders, Dysphagia, Primary Osteoarthritis, and Hyperlipidemia.
Review of Resident #33's annual MDS with an ARD of 12/26/2023 revealed a BIMS score of 0, indicating severe cognitive impairment. Resident #33 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, and bathing.
Review of Resident #33's Care Plan with a review date of 03/26/2024 revealed in part .Resident required staff assistance for all ADL's. Clean/trim fingernails/toenails daily.
An observation on 01/08/2024 at 11:22 a.m. revealed Resident #33's fingernails to right contracted hand was ½ inch long with brown substance noted under the nails.
An observation on 01/09/2024 at 11:12 a.m. revealed Resident #33 continued with brown substance under the long fingernails to her right contracted hand.
An interview on 01/09/2024 at 11:50 a.m. with S7 LPN revealed the nursing staff were responsible for monitoring residents nails daily and were to trim the nails if they needed to be trimmed. S7 LPN confirmed Resident #33's nails were long and needed to be trimmed, but had not been.
Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 2 (Resident #40 and Resident #33) of 4 (Resident #2, Resident #29, Resident #33, and Resident #40) residents sampled for ADLs.
Findings:
Review of the facility policy titled: Fingernail/Toenail Care, revealed in part .Nail care includes daily cleaning and regular trimming.
#40
Review of Resident #40's Comprehensive Plan of Care revealed in part . Requires staff assistance with ADL's. Clean/trim fingernails/toenails daily & prn.
Review of Resident #40's Physician's Orders revealed in part .
05/01/2023 Nurse to ensure nail care is performed daily.
Review of Resident #40's December 2023 MAR revealed in part .Nurse to ensure nail care is performed daily.
Observation on 01/08/2024 at 9:50 a.m. revealed contractures to Resident #40's bilateral lower extremities and foot drop to both feet. Resident #40's toe nails on bilateral feet were noted to be thickened and in need of trimming, varying 1/4 to 1/2 inch in length.
Observation on 01/09/2024 at 1:01 p.m. revealed Resident #40's fingernails had been recently trimmed. Resident #40's toenails remained of varying lengths between 1/4 to 1/2 inch.
Interview on 01/09/2024 at 1:03 p.m. with S4 CNA revealed she was assigned to Resident #40. S4 CNA stated there was supposed to be a CNA in the facility every day assigned to trim fingernails and toenails. S4 CNA stated she thought the CNA Supervisor had trimmed Resident #40's fingernails that morning and confirmed Resident #40's toenails had not been trimmed.
Observation on 01/09/2023 at 1:12 p.m. of Resident #40's feet accompanied by S2 ADON revealed Resident #40's toenails remained untrimmed and appeared to not have been trimmed in awhile as stated by S2 ADON and should have been. S2 ADON stated S5 CNA was responsible for performing non-diabetic nail care.
Interview on 01/09/2024 at 1:14 p.m. with S5 CNA revealed she had last trimmed Resident #40's toenails on 11/23/2023 and had not attempted since then.
Interview on 01/09/2024 at 1:24 p.m. with S1 DON revealed she was unsure how often nail care was supposed to be performed and would have to refer to the facility policy.
Interview on 01/10/2024 at 3:30 p.m. with S3 LPN confirmed she had initialed that nail care was performed daily for Resident #40 on 12/05/2023, 12/06/2023, 12/08/2023, 12/09/2023, 12/10/2023, 12/18/2023, 12/22/2023, 12/23/2023, 12/24/2023, 12/27/2023 and 12/28/2023. S3 LPN stated there was a CNA that went around cutting nails every day so she just had to initial. S3 LPN revealed she was not aware Resident #40's toenails had not been trimmed since 11/23/2023 and should have been.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations the facility failed to ensure all mechanical, electrical, and patient care equipment were m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations the facility failed to ensure all mechanical, electrical, and patient care equipment were maintained in a safe operating condition. The facility failed to ensure the walk-in freezer was functioning properly. The deficient practice had the potential to affect the 52 residents that received meals prepared in the kitchen.
Findings:
Review of the Facility's policy titled Dietary Equipment read in part . All Kitchen equipment (ovens, refrigerator/freezers, compartment sink, dishwasher, etc.) will be maintained and operated per manufacturer specifications.
An observation on 01/08/2023 at 8:50 a.m. accompanied by S9 Dietary Manager revealed a large amount of frost and ice noted on floor on the outside of the walk in freezer entrance door. Inside the freezer a thick layer of frost covered all crates and food boxes. Ice [NAME] were observed hanging from the 2 fans inside the freezer. Upon exiting the freezer, the door did not appear to seal, leaving a small gap, after attempting to shut the door.
An interview on 01/08/2023 at 9:00 a.m. with S9 Dietary Manager confirmed the large amount of frost and ice [NAME] to the walk in freezer. S9 Dietary Manager revealed the facility had received a quote from a repair company to replace the freezer but was unaware of the status. She revealed the freezer had been in the same condition for over a year.
An interview on 01/08/2024 at 11:10 a.m. with S10 Administrator revealed the facility was given a quote to replace the walk in freezer but the amount was not feasible. S10 Administrator stated the same company was reworking the quote for repairs but the facility had not received it yet. S10 Administrator stated she had not received any other quotes to repair or replace the freezer.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a winged mattress to his bed was followed for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility had a total census of 63.
Findings:
Review of Resident #1's clinical record revealed an admit date [DATE] with diagnoses which included: Unspecified Dementia, Seizures, Depressive episodes, Anxiety disorders, Type 1 Diabetes Mellitus, History of Falling and Fracture of the Skull and Facial Bones left side.
Review of Resident #1's Quarterly MDS with an ARD of 08/01/2023 revealed a BIMS score of 10 (indicating moderately impaired cognition), and required extensive assistance of one person with transfers and toilet use. Resident #1 had no impairment of ROM to his upper or lower extremities.
Review of Resident #1's care plan with a review date of 08/02/2023 revealed he had a fall from his bed on 07/25/2023 with interventions that included a winged mattress to his bed.
Observation and interview on 10/18/2023 at 4:25 p.m. revealed Resident #1 in his room in a wheelchair. Resident #1 stated he had recently fallen and broke his nose. Resident #1 stated he had gotten out of his bed and fallen face first to the floor. A regular blue mattress without wings was observed on Resident #1's bed.
Observation and interview on 10/19/2023 at 8:45 a.m. revealed Resident #1 sitting in a wheelchair in his room. Resident #1 stated he had fallen several times in the past. Resident #1 stated he had slept on the mattress that was on his bed. Bed noted to have been in low positon with a blue mattress without wings on it.
Observation on 10/24/2023 at 10:55 a.m. revealed Resident #1 sitting in a wheelchair in his room. A regular blue mattress without wings noted to his bed.
Observation and interview with S1 LPN ADON on 10/24/2023 at 11:00 a.m. revealed a regular blue mattress without wings to Resident #1's bed. S1 LPN ADON confirmed the regular blue mattress belonged to Resident #1 and it was not a winged mattress and it should have been. S1 LPN ADON stated Resident #1 had transferred rooms and the winged mattress was not transferred with him and it should have been.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident received the necessary care and services, consis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident received the necessary care and services, consistent with standards of practice to promote healing of pressure ulcers for 1 (#2) of 5 (#1, #2, #3, #4, #5) residents reviewed for pressure ulcers. The facility failed to ensure an RN assessed and documented the stage of the pressure wound on a weekly basis for Resident #2.
Findings:
Resident #2
Review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with diagnoses that include: Pressure Ulcer of other site, Unstageable; Abnormal Weight Loss, Primary Generalized Osteoarthritis and Acute Cystitis with Hematuria.
Review of Resident #2's July 2023 Physician orders revealed:
06/27/2023 Cleanse left buttock pressure ulcer with normal saline, pat dry, apply collagen, cover with border gauze daily/PRN until healed.
Review of the Wound Assessment Report for Resident #2 revealed the following:
Assessment date 06/01/2023 completed by S2 Treatment Nurse- Date wound identified-05/11/2022, Stage 2 Pressure ulcer to left buttock: Left inner trochanter. Measurements 0.00cmX0.00cmX0.00cm, scant amount serosanguineous drainage and 100% granulation tissue to the wound bed. Treatment: weekly body audit every Thursday and cleanse left buttock pressure ulcer with normal saline, pat dry, apply collagen, cover with boarder gauze daily/PRN until healed.
Assessment date 06/08/2023 completed by S2 Treatment Nurse- Date wound identified-05/11/2022, Stage 2 Pressure ulcer to left buttocks: Left inner trochanter. Measurements 0.00cmX0.00cmX0.00cm, scant amount serosanguineous drainage and 100% granulation tissue to the wound bed. Treatment: weekly body audit every Thursday and cleanse left buttocks pressure ulcer with normal saline, pat dry, apply collagen, cover with border gauze daily/PRN until healed.
An interview on 07/12/2023 at 3:05 p.m. with S2 Treatment Nurse revealed that she provided wound care for Resident #2's left buttock wound every other day and calls Resident #2's responsible party weekly to notify them of any changes observed with the wound. S2 Treatment Nurse stated that she was unaware of how long Resident #2 had the left buttock pressure ulcer and that she was not aware of anyone in the facility completing a weekly wound assessment, including measurements for the left buttock pressure ulcer. S2 Treatment nurse confirmed that she had not documented the measurement or characteristrics of the left buttock pressure ulcer in a nurse's note weekly.
An interview on 07/12/2023 at 4:10 p.m. with S1 DON confirmed that a weekly wound assessment for Resident #2's left buttocks wound had not been completed weekly and it should have been.
Jun 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 interview and record review, the facility failed to protect Resident #5's right to be free from resident to resident ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect Resident #5's right to be free from resident to resident physical abuse by Resident #1, in a sample of 5 residents reviewed for abuse (#1, #2, #3, #4 and #5).
This deficient practice resulted in an actual harm situation for Resident #5 on 02/28/2023 at 8:20 p.m., when Resident #5 who had a diagnoses of Dementia and had wandering behaviors, was observed on the floor with Resident #1 standing over Resident #5 kicking, hitting and yelling at her. Resident #1 was pulled off of Resident #5 by staff. Abrasions were observed to Resident #5's bilateral knees, and her left upper arm was red with non-pitting edema. Resident #5 complained of pain to her left hip with a rating of 6 out of 10. Resident #5 was sent to the emergency room on [DATE] at 8:42 p.m. for complaints of left hip pain, abrasions to bilateral knees and left arm edema, and was diagnosed with Strain of back muscle and Contusion of lower back.
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Non Compliance citation.
Findings:
Review of the Facility's policy titled Abuse, Neglect-Exploitation or Misappropriation-Reporting and Investigating revealed the following in part .upon receiving any allegations of abuse, the Administrator is responsible for determining what actions (if any) are needed for the protection of residents.
Resident #5
Review of Resident #5's medical record revealed an admit date of 04/20/2022, and diagnoses which included: Unspecified Dementia, Other specified Depressive Episodes, Primary Generalized Osteoarthritis and Pain Unspecified. Resident #5's medical record revealed she resided on Hall A.
Review of Resident #5's Quarterly MDS assessment, with an ARD of 05/16/2023, revealed a BIMS score of 2, which indicated severely impaired cognition. The MDS revealed Resident #5 was independent with bed mobility, transfer, eating, locomotion on and off room/unit, and required limited one person physical assistance with bathing and personal hygiene.
Review of Resident #5's Comprehensive Plan of Care with a target date of 08/16/2023 revealed in part . a problem of wandering, with approaches to place resident in an area where constant observation is possible, and to assign staff to account for resident whereabouts at all times.
Review of Resident #5's CNA Care Guide revealed Resident #5 was to be monitored by staff every 1 hour, although Resident #5's Comprehensive Plan of Care revealed approaches to place resident in an area where constant observation is possible, and to assign staff to account for resident whereabouts at all times.
Review of an Incident/Accident Reporting Form dated 02/28/2023 at 8:20 p.m. and prepared by S10 LPN read as follows in part .Description: Resident #1 was observed standing over Resident #5, kicking, hitting and yelling at her in the corner of the doorway beside Hall A. Resident #5 was observed lying on her back in the corner of the doorway beside Room A kicking Resident #1 to defend herself. Resident #1 was pulled off of Resident #5 by staff, and Resident #1 walked away to his room while continuing to yell. Resident #1 stated that Resident #5 had been coming in his room all day. Resident #5 was assisted to the medication room and a head to toe assessment was given. Abrasions were noted to Resident #5's bilateral knees, and her left upper arm was red with non-pitting edema. Resident #5 complained of pain to left hip with a rating of 6 out of 10. Tylenol 650 MG administered.
Review of Resident #5's hospital records dated 02/28/2023 revealed diagnoses of Strain of back muscle, and Contusion of lower back. Medications prescribed were: Ultram 50 MG (used to treat moderate to severe pain), and Flexeril 10 MG (used to treat pain and stiffness).
Review of Resident #5's physician's order dated May 2023 revealed an order to monitor Resident #5 every hour, with a start date of 04/2022.
Observation and interview on 05/30/2023 at 11:00 a.m. revealed Resident #5 in bed in her room. Resident #5 stated she remembered going to the hospital recently, but did not remember why. Resident #5 was unable to recall any details about the incident that occurred on 02/28/2023.
Interview on 05/30/2023 at 2:19 p.m. with S4 LPN revealed she provided care for Resident #5 on the 7:00 a.m. to 7:00 p.m. shift. S4 LPN stated Resident #5 had Dementia, was very confused, and was ambulatory with no behaviors other than wandering. S4 LPN stated she was not on duty the evening of 02/28/20223 when Resident #5 was physically abused, but it was reported to her the next morning that Resident #5 wandered into Resident #1's room and said something to him. S4 LPN stated Resident #1 physically attacked Resident #5, and she was sent to the hospital for evaluation and treatment.
Interview on 05/31/2023 at 1:05 p.m. with S6 CNA revealed she provided care for Resident #5 on the 6:00 a.m. to 2:00 p.m. shift, and had to redirect her often because she wandered. S6 CNA stated resident wandered into other resident's rooms at times. S6 CNA revealed Resident #5 was on every one hour monitoring but she was not aware that Resident #5 had to be in constant sight.
Interview on 05/31/2023 at 1:18 p.m. with S4 LPN revealed Resident #5 was on every one hour checks by the nurses.
Review of Resident #5's medical record with S4 LPN on the above date and time revealed the following: a physician's order dated 05/2023 to monitor Resident #5 every one hour, and Resident #5's E-MAR for 05/2023 revealed there was no documentation of monitoring of Resident #5's whereabouts by the nurses.
Interview on 05/31/2023 at 1:30 p.m. with S7 CNA revealed she worked the 6:00 a.m. to 2:00 p.m. shift, and provided care for Resident #5. S7 CNA stated Resident #5 was ambulatory throughout the facility, and had to be redirected often. S7 CNA stated Resident #5 would try and assist other residents to their rooms, and sometimes opens other residents' doors. S7 CNA stated she was aware that Resident #5 was to be checked on every hour, but she worked Hall A by herself and it was impossible that she could have Resident #5 in her eyesight at all times.
Interview on 05/31/2023 at 2:21 p.m. with S5 [NAME] Clerk /CNA revealed she was working as the [NAME] Clerk on the night of 02/28/2023 when Resident #1 physically abused Resident #5. S5 [NAME] Clerk/CNA stated she was seated at the nurse's station when she heard a loud outburst. S5 [NAME] Clerk/CNA stated she was unable to see down Hall A, so she had to push her chair back from the desk so she could see down Hall A, and witnessed Resident #1 kicking and hitting Resident #5. Resident #5 in her stomach/side like she was a dead dog, and yelling at Resident #5 because she had opened the door to his room. S5 [NAME] Clerk/CNA stated she hollered for help and ran down Hall A to assist Resident #5. S5 [NAME] Clerk /CNA stated Resident #1 hit her (S5 [NAME] Clerk/CNA) upside the head when she attempted to intervene. S5 [NAME] Clerk/CNA stated S10 LPN made it to the incident and put herself between Resident #1 and Resident #5, enabling them to slide Resident #5 away from Resident #1. S5 [NAME] Clerk/CNA stated Resident #5 had bruising on the left side of her arm and she said she was hurting. S5 [NAME] Clerk/CNA confirmed Resident #5 was not in her eyesight when the incident occurred, and she only knew the incident was occurring because she heard Resident #1 yelling. S5 [NAME] /Clerk CNA stated she was not aware that Resident #5 had to be in constant sight.
Surveyor was unsuccessful in contacting the two nurses who worked the night of 02/28/2023. Administrator of the facility at the time of the incident, is no longer employed at the facility.
Interview on 05/31/2023 at 3:30 p.m. with S8 CNA revealed she provided care for Resident #5 on the 2:00 p.m. to 10:00 p.m. shift. S8 CNA stated Resident #5 wandered about the facility, and had to be redirected because she went into other residents' rooms. S8 CNA stated she checked on Resident #5 every 2 hours. S8 CNA did not know Resident #5 was to be checked on every hour or within constant sight.
Interview on 06/01/2023 at 9:13 a.m. with S9 CNA revealed she provided care for Resident #5 on the 6:00 a.m. to 2:00 p.m. shift. S9 CNA stated Resident #5 had to be redirected often because she wandered into other residents' rooms to assist them, because she thought she was an employee at the facility. S9 CNA stated she knew Resident #5 was on every hour monitoring but was not aware that Resident #5 should have been within eyesight at all times.
Interview on 05/31/2023 at 4:10 p.m. with S2 DON and S3 ADON MDS Coordinator confirmed Resident #5's current care plan with a target date of 08/16/2023 revealed Resident #5 wanders, with a goal for Resident #5 to only wander within specified boundaries (inside the facility). S2 DON and S3 ADON/MDS Coordinator confirmed care plan approaches instructions included to place Resident #5 in an area where constant observation was possible, and to assign staff to account for resident's whereabouts at all times. S3 ADON stated the staff on Resident #5's hall were to provide supervision of Resident #5, and although the care plan stated that staff were to be assigned to account for Resident #5's whereabouts at all times, staff were not assigned because the nurse was responsible for checking on Resident #5 every hour. S2 DON and S3 ADON/MDS Coordinator confirmed Resident #5's whereabouts had not been constantly observed when Resident #5 was physically abused by Resident #1 on 02/28/2023.
Observation of Resident #5 during the survey revealed she was being observed by staff every hour, and monitoring was documented on the MAR.
Resident #1
Review of Resident #1's medical record revealed an admit date of 07/09/2021 and diagnoses which included: Cerebrovascular disease, Hypertension, Hyperlipidemia and Lack of Coordination.
Review of Resident #1's Quarterly MDS assessment with an ARD of 01/03/2023, revealed a BIMS score of 1, which indicated severely impaired cognition. The MDS revealed Resident #1 was independent with bed mobility, transfer, locomotion on/off unit, dressing, eating, personal hygiene and toilet use.
Review of Resident #1's Care Plan with a target date of 04/03/2023 revealed in part .potential for social isolation because Resident stays in his room most of the time. Approaches included to remind resident with verbal reminders of upcoming activities and document resident response to intervention. The Care Plan did not reveal Resident #1 had a history of abuse or aggressive behaviors.
Interview on 05/30/2023 at 2:19 p.m. with S4 LPN revealed Resident #1 did not attend activities and ate meals in his room. S4 LPN revealed Resident #1 kept to himself and to her knowledge had no prior history of aggressive behavior. S4 LPN stated she was not on duty the evening of 02/28/20223 when Resident #1 physically abused Resident #5, but it was reported to her the next morning that Resident #5 wandered into Resident #1's room and said something to him.
Interview on 05/30/2023 at 3:11 p.m. with S2 DON revealed after the incident on 02/028/28 the MD was notified and gave orders to PEC (Physician's Emergency Certificate) Resident #1 to the hospital. S2 DON stated Resident #1 did not agree to leave the facility and law enforcement had to intervene. S2 DON stated from the hospital Resident #1 was sent to a behavioral hospital and discharged from the facility. S2 DON stated Resident #5 did not attend activities and ate meals in his room. S2 DON revealed Resident #5 kept to himself and to her knowledge had no prior history of aggressive behavior.
The facility has implemented the following actions to correct the deficient practice:
There have been no resident to resident abuse incidences prior to 02/28/2023 or afterwards.
There is one other resident identified as a wanderer.
1. In review of the incident with Resident #1 (accused) and Resident #5 (victim), the following was done:
Investigation: On 2/28/23 at approximately 8:20 pm. , Resident #5 opened the door of Resident #2 and closed it after realizing it was not her room and proceeded to walk away from the door, down the hall towards the nursing station. Resident #1 came out of his room and came up behind Resident #5 and pushed her to the floor, standing over her pointing and shouting, and began to punch and kick her. Resident #5 was noted to kick back towards Resident #1 while lying on the floor. Staff members intervened to separate both residents.
2. Resident #1 was returned to his room with one-on-one supervision. MD was notified and order received to send to ER for evaluation and treatment. The paramedics arrived with one sheriff deputy to assist. Ambulance staff and sheriff spoke with Resident #1 for several minutes and a second deputy arrived to assist in taking resident to ER. Resident #1 agreed to be transported to ER for evaluation and was then transferred to Behavioral Health Unit for treatment from local ER. The accused resident has no previous behaviors of this type in the past 6 months. This facility is in the process of administering an involuntary/emergency discharge of the accused.
3. Resident #5 was removed to another area. Upon assessment MD was notified and Resident #1 was sent to local ER for evaluation and treatment. RP was notified of the incident. Resident #5 returned to facility the same night with no injury, With prescriptions for pain med and muscle relaxer PRN and was placed on a separate hall until it was determined that Resident #1 was not returning. She was then returned to her room on 100-hall. She remains ambulatory throughout the facility, no change in gait. Remains unchanged in cognition. Administrator has spoken with victim's family on several occasions, victim has no recollection of incident and does not appear to have been negatively affected by incident and no further complaint of pain.
4. An in-service was immediately provided with the staff on duty at the time of the incident. The entire staff was provided with an in service the day following the incident (03/01/2023). Training included Dementia Training, to include handling residents with difficult behaviors, residents who wander, and resident to resident abuse. Dementia training, to include handling residents with difficult behaviors was conducted on 2 February 2023 and 11 November 2022, and following the 02/28/2023 incident.
5. Abuse Policy reviewed with no revisions.
6. Resident #5's care plan was reviewed and updated. Resident #5 was to be monitored every one hour and document monitoring on the MAR every shift.
7. Training is scheduled for March 13, 2023 for the entire staff on crisis prevention with a certified instructor with a focus on handling resident to resident crisis.
8. Incident discussed in the morning department head QA meeting the day after the incident and interventions discussed. Abuse will be included in monthly QA meetings with evaluations and interventions as needed.
Monitoring:
1. Resident #5's nurse on duty will monitor Resident #5 every 1 hour and document on MAR. This is to be continued as long as ordered by the physician.
2. The other resident identified as a wanderer has an intervention to monitor every one hour, and will be monitored every 1 hour by her nurse on duty and document on MAR.
3. ADON will review MARs weekly to ensure monitoring is taken place as instructed. ADON will randomly observe Resident #5 and other resident for wandering and interventions being taken by staff.
4. QA - Monitor weekly for 2 months by ADON. Evaluate and revise interventions as needed.
Correction date: 03/13/2023
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
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 review and interview the Facility failed to notify the Resident of discharge in writing and in a language and ma...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the Facility failed to notify the Resident of discharge in writing and in a language and manner they understood at least 30 days before the Facility discharged the Resident for 1 (Resident #1) of 5 sampled Residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5). Facility census was 59.
Findings:
Review of the Facility's policy titled Emergency Discharge or Transfer read in part .
Policy Interpretation and Implementation
2. A discharge notice must be in writing and in a language and manner the resident/responsible party understands. The notice must be given to the resident and the resident's responsible party. The notice must be given at least 30 days prior to the discharge date . It must include:
c.) The location to which a resident will be discharged
Review of Resident #1's medical record revealed an admit date of 07/07/2021 and diagnoses which included: Other Cerebrovascular Disease, Secondary Hypertension, Other Lack of Coordination and Other Hyperlipidemia.
Review of Resident #1's Quarterly MDS assessment, with an ARD of 01/03/2023, revealed a BIMS score of 1, which indicated severely impaired cognition, and revealed Resident #1 was independent with bed mobility, transferring, eating, locomotion on and off room/unit, dressing, toilet use and personal hygiene.
Review of Resident #1's Care Plan with a target date of 04/23/2023 revealed a potential for social isolation because resident stays in room most of the time with approaches to remind resident with verbal reminders of upcoming activities and if resident unable to tolerate group activities setting, provide one to one visits and individualized activities program.
Record review of a Facility document titled Emergency Transfer Log revealed Resident #1 was transferred to a local emergency room on [DATE] for violent behaviors with no return date.
Record review of a Facility document titled Notice of Involuntary Emergency Discharge which read in part .The Nursing Home gave Resident #1 this Notice of Involuntary Emergency discharge on [DATE] and followed up with a mailed revised copy on 03/03/2023.
This is an Emergency Discharge due to the Nursing Home cannot meet the needs of this Resident.
This revised Discharge Notice was mailed to Resident #1 on 03/03/2023 at the following address:
The name of the Behavioral Hospital ATTENTION: Resident #1 Address of the Behavioral Hospital
Document signed by the Administrator and dated 03/03/2023.
Interview with S2 DON on 05/30/2023 at 3:11 p.m. revealed Resident #1 was discharged from the facility because he physically attacked another resident on 02/28/2023. S2 DON stated on 02/28/28 the MD was notified and gave orders to PEC (Physician's Emergency Certificate) Resident #1 to the hospital. S2 DON stated from the hospital Resident #1 was sent to a behavioral unit and at that point the facility began working on finding other placement for Resident #1 due to his violent behavior.
Telephone interview on 05/31/2023 at 10:20 a.m. with the DON at the behavioral unit revealed the facility's administrator at the time, called and stated Resident #1 would not be returning to the nursing home under any circumstances. The DON at the behavioral unit stated she told the administrator Resident #1 would be returning to the nursing home when his treatment was completed and the administrator reiterated Resident #1 would not be returning.
Interview on 05/31/2023 at 5:00 p.m. with S1 Administrator revealed she instructed the previous administrator to issue Resident #1 a 30 day notice for discharge; however the previous Administrator did not.
Nov 2022
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to ensure a Resident was treated with respect and dignity and cared for in a manner that promotes the enhancement of his or her own quality of li...
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Based on observation and interview the facility failed to ensure a Resident was treated with respect and dignity and cared for in a manner that promotes the enhancement of his or her own quality of life. The facility failed to ensure a Resident's urinary catheter drainage bag was covered to ensure privacy for 1 (#19) of 1 Residents reviewed for dignity in a total sample of 27. Findings:
Review of Resident #19's Clinical Record revealed an admit date of 06/15/2022 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Pain, Asthma, Depressive Disorder, and Diabetes Mellitus Type II.
Review of Resident #19's Quarterly MDS with an ARD of 09/13/2022 revealed Resident #19 had a BIMS score of 15 (indicating intact cognition) and an indwelling catheter.
Observation on 11/28/2022 at 9:35 a.m. revealed Resident #19 lying in bed with her room door open. A Foley catheter drainage bag was observed hanging from the left side of the Resident's bed frame with no drainage bag covering in use. The Foley catheter drainage bag contained yellow urine and was visible from the hallway.
Observation on 11/29/2022 at 9:45 a.m. revealed Resident #19 lying in bed with her room door open. A Foley catheter drainage bag was observed hanging from the left side of the Resident's bed frame with no drainage bag covering in use. The Foley catheter drainage bag contained yellow urine and was visible from the hallway.
Interview on 11/29/2022 at 9:48 a.m. with S3 CNA confirmed Resident #19's Foley catheter bag was not covered and was visible from the hallway.
Interview on 11/29/2022 at 9:55 a.m. with S1 DON confirmed Resident #19's Foley catheter bag should be covered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote and facilitate self-determination by failing to allow a Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote and facilitate self-determination by failing to allow a Resident to make choices about aspects of his or her life that are significant to the Resident for 1 (#21) of (#9 and #21) residents reviewed for choices. Findings:
Review of Resident #21's record revealed she had an admission date of 08/27/2021. Further review of Resident #21's record revealed her last Quarterly MDS dated [DATE] revealed her BIMS was a 15, indicating the resident was cognitively intact.
Review of the facility's Resident Rights policy and procedure revealed in part 1.f Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: communication with and access to people and services, both inside and outside the facility. (Move Policy to front of tag)
Interview with Resident #21 on 11/28/2022 at 10:32 a.m. stated she has been trying to get a copy of her birth certificate for a while and has asked for assistance but keeps being putting her off by S1 Administrator and S4 SSD.
Interview with S4 SSD on 11/29/2022 at 08:45 a.m. stated Resident #21 had requested her birth certificate a little over a month ago. S4 SSD stated she had completed the application on-line for the Resident's birth certificate. The application fee was $50.00 payable by debit and/or credit card. S4 SSD stated that she informed S1 ADM of the fee and he stated that he would have to check with the Facility's Corporate Office for the form of payment requested since Resident #21 had neither a debit card and/or a credit card and it has been about a month and she has not heard anything back from S1 Administrator.
Interview with S1 Administrator on 11/29/22 at 8:50 a.m. revealed he was aware that Resident #21's had requested her birth certificate and that S4 SSD had completed the necessary paperwork. S1 Administrator stated he just hadn't thought about it. S1 Administrator confirmed that it had been at least a month since the paperwork had been filled out, but not completed due to payment. S1 Administrator stated they should have been more on top of getting Resident #21's birth certificate as requested.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to respect the resident's right to personal privacy by fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to respect the resident's right to personal privacy by failing to ensure a resident had privacy curtains around the bed for 1 (#9) of the 2 (#9 and #21) residents reviewed for privacy in the initial pool. Findings:
Review of the Facility's Policy and Procedure for Confidentiality of Information and Personal Privacy revealed in part 2.d. The facility will strive to protect the resident's privacy regarding his or her: personal care.
Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Chronic Kidney Disease, Convulsions, Gastric-esophageal Reflux Disease and Chronic Ischemic Heart Disease.
Review of Resident #9's admission MDS revealed the resident was assessed to have a BIMS of 14, which indicated the resident was cognitively intact.
Observation on 11/28/2022 at 9:27 a.m. revealed Resident #9 was lying in bed next to the door, when S5 CNA was observed closing his brief. There was no curtain pulled to provide privacy when the door was opened.
Interview with S5 CNA on 11/28/2022 at 9:29 a.m. revealed she would normally have closed the curtain to provide privacy, but there was no privacy curtain in the front to pull to provide the privacy. S5 CNA stated that the curtain had been missing for a while and she had reported it to maintenance.
Interview with Resident #9 on 11/28/2022 at 9:35 a.m. revealed his curtain had been missing since he was admitted and he hoped he could get one.
Interview with S12 Housekeeping Supervisor on 11/29/22 at 08:57 a.m. stated he was not aware the privacy curtain in Resident #9's room was missing. S12 Housekeeping Supervisor revealed S13 Housekeep Staff was the one who checked the rooms to ensure they were all functioning properly. S12 Housekeeping Supervisor stated he had not received a note about the missing curtain. S12 Housekeeping Supervisor confirmed there was no facility log book where staff reported maintenance issues or when maintenance issues had been resolved.
Interview with S13 Housekeeping Staff on 11/29/22 at 09:02 a.m. stated she was not aware that the privacy curtain was missing in Resident #9's room. S13 Housekeeping Staff stated she had been working in the laundry the past few days and was not checking the maintenance of the rooms. S3 Housekeeping Staff stated she would verbally tell S12 Housekeeping Supervisor when something was broken or write him a note. S13 Housekeeping Staff confirmed there was no maintenance log to document maintenance issues or when they had been fixed.
Interview with S1 Administrator on 11/29/2022 at 10:00 a.m. confirmed the facility had not been keeping a maintenance log and were not aware the curtain was missing, but should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to maintain a clean, safe, comfortable and homelike environment by failing to ensure the cleanliness of patient care equipment for 1(#60) ...
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Based on observation and staff interview, the facility failed to maintain a clean, safe, comfortable and homelike environment by failing to ensure the cleanliness of patient care equipment for 1(#60) of 3(#8, #41, #60) sampled Residents.
Findings:
Review of the Facility's Policy & Procedure titled Patient Care Equipment Cleaning read:
Purpose: The purpose of this policy is to ensure that equipment (e.g., wheelchair, lifts, etc.) is cleaned timely and appropriately.
Policy:
1.
The equipment will be cleaned by the CNAs on the night shift (11-7AM) or as needed and monitored by the CNA supervisor.
2.
Wheelchairs will be cleaned on a rotating schedule: A beds Monday, Wednesday, and Friday. B beds Tuesday, Thursday, Saturday.
3.
All other equipment will be monitored daily and cleaned as needed or per use.
During an observation on 11/28/2022 at 1:20 p.m. revealed Resident # 60's feeding pump was noted to have a large amount of dried brown liquid on the feeding pump machine, feeding machine clamp, feeding pole shaft, and base of feeding pole. Further observations on 11/29/2022 at 9:08 a.m. and 11/30/2022 at 8:40 a.m. revealed that the feeding machine, feeding machine clamp, feeding pole shaft, and base of feeding pole continued to have large amount of dried brown liquid.
An interview and observation with S2 DON on 11/30/2022 at 08:45 a.m. confirmed that the dried brown substance on feeding pole was dried tube feeding and she confirmed that the equipment should have been monitored daily and cleaned by a CNA or nurse and it was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#59) of 1 (#59) sampled residents with MDS records over 120 days old. The total sample size was 27.
Findings:
Review of the Facility's Policy & Procedure titled MDS Completion and Submission Timeframes read in part:
Policy statement - Our Facility will conduct and submit Resident Assessment in accordance with current federal and state submission timeframes.
Policy Interpretation and Implementation- 1. The Assessment Coordinator or designee is responsible for ensuring that Resident Assessments are submitted to CMS' (Centers for Medicare and Medicaid Services) QIES (The Quality Improvement and Evaluation System) Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines.
Review of the clinical record for Resident #59 revealed the Resident expired on [DATE]. Continued review of Resident #59's record revealed there was no documented evidence that a Discharge MDS was completed and transmitted.
Interview on [DATE] at 4:00 p.m. with S9 ADON revealed that she was not the nurse assigned to completing Resident #59's MDS, the nurse who was assigned to Resident #59 was out of the office today. S9 ADON stated she was not aware that Resident #59's Discharge MDS Assessment had not been completed and transmitted.
Interview on [DATE] at 4:15 p.m. with S2 DON confirmed that there was no Discharge MDS which had been completed and/or transmitted for Resident #59 and should have been. S2 DON stated that she was not certain why the assigned ADON had not completed the Discharge MDS in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment an...
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Based on observation, interview, and review of policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure signage was posted at facility entrances alerting visitors when they should not enter the facility (e.g., symptoms of illness, under quarantine, tested positive for COVID-19). Findings:
Review of the facility's COVID-19 Testing/Return to Work policy and procedure read in part Ensure everyone is aware of recommended IPC practices in the facility. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., breakrooms, sitting areas, nurses' station and etc).
Upon entrance into the facility for two consecutive days 11/28/2022 and 11/29/2022 at 8:20 a.m. there were no visual COVID-19 signage noted at the entrance to the facility.
Interview with S7 [NAME] Clerk on 11/28/2022 at 8:20 a.m. revealed there were positive COVID-19 Residents in the facility.
Interview with S1 Administrator on 11/29/2022 at 8:50 a.m. revealed he was not aware that there was no visual COVID-19 signage on the front entrance to the facility, but there should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control.
...
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Based on interview and record review, the facility failed to ensure that the individual designated as the Infection Preventionist, completed specialized training in infection prevention and control.
Findings:
Review of the facility's Infection Control Records revealed there was no documented evidence that S1 DON, who was the facility's designated Infection Preventionist, had completed specialized training in infection prevention and control.
In an interview on 11/28/2022 at 1:00 p.m., S2 DON stated she was the facility's Infection Preventionist. S2 DON stated her date of hire was 03/28/2022, however she had not completed Infection Preventionist training but hoped to have it completed by the end of 2022. S2 DON confirmed there was no other staff employed by the facility that had completed the Infection Preventionist training.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on interview the facility failed to ensure Residents received mail on Saturdays. This had the potential to affect 66 Residents residing in the facility. Findings:
Interviews on 11/28/2022 at 1:...
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Based on interview the facility failed to ensure Residents received mail on Saturdays. This had the potential to affect 66 Residents residing in the facility. Findings:
Interviews on 11/28/2022 at 1:30 p.m. with Residents in the Resident Council Meeting revealed they do not receive mail on Saturdays. S8 Activity Director who was present at the meeting stated mail was delivered to the facility on Saturdays and was kept at the nurse's station until Monday.
Interview on 11/28/2022 at 10:59 a.m. with S6 Bookkeeper revealed mail was delivered to the facility on Saturday but was held until Monday. S6 Bookkeeper stated this was done so if a Resident received a bill it would not upset the Resident and have them worried all weekend.
Interview on 11/30/2022 at 8:57 a.m. with S1 Administrator confirmed mail should be passed out to the Residents on Saturdays when it's delivered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure the nurse staffing pattern was posted daily and readily accessible for residents and visitors. Findings:
Observation on 11/28/2022 at 1...
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Based on observation and interview the facility failed to ensure the nurse staffing pattern was posted daily and readily accessible for residents and visitors. Findings:
Observation on 11/28/2022 at 10:30 a.m. revealed no posting of the staffing pattern.
Interview with S7 [NAME] Clerk stated the staffing pattern was on a clip board located on top of the medical record cabinet. S7 [NAME] Clerk revealed the last documented staffing pattern was dated 11/23/2022 and she also revealed that the DON was the one who completed it daily but had been on vacation during the holiday time.
Interview with S2 DON on 11/29/2022 at 9:30 a.m. stated she had completed the staffing patterns for 11/23/2022 - 11/28/2022, but had forgotten them on her desk. S2 DON confirmed they were done but not posted them so they were visible to residents and visitors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on interviews and observations the facility failed to ensure all mechanical, electrical, and patient care equipment were maintained in safe operating condition. The facility failed to ensure the...
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Based on interviews and observations the facility failed to ensure all mechanical, electrical, and patient care equipment were maintained in safe operating condition. The facility failed to ensure the oven and walk-in freezer was functioning correctly at all times as evidenced by:
1. The oven door not closely tightly.
2. The walk-in freezer had large amount of ice mounds on the outside of the door, floor, ceiling, crates and food packing.
This deficient practice had the potential to affect the 60 Residents that received meals prepared in the kitchen. Findings:
Observation on 11/28/2022 at 9:15 a.m. accompanied by S10 Dietary Manager revealed a stainless steel stove top with double ovens, the right oven door was noted not to be open. The oven was on with a pan of chicken being baked for the Residents' lunch meal.
Observation on 11/28/2022 at 9:30 a.m. accompanied by S10 Dietary Manager revealed: a large mound of solid ice outside the entrance to the freezer door, 2 freezer fans were covered with ice and not working, food items were covered with frost, icicles were dangling from food packages, crates, boxes, and the top of the freezer. Upon exiting the freezer, the door handle would not close and there was a gap between the door and the hinges. Further observation revealed the door was not aligned with the gasket.
Interview on 11/28/2022 at 10:00 a.m. S10 Dietary Manager confirmed both the oven door and the freezer doors had been repaired several times in the past and both were unable to close tightly as they should. S10 Dietary Manger confirmed the oven was still being used in food preparation. S10 Dietary Manager further stated when using the right oven, the cooks had to watch it closely and the oven door had to constantly be pushed closed with the door springing back open.
Interview on 11/28/2022 at 11:15 a.m. with S11 Dietary Worker revealed she was not sure how long the oven door and the freezer door would not close securely. S11 Dietary Worker stated that it takes the right oven longer to preheat and sometimes extra cooking time would have to be added because of the heat escaping from the door not closing tight. S11 Dietary Worker stated at times, they (Dietary workers) would place a piece of cardboard between the oven door in order to make a tight seal so the oven would keep the heat in and bake the food properly without delay in serving the Residents' meals.
Observation on 11/28/2022 at 11:40 a.m. accompanied by S1 ADM. confirmed the oven door would not closely tightly and the freezer door would not close all the way. S1 ADM. stated that both doors had been repaired before and was in need of repairs and/or replacement.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $78,891 in fines, Payment denial on record. Review inspection reports carefully.
- • 42 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $78,891 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (1/100). Below average facility with significant concerns.
Bottom line: Trust Score of 1/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Camelot Leisure Living's CMS Rating?
CMS assigns Camelot Leisure Living 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 Camelot Leisure Living Staffed?
CMS rates Camelot Leisure Living's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 47%, compared to the Louisiana average of 46%.
What Have Inspectors Found at Camelot Leisure Living?
State health inspectors documented 42 deficiencies at Camelot Leisure Living during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 39 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Camelot Leisure Living?
Camelot Leisure Living 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 PARAMOUNT HEALTHCARE CONSULTANTS, a chain that manages multiple nursing homes. With 91 certified beds and approximately 66 residents (about 73% occupancy), it is a smaller facility located in FERRIDAY, Louisiana.
How Does Camelot Leisure Living Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Camelot Leisure Living'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 (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Camelot Leisure Living?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Camelot Leisure Living Safe?
Based on CMS inspection data, Camelot Leisure Living has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Camelot Leisure Living Stick Around?
Camelot Leisure Living 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 Camelot Leisure Living Ever Fined?
Camelot Leisure Living has been fined $78,891 across 2 penalty actions. This is above the Louisiana average of $33,868. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Camelot Leisure Living on Any Federal Watch List?
Camelot Leisure Living 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.