GUEYDAN MEMORIAL GUEST HOME
Government - Hospital district
66 Beds
Independent
Data: November 2025
Trust Grade
50/100
#128 of 264 in LA
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Gueydan Memorial Guest Home has a Trust Grade of C, indicating that it is average compared to other facilities. It ranks #128 out of 264 in Louisiana, placing it in the top half of nursing homes in the state, and #4 out of 6 in Vermilion County, meaning there are only three better local options. The facility is improving, with the number of reported issues decreasing from 11 in 2024 to 7 in 2025. Staffing is a relative strength, with a turnover rate of 33%, which is better than the state average, but it has an average RN coverage rating. While there have been no fines, there are some significant concerns, such as residents not having access to their personal funds during non-banking hours, mail not being delivered on Saturdays, and a lack of clarity on grievance procedures, which could affect residents' ability to voice their concerns. Overall, while there are positives regarding staffing and a lack of fines, the facility needs to address these compliance issues to ensure better resident care.
- Trust Score
- C
- In Louisiana
- #128/264
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 33% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Top 48%
No red flags
11 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (33%)
15 points below Louisiana average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 33%
13pts below Louisiana avg (46%)
Typical for the industry
The Ugly 26 deficiencies on record
Aug 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure that a resident's enteral feeding was properly...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure that a resident's enteral feeding was properly labeled for 1 (#5) out of 1 (#5) resident investigated for tube feeding.Findings:On 08/25/2025, a review of the facility's policy titled, Enteral Tube Feeding via Continuous Pump, with a last review date of August 2025, revealed in part.Purpose: The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings.Initiate Feeding:.5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Review of Resident #5's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, muscle wasting and atrophy, dysphagia, and gastrostomy status. Review of Resident #5's August 2025 physician's orders revealed an order dated 07/30/2025 that read in part.Enteral Feed Order every shift.Osmolite 45 ml (milliters) q (every) hour. On 08/25/2025 at 10:47 a.m., an observation of Resident #5's tube feeding bag and administration set revealed the formula bag had no label. On 08/25/2025 at 11:04 a.m., an interview and observation was conducted with S5LPN (Licensed Practical Nurse) who stated that tube feeding bags should be labeled with resident's name, date, time, rate, and nurse's initial. An observation was made with S5LPN of Resident #5's tube feeding, who confirmed the resident's tube feeding bag was not labeled, and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide necessary care and services in accordance with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 1 (#18) out of 1 (#18) resident investigated for respiratory care.Findings:On 08/25/2025, a review of the facility's policy titled, Oxygen Administration, with a last review date of August 2025, revealed in part.Purpose: The purpose is to provide guidelines for safe oxygen administration. Oxygen shall only be administered by physician order.Steps in the Procedure.4. Turn on the oxygen. Start the flow of oxygen at the rate order by physician. Review of Resident #18's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic obstructive pulmonary disease and pneumonia. Review of Resident #18's Annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 07/02/2025 revealed she had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. Review of Resident #18's August 2025 physician's orders revealed an order dated 03/24/2025 for O2 (oxygen) at 2L (liters) per NC (nasal cannula) QHS (every night) and PRN (as needed). On 08/25/2025 at 11:41 a.m., an observation was made of Resident #18 in the dining room with oxygen on and in place per nasal cannula. The oxygen setting was observed at 4L.On 08/25/2025 at 11:49 a.m., an observation and record review was conducted with S3LPNTX (Licensed Practical Nurse/Treatment Nurse). S3LPNTX observed Resident #18's oxygen setting at 4L. She then reviewed Resident #18's August 2025 physician's orders and confirmed the oxygen should be at 2L. She confirmed the oxygen rate was incorrectly set on 4L and should have been on 2L as per the physician's orders. On 08/27/2025 at 12:09 p.m., an interview was conducted with Resident #18 who stated she does not touch the machine at all.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure: 1. Resident #13 was assessed for the risk of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure: 1. Resident #13 was assessed for the risk of entrapment from assist bars. 2. Informed consent was obtained from the resident or the resident's representative prior to installation of assist bars for Resident #13. The deficient practice occurred for 1 (Resident #13) of 29 sampled residents. Findings: A review of the facility's policy, Bed Safety and Bed Rails, with a last review date of August 2025, revealed in part: Use of Bed Rails, The resident assessment to determine risk of entrapment includes, but is not limited to : a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medications; e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. cognition, j. communication; k. mobility (in and out of bed); and i. risk of falling. 8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternative that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. Review of Resident #13's Electronic Health Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere with behavioral disturbance, repeated falls, and osteoarthritis. Review of Resident #13's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 2, which indicated the resident's cognition was severely impaired. Further review revealed that Resident #13 required substantial/maximal assistance with bed turning left and right and was dependent with chair to bed transfers. Review of Resident #13's care plan revealed in part: 5. Resident #13 has an ADL (Activities of Daily Living) self-care performance/functional abilities deficit r/t (related to) Dx (Diagnosis) Osteoarthritis. Resident #13 requires assistance with ADL functioning. Bed mobility: Resident #13 needs assistance of 2 staff for reposition while in bed. May use assist bars x 2 as needed to assist with bed mobility. On 08/26/2025 at 2:00 p.m., an observation of Resident #13 was made, with her in bed, both left and right upper assist bars in the raised position. Review of Resident #13's medical record revealed no evidence of assessment for the risk of entrapment from assist bars nor consent from the resident or the resident's responsible party for the use of assist bars. On 08/27/2025 at 11:26 a.m., an interview and record review was conducted with S1DON (Director of Nursing). S1DON confirmed that the side rail assessment for Resident #13 did not include assessing for the risk of entrapment. She further confirmed that informed consent was not obtained from Resident #13's responsible party nor the resident, prior to the use of assist bars.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including accurately documenting controlled medication reconciliation in 1 (Med (medicatio...
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Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including accurately documenting controlled medication reconciliation in 1 (Med (medication) Cart 1) of 2 (Med Cart 1 and Med Cart 2) med carts for Resident #43. Findings:A review of the facility's policy titled, Controlled Substances with a last review date of 08/2025, read in part, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medication. The policy also indicated general guidelines, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up.A review of Resident #43's electronic medical record revealed she was admitted to the facility on 0721/2022 with a diagnosis that included in part, Anxiety Disorder.A review of Resident #43's physician's orders revealed a start date of 08/16/2025: Lorazepam Oral Tablet 1 mg (milligram) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for Anxiety.A review of Resident #43's Lorazepam Oral Tablet 1mg administration details in the EHR (electronic health record) revealed the controlled drug was administered on 08/27/2025 at 8:34 a.m. A review of the facility's form labeled, Individual Resident's Narcotic Record, for Resident #43 failed to reveal the administration of Lorazepam Oral Tablet 1 mg on 08/27/2025 at 8:34 a.m.On 08/27/2025 at 9:20 a.m., a controlled drug count and interview was conducted with S2LPN (Licensed Practical Nurse). A review of Resident #43's Individual Resident's Narcotic Record, for Lorazepam Oral Tablet 1mg give 1 tablet by mouth every 4 hours as needed stated that 30 tablets were supposed to be in the blister pack. Blister pack reviewed with S2LPN for Resident #43's Lorazepam Oral Tablet 1 mg which revealed 29 tablets. S2LPN stated she administered Resident #43's Lorazepam Oral Tablet 1 mg this morning, and forgot to sign it off on the resident's Individual Resident's Narcotic Record. She confirmed that she should have documented on Resident #43's Individual Resident's Narcotic Record, as soon as she administered the medication and she did not. On 08/27/2025 at 10:02 a.m. an interview was conducted with S1DON (Director of Nursing). She confirmed after a narcotic/controlled medication is administered it is to be documented on the resident's Individual Resident's Narcotic Log immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on interviews, observations, and record review the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles as evidenced by: 1. fa...
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Based on interviews, observations, and record review the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles as evidenced by: 1. failing to discard an expired medication in 1 (Med (medication) Cart 1) of 2 (Med Cart 1 and Med Cart 2) med carts, 2. failing to discard 2 expired medications in 1 (Med Room) of 1 (Med Room), and 3. failing to ensure food was stored separately from medications. Findings:A review of the facility's policy titled, Storage of Medications with a last review date of 08/2025, read in part, The facility stores all drugs and biologicals in safe, secure, and orderly manner. The policy also indicated general guidelines, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Medications are stored separately from food. On 08/27/2025 at 9:03 a.m., observation was conducted of Med Cart 1 with S2LPN (Licensed Practical Nurse) which revealed the following: 1 Linzess 72 mcg (microgram) bottle with an expiration date of 06/05/2025.On 08/27/2025 at 9:20 a.m., an observation and interview was conducted with S2LPN who confirmed the expiration date on the Linzess 72 mcg bottle was 06/05/2025, and it should have been discarded and not in the med cart.On 08/27/2025 at 9:25 a.m., observation was conducted of the Med Room with S2LPN which revealed the following: 1 Trazadone 100 mg (milligram) blister packet with an expiration date of 04/29/2025. 1 Mirtazapine 15 mg blister packet with an expiration date of 06/14/2025. 1 bottle of Orange Juice in the Medication Only refrigerator. On 08/27/2025 at 9:35 a.m., an observation and interview was conducted with S2LPN who confirmed the expiration date on the Trazadone 100 mg blister packet's expiration date was 04/29/2025, and the Mirtazapine 15 mg blister packet's expiration date was 06/14/2025, and both medications should have been discarded and not in the med room. She also confirmed that food items should not be in the same refrigerator as medications.On 08/27/2025 at 10:02 a.m., an interview was conducted with S1DON (Director of Nursing). She confirmed that no expired medications should be in any med carts or in the med room. She confirmed that food items should not be in the same refrigerator as medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the designated interdisciplinary team member obtained the mo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the designated interdisciplinary team member obtained the most recent hospice plan of care, and the physician recertification of the terminal illness for 1 (#9) of 1 (#9) resident investigated for hospice care.Findings:On 08/27/2025, a review of the facility's policy titled Hospice Program, read in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation.11.Our facility has designated S1DON (Director of Nursing) to coordinate care provided to the resident by our facility staff and the hospice staff.she is responsible for the following.d. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident.3. Physician certification and recertification of the terminal illness specific to each resident.Resident #9 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, chronic diastolic (congestive) heart failure, and acute kidney failure.Review of Resident #9's quarterly Minimum Data Set (MDS) dated [DATE], revealed in Section J1400. Prognosis that he had a chronic disease that may result in a life expectancy of less than 6 months.Review of Resident #9's physician orders revealed an order written on 01/20/2025 to admit to hospice service. Further review revealed no order to discharge the resident from hospice service.Review of the Resident #9's medical records revealed no current hospice certification or plan of care. The last certification period and plan of care were dated 04/10/2025 to 07/18/2025.On 08/26/2025 at 4:15 p.m., an interview and review of Resident #9's hospice records was conducted with S3LPN/TX (Licensed Practical Nurse/Treatment Nurse). She confirmed that the resident did not have a current certification and plan of care in his records.On 08/27/2025 at 2:47 p.m., an interview was conducted with S1DON. She stated that she was responsible for obtaining Resident #9's hospice certification and plan of care from the hospice provider. S1DON confirmed that she was aware that the current certification and plan of care were not in the facility and stated that they should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (#2, #13, and #42) residents out of 29 sampled residents. Findings: Resident #2 Review of Resident #2's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with a diagnoses which included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an assessment reference date of 07/01/2025 revealed Section N0415 (J) Hypoglycemic was coded no which indicated the resident did not receive a hypoglycemic in the 7 day look back period. Review of Resident #2's Medication Administration Record (MAR) revealed that Lantus and Novolog were administered 06/25/2025 through 07/01/2025. On 08/26/2025 at 4:02 p.m., an interview and review of Resident #2's MDS with an assessment date of 07/01/2025 was conducted with S4MDS. S4MDS confirmed that yes should have been coded for section N0415 (J) Hypoglycemic and was not. Resident #13 Review of Resident #13's Electronic Health Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia in other diseases classified elsewhere with behavioral disturbance and repeated falls. Review of Resident #13's Quarterly MDS with an assessment reference date of 07/25/2025 revealed Sections P0200 (A) Bed alarm and P0200 (B) Chair alarm were coded as not used which indicated the resident did not utilize a bed or chair alarm during the 7 day look back period. Review of Resident #13's physician's order revealed an order dated 01/24/2024 for clip alarm to resident at all times due to poor safety awareness, q (every) 1 hour checks. Review of Resident #13's July 2025 MAR revealed that that her clip alarm was in place at all times for the entire month. On 08/26/2025 at 4:15 p.m., an interview and review of Resident #13's MDS dated [DATE] was conducted with S4MDS. S4MDS confirmed that the resident used a chair alarm and a bed alarm for the month of July 2025. She confirmed Sections P0200 (A) Bed alarm and P0200 (B) Chair alarm should have been coded as used and were not. Resident #42 Review of Resident #42's EHR revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus without complications and depression, unspecified. Review of Resident #42's significant change in status MDS with an assessment reference date of 05/28/2025 revealed section I5800 Depression (other than bipolar) was coded no indicating the resident did not have an active diagnosis of depression. Section N0415 (J) Hypoglycemic- including insulin was coded no indicating the resident did not receive a hypoglycemic during the 7 day look back period. Review of Resident #42's May 2025 MAR revealed from 05/22/2025 through 05/28/2025 the resident was administered Sertraline for depression and Glimepiride and Pioglitazone as hypoglycemics. On 08/27/2025 at 11:20 a.m. an interview and review of Resident #42's MDS dated [DATE], was conducted with S4MDS. S4MDS confirmed that yes should have been coded for sections section I5800 Depression (other than bipolar). She further confirmed that yes should have been coded for Section N0415 (J) Hypoglycemic.
Aug 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 provide the resident and the resident's representative a written no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the resident and the resident's representative a written notice that specified the duration of the bed-hold policy for 1 (#102) of 1 (#102) residents investigated for hospitalizations in a final sample of 23 residents. This deficient practice had the potential to effect a census of 49.
Findings:
Review of the facility's policy titled, Bed-Holds and Returns, with a revision date of 04/2024, revealed in part: Policy statement: Resident and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. Policy interpretation and implementation: 1. all residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during period of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within 24 hours).
Review of Resident #102's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses not limited to: Pneumonia, Hypoxia, Edema, Heart Failure and Anxiety. The resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident's cognition was intact.
Review of the Ombudsman Notification of Transfer logs from May 2024- August 2024 revealed Resident #102's transfer dates as 05/17/2024, 06/08/2024, 07/19/2024, 07/22/2024 and 07/31/2024. Review of the column titled written notification to resident date revealed the date of the transfer. There was no furhter evidence provided that a written notification had been sent to the resident's RP (responsible party).
On 08/06/2024 at 9:30 a.m., an interview was conducted with Resident #102, she stated she did not recall getting a letter/notice of a bed hold when she had gone out to the hospital.
On 08/06/2024 at 9:52 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection preventionist), she reported the facility does not send out letters for bed-hold when a resident goes out to the hospital. S2DON/IP stated S1ADM (Administrator) informed her that sending a bed-hold letter to the resident/RP was not necessary becasue the facility always had open beds. She also confirmed a letter was not sent to Resident #102 nor the RP when the resident was sent out to the hospital.
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 observation, record review and interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to ensure oxygen was deli...
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Based on observation, record review and interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 2 (#2, #102) out of 2 (#2, #102) residents investigated for respiratory care in a final sample of 23 residents.
Findings:
Resident #2
A review of Resident #2's EMR (Electronic Medical Record) revealed an admission date of 11/18/2020 with diagnoses that included Pneumonia, Sepsis, and Dementia.
A Review of Resident #2's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 06/18/2024 revealed she had a BIMS (Brief Interview for Mental Status) score of 03, indicating severely impaired cognition.
Further review of Resident #2's August 2024 physician's orders revealed in part . Oxygen at 2L (Liters) per nasal cannula continuously with an order start date of 12/26/2023.
On 08/05/2024 at 11:16 a.m., an observation was made of Resident #2 in the dining room with oxygen on and in place per nasal cannula. The oxygen setting was observed at 3L.
On 08/07/2024 at 9:03 a.m., a second observation was made of Resident #2 in her bed with oxygen on and in place per nasal cannula. The oxygen setting was observed at 3L.
On 08/07/2024 at 9:45 a.m., a record review and observation was made with S6LPN (Licensed Practical Nurse). S6LPN reviewed Resident #2's August 2024 physician's orders and confirmed the oxygen should be at 2L. She then observed Resident #2's oxygen setting. She confirmed the oxygen rate was incorrectly set on 3L and should have been on 2L as per the physician's orders.
Resident #102
Review of Resident #102's EMR (Electronic Medical Record) revealed an admission date of 04/17/2020 with diagnoses that included Pneumonia, Edema, Heart Failure, Tachycardia and Anxiety.
Review of Resident #102's August 2024 physician's orders dated 06/24/2024 revealed O2 (oxygen) at 3 L/NC (liters per nasal cannula) continuous related to pneumonia.
Review of Resident #102's MAR (Medication Administration Record) for August 2024 revealed O2 at 3L/NC continuously related to pneumonia.
Review of Resident #102's Care Plan revealed there was no Focus or Goal related to managing symptoms associated with Pneumonia nor was there an intervention including the continuous use of oxygen.
On 08/06/2024 at 2:18 p.m., an interview was conducted with S5MDS (Minimum Data Set nurse). S5MDS reviewed Resident #102's care plan and confirmed the Focus of Pneumonia and intervention of continuous oxygen was not identified. S5MDS confirmed the use of oxygen at 3 L/NC should have been addressed on the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day 7 days per week. This deficient practice had the potential to ...
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Based on record review and interviews, the facility failed to ensure an RN (Registered Nurse) was on duty for 8 consecutive hours per day 7 days per week. This deficient practice had the potential to affect all 49 residents residing in the facility.
Findings:
Review of Time Card Reports for RN hours from January 2024 through March 2024 revealed an RN did not work a total of 8 consecutive hours for the following dates in February 2024:
02/19/2024 S2DON/IP (Director of Nursing/Infection Preventionist) had a clock-in time of 11:50 a.m. and clock-out time of 5:42 p.m. with 5.5 hours worked. No other RN had time on the time card reports.
02/26/2024 S11RN had a clock-in of 5:29 a.m. and clock-out time 12:00 p.m., with 6.35 hours worked. S2DON/IP had a clock-in time of 6:57 a.m. and clock-out time 1:18 p.m. The facility's RN coverage totaled 7 hours and 48 minutes.
Further review of time cards for March 2024 revealed no RN for had time documented on the time card report for March 10, 2024.
On 08/07/2024 at 11:00 a.m., an interview was conducted with S2DON/IP as she reviewed the time card reports. S2DON/IP confirmed on 02/19/2024 and 02/26/2024 the facility did not have 8 consecutive hours of RN coverage.
On 08/07/2024 at 2:45 p.m., an interview was conducted S4SEC (Secretary) who reported S10RN worked on 03/10/2024. S4SEC did not provided a time card report with the reported information by exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received a mechanically altered die...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received a mechanically altered diet as ordered by the physician for 1 (#35) out of 6 (#2, #34, #35, #43, #44, and #102) residents reviewed for dining.
Findings:
Review of Resident #35's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Non-infective Gastroenteritis and Colitis and Dysphagia.
Review of Resident #35's most recent admission Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating her cognition was intact. Section K: Swallowing/Nutritional Status was checked for mechanically altered diet.
Review of Resident #35's physician's orders revealed an order dated 06/24/2024 that read, NAS (No Added Salt) diet, Finely Chopped texture, Regular Consistency.
On 08/05/2024 at 11:55 a.m. an observation was made of Resident #35's meal ticket and meal tray. Resident #35's meal ticket read in part, Finely Chopped. Observations of the meal tray served to the resident revealed 1 whole slice of meat loaf and 1 whole slice of garlic bread. Both items were not finely chopped.
On 08/05/2024 at 11:57 a.m. an interview was conducted with S8RN (Registered Nurse). S8RN confirmed that Resident #35 was on a finely chopped diet as ordered by the physician and the items on her meal tray were not finely chopped.
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 record review and interview, the facility failed to maintain an effective infection control and prevention program by failing to conduct yearly review of the infection program policies and pr...
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Based on record review and interview, the facility failed to maintain an effective infection control and prevention program by failing to conduct yearly review of the infection program policies and procedures.
Findings:
On 08/06/2024, a review of the facility's policy titled, Infection Prevention and Control Program read in part: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to prove a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Further review revealed the policy was last updated on 10/2018.
On 08/06/2024 at 9:56 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Preventionist). S2DON/IP stated that she was responsible for oversight of the infection control program. S2DON/IP failed to provide documentation when requested regarding when the facility's IPCP policies and procedures were last reviewed. S2DON/IP stated she was unaware that IPCP policies and procedures were to be reviewed annually.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviews and interviews the provider failed to ensure that a resident's assessment accurately refl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviews and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status for 3 (#14, #28, #102) residents records reviewed out of a finalized sample of 23 residents as evidenced by:
1. failing to ensure Resident #14's MDS (Minimum Data Set) assessment reflected dialysis;
2. incorrectly identifying physical restraint use on Resident #28's MDS assessment; and
3. failing to ensure Resident #102's MDS assessment reflected oxygen use.
Findings:
1. Resident # 14
A review of Resident #14's EMR (Electronic Medical Record) revealed an admission date of 11/21/2022 with diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis.
A review of Resident #14's Physician's Orders, revealed and order dated 11/21/2022, that read in part, Dialysis on Monday, Wednesday and Fridays.
A review of Resident #14's Quarterly MDS assessment dated [DATE], under Section O-Special Treatments, Procedures, and Programs; dialysis was not indicated.
On 08/07/2024 at 12:42 p.m., a concurrent record review and interview was conducted with S5MDS (Minimum Data Set). S5MDS confirmed Resident #14 had an order for and received dialysis 3 times a week. S5MDS confirmed the 05/31/2024 MDS assessment failed to identify Resident #14 received dialysis and should have been indicated.
2. Resident #28
A review of Resident #28's EMR revealed an admission date of 02/24/2020 with diagnoses that included, Cognitive Communication Deficit, Dementia, and Primary Generalized Osteoarthritis.
A review of Resident #28's Physicians Orders failed to reveal an order for physical restraints.
Further review of Resident #28's Care Plan failed to reveal a problem or plan for physical restraints. There was no documentation found elsewhere in the resident's record that physical restraints were used.
A review of Resident #28's Quarterly MDS assessment dated [DATE], under Section P-Physical Restraints; bed rail was indicated as used daily.
On 08/05/2024 at 10:00 a.m., an observation was conducted of Resident #28 in her room. There was no evidence of any physical restraints.
On 08/06/2024 at 9:50 a.m., a second observation was conducted of Resident #28 in her room. There was no evidence of any physical restraints.
On 08/06/2024 at 10:00 a.m., a concurrent record review and interview was conducted with S5MDS. S5MDS viewed Resident #28's EMR and was unable to find any indications that physical restraints had been ordered or utilized. S5MDS confirmed the 5/30/2024 MDS assessment indicated that bed rails were used daily as a physical restraint and should not have been coded.
3. Resident #102
A review of Resident #102's EMR revealed an admission date of 04/17/2020 with diagnoses that included Pneumonia, Hypoxia, and Heart Failure.
A review of Resident #102's Physician's Orders, revealed an order dated 06/24/2024, that read O2 (Oxygen) at 3L (Liters)/NC (per nasal cannula) continuously.
A review of Resident #102's Quarterly MDS assessment dated [DATE], under Section O-Special Treatments, Procedures, and Programs; oxygen use was not indicated.
On 08/06/2024 at 2:18 p.m., a concurrent record review and interview was conducted with S5MDS. S5MDS confirmed Resident #102's order for oxygen and had received it. S5MDS confirmed the 07/26/2024 MDS assessment failed to identify Resident #102 received oxygen and should have been indicated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who smoked were free from potentia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who smoked were free from potential accidents and hazards, by failing to implement the facility's policy that required unsafe smokers to be provided a smoking apron for 3 (#36, #41 and #43) of 3 (#36, #41 and #43) residents who were care planned as unsafe smokers. The final sample size was 23 residents.
Findings:
On 08/07/2024, a review of the facility's smoking policy titled, Smoking Policy for Residents, with no documented revision date, read in part .Purpose: To assure that a resident desiring to smoke is allowed to do so in a manner and area which will not compromise his/her safety or that of others in this facility .Resident found to be unsafe smoker will be provided smoking apron and will be supervised by staff member while in smoke room .
Resident #36
Review of Resident #36's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, Dementia, Major Depressive Disorder, Anxiety Disorder and Repeated Falls.
Review of Resident #36's care plan read in part .is an unsafe smoker .04/28/2022. Resident will smoke only in designated areas and will not burn holes in furniture of clothing .Supervise resident at all times while smoking .08/21/2022 Re-assessed-Remains an unsafe smoker .
Resident #41
Review of Resident #41's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dementia, Cognitive Communication Deficit, Depression, Muscle Wasting and Atrophy and Lack of Coordination.
Review of Resident #41's care plan read in part .is an unsafe smoker .07/25/2022 .Will be supervised when smoking at designated times .
Resident #43
Review of Resident #43's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease, Chronic Obstructive Pulmonary Disease, Asthma, Anxiety Disorder, and Major Depressive Disorder.
Review of Resident #43's care plan read in part .is an unsafe smoker .12/21/2023 .will smoke only in designated areas and will not burn holes in furniture or clothing .Supervise at all times while smoking .
08/05/2024 at 10:35 a.m., an interview was conducted with S2DON/IP (Director of Nursing/Infection Preventionist). She stated all five residents who smoke in the facility were considered unsafe smokers.
On 08/07/2024 at 12:34 p.m., an observation was made of Resident #36, Resident #41 and Resident #43 in the smoking area smoking cigarettes. The residents were not observed wearing a smoke apron.
S13CNASA (Certified Nursing Assistant/Smoke Aide) was observed monitoring the residents in the area.
On 08/07/2024 at 12:35 p.m., an interview was conducted with S13CNASA. She stated that Resident #36, Resident #41, and Resident #43 were all unsafe smokers, but that the residents did not require an apron. All residents continued to smoke without an apron.
On 08/07/2024 at 12:45 p.m., an interview was conducted with S2DON/IP. She stated that Resident #36, Resident #41 and Resident #43 were not required to wear a smoke apron even though all are considered unsafe smokers. The facility's policy, Smoking Policy for Residents was reviewed with S2DON/IP who confirmed policy stated resident found to be an unsafe smoker should be provided and wear a smoking apron.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure residents' personal funds were available during non-banking hours. This failed practice had the potential to affect 51 residents who...
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Based on record review and interview, the facility failed to ensure residents' personal funds were available during non-banking hours. This failed practice had the potential to affect 51 residents who deposited funds in the residents' trust fund. The facility's total census was 51 with a census of 49 residents physicially in the nursing home at the time of the survey.
Findings:
During a resident council meeting conducted with 4 (#8, #11, #24, #37) residents and S9ACT (Activities Director) on 08/05/2024 at 2:05 p.m., the residents were asked about personal funds and petty cash. Resident #24 stated they could not get petty cash on the weekend, and the other residents agreed. Resident #24 reported the only time residents could get cash was when the business office was open during weekdays not weekends. The residents present in the meeting all agreed, they were not aware they should have petty cash available to them at any time, including weekends.
On 08/07/2024 at 8:37 a.m., an interview was conducted with S3SSD (Social Services Director), she reported she was responsible for resident's petty cash. S3SSD stated petty cash was only available to resident's Monday through Friday except for holidays. S3SSD confirmed petty cash was not available to residents on weekends when the business office was closed. S3SSD stated she was not aware petty cash needed to be available to resident at all times.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected most or all residents
Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 49 residents residing in the facility.
Findings:
On 08/05/2...
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Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays. This had the potential to affect 49 residents residing in the facility.
Findings:
On 08/05/2024 at 2:05 p.m., during a resident council meeting, Residents #11, #24 and #37 each stated they do not receive their unopened mail on Saturdays. Residents #11 and #24 stated they only get their mail when the office is open Monday through Friday.
On 08/07/2024 at 10:52 a.m., an interview was conducted with S4SEC (Secretary/Transportation Supervisor/Medical Record). She reported there was no one in the business office on Saturdays to deliver mail to residents. S4SEC stated the Saturday mail was delivered to residents first thing on Monday morning. S4SEC confirmed mail was not delivered to residents on Saturdays.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on record reviews and interviews, the facility failed to ensure that their grievance policy and procedure was followed. The facility failed to ensure the residents and staff were aware of the pr...
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Based on record reviews and interviews, the facility failed to ensure that their grievance policy and procedure was followed. The facility failed to ensure the residents and staff were aware of the procedure for filing grievances. The deficient practice had the potential to effect a census of 49 residents.
Findings:
Review of the facility's policy and procedure titled, Resident Care Grievance Policy, with a revision date of April 2017 and a review date of April 2023, revealed in part: Policy statement: all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Policy interpretation and implementation: 2. upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations .5. The grievance officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log. 6. The resident grievance/complaint investigation report form will be filed with the administrator within 5 working days of the incident. 7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance or complaint 10. Upon request, a copy of grievance must be given to the resident or representative.
Review of facility's grievances from July 01, 2023 to July 31, 2024 revealed only 5 grievances had been filed. Each grievance had a complaint and action taken to solve section. Only 3 of the grievances noted the problem was solved. The other 2 complaints had no for problem solved and were greater than 5 days to be signed by Administrator.
On 08/05/2024 at 2:05 p.m., during a resident council meeting, Resident's #8, #11, #24 and #37 each reported they did not know how to file a grievance or who to talk to about filing a grievance. Resident #24 stated residents were not aware if grievances were filed when complaints or issues are voiced. Resident #24 also stated residents do not get feedback or a written resolution when a complaint is reported as to what the resolution was.
On 08/06/2024 at 11:17 a.m., an interview was conducted with S3SSD (Social Services Director), she confirmed she was responsible for the facility's grievances. She reported she was not sure of what all should be filed as a grievance. She stated usually S9ACT (Activities Director), would receive the initial complaints from the residents in the mornings, while serving them coffee. S3SSD stated when staff had their morning meetings, S9ACT would inform them of any complaints and administrative staff wouldreview the concern and address. S3SSD stated a grievance/complaint was not completed because if there was a complaint the staff worked to get it resolved at the time. S3SSD again stated she did not know that resident complaints should be filed as a grievance. She confirmed the facility only had 5 grievances for the past year, as she was unaware of what should have been filed as a grievance.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and review of the facilty's policy and procedures,the facility failed to maintain a clean and sanitary kitchen. This deficient practice had the potential to affect t...
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Based on observations, interviews, and review of the facilty's policy and procedures,the facility failed to maintain a clean and sanitary kitchen. This deficient practice had the potential to affect the 44 residents who consumed food from the kitchen. The facility's census was 49.
Findings:
On 08/05/2024, a review of the facility's policy titled, Fryer with no date of implementation or revision, read in part: After each use, fryer must be drained and thoroughly cleaned. The procedure to use is as follows: 1. Drain grease into thick container after cooled and dispose of .
On 08/05/2024, a review of the facility's policy titled, Conventional Oven with no date of implementation or revision, read in part: Wipe oven doors, outside surface and racks with clean damp cloth . The porcelain interior can easily be cleaned with oven cleaners .
On 08/05/2024, a review of the facility's policy titled, Pantry with no date of implementation or revision, read in part: . 2. dented can and spoiled foods should be disposed of promptly to prevent contamination of other foods .
On 08/05/2024, a review of the facility's policy titled, Refrigerators and Freezers and Walk-in Cooler with no date of implementation or revision, read in part: . 3. Mop floors in walk-in refrigerators daily .
On 08/05/2024, a review of the facility's policy titled, Labeling and Dating of Food Received with no date of implementation or revision, read in part: . Once opened, the product should be dated again with the date it was opened .
On 08/05/2024, a review of the facility's policy titled, Dietary Services with no date of implementation or revision, read in part: . 2. Hair . cover the hair completely .
On 08/05/2024, a review of the facility's policy titled, Ingredient Bins with no date of implementation or revision, read in part: . 6. Scoops used in bins are not to be left in the bin. Scoops are to be kept covered in a protected area conveniently located near the bins.
On 08/05/2024 at 8:26 a.m. and initial tour of the kitchen was conducted with S7DM (Dietary Manager). S12CH was observed walking around the kitchen and cleaning the dishes with his beard exposed and not covered.
On 08/05/2024 at 9:20 a.m. a second observation was made of S12CH walking past the prep station where food is being prepared for lunch with his beard exposed and not covered. Continued observations of the kitchen with S7DM revealed the following:
1.Equipment:
A. Food residue noted on the kitchen fryer.
B. Dark black grease noted in the kitchen fryer.
C. Build-up of brown substance noted on the outside of the deep freezer.
D. Build-up of debris and brown substance inside of the convention oven and the inside of the oven doors.
2. Food storage:
A. Refrigerated items:
1. A chicken base container not labeled with the date it was opened.
2. A bag of cheese with multiple areas of black spots noted to the cheese and packaging indicated it was spoiled.
B. Dry Storage:
1. Two dented canned goods in the dry storage room.
2. A bag of pasta not labeled with the date it was opened.
C. Walk-in Refrigerator:
1. Pitcher of soda not labeled with the date it was prepped.
2. Food residue and debris noted on the floor.
D. Main Kitchen:
1. A container of vanilla flavoring not labeled with the date it was opened.
2. A bottle of soda flavoring not labeled with the date it was opened.
3. A container of cream potatoes not labeled with the date it was prepped.
3. S12CH (Cook Help) without a beard restraint while in the kitchen.
4. A scoop noted inside of cereal container.
On 08/05/2024 at 1:45 p.m. an interview was conducted with S7DM. S7DM confirmed the findings listed above throughout the kitchen tour. She stated if food items are opened or prepped by staff they must be labeled with the open or prep date. She stated if there are any discolored spots noted on food and if there are dented cans in the pantry it should be discarded immediately. She confirmed the floors in the walk-refrigerator consisted of old food residue and floors should be swept and mopped daily she was unsure when it was last cleaned. She stated that no scoops should be inside any containers they should be stored on the outside of the containers in their designated area. She confirmed the fryer should have been cleaned and the grease was dark and it should have been drained when it was last used on 08/04/2024. She stated the conventional oven consisted of debris and brown substance on the inside and brown substance was noted on the outside of the deep freezer and this should have been cleaned. She confirmed that S12CH should have had a beard covering on this morning while working in the kitchen.
Aug 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status by failing to ensure a resident's discharge status was accurately coded for 1 (#46) resident of 23 sampled residents.
Findings:
Resident #46 was admitted to the facility on [DATE] with diagnoses including in part: Iron deficiency Anemia, Urinary Tract Infection, and Age Related Osteoporosis.
A review of Section A2100 of Resident #46's Discharge MDS (Minimum Data Set) dated 06/27/2023 revealed that the resident was discharged to acute hospital.
A review of Resident #46's June 2023 Physician's Orders revealed an order written on 06/27/2023 that read: Ok to D/C (discharge) to . nursing home. A review of Resident #46's Discharge summary dated [DATE] revealed that she was discharged to a nursing facility.
On 08/16/2023 at 9:41 a.m., an interview and record review was conducted with S3MDS. S3MDS confirmed that resident #46 was discharged to a different nursing facility. A review of Section A of Resident #46's Discharge MDS was reviewed with S3MDS. S3MDS confirmed that Resident #46's discharge status read acute hospital. S3MDS also confirmed that that the resident's MDS was coded incorrectly, and her discharge status should have been coded as discharge to nursing facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to refer all residents with a newly evident or serious mental disorde...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to refer all residents with a newly evident or serious mental disorder, intellectual disability, or a related condition for level II resident review for 1(#10) out of 1 (#10) resident reviewed for Pre-admission Screening and Resident Review (PASARR). The deficient practice had the potential to affect a total census of 43 residents.
Findings:
Resident #10 was admitted to the facility on [DATE] with diagnosis in part: Bipolar Disorder, Diabetes Mellitus II, Major Depressive Disorder, Peripheral Vascular Disease, Panic Disorder and Anxiety Disorder.
A review of Resident #10's Level I Pre-admission Screening and Resident Review dated 06/05/2019 revealed the resident had no mental illness, mental disorder that may lead to chronic disability.
Further review of Resident #10's OBH (Office of Behavioral Health)-PASARR Level II evaluation summary and determination notice dated 06/17/2019 revealed the individual does not have a serious mental illness and a level II is not required.
Review of Resident #10's electronic record revealed on 06/24/2019 she had new diagnosis of Bipolar Disorder and on 11/05/2020 a new diagnosis of Major Depressive Disorder.
On 08/15/2023 at 1:30 p.m., an interview was conducted with S1DON, she confirmed the resident had a diagnosis of Bipolar disorder dated 6/24/2019 and Major Depressive Disorder dated 11/05/2020. She also confirmed the resident did not have a PASARR level II evaluation since diagnosis of Bipolar Disorder on 6/24/2019.
On 08/16/2023 at 12:45 p.m., an interview was conducted with S1DON, she stated the facility did not have a policy on PASARR and the facility follows Louisiana Department of Health guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that 1 resident (#37) was invited to participate in carepl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that 1 resident (#37) was invited to participate in careplan meetings out of a total sample of 23 residents.
Findings:
A review of the facility's policy titled, Care Planning - Interdisciplinary Team read in part: The interdisciplinary team is responsible for the development of resident care plans .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.
Resident #37 was admitted to the facility on [DATE] with diagnoses including: Muscle Wasting and Atrophy, Weakness, Major Depressive Disorder, and Generalized Edema.
A review of a signature list for a care planning meeting conducted by the facility's care team for Resident #37 on 08/10/2023 revealed that the resident or a family representative did not sign the sheet.
On 08/14/2023 at 10:12 a.m., an interview was conducted with Resident #37. The resident stated she didn't know what medicines she was on and had never participated in a care planning meeting.
On 08/15/2023 at 3:33 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated that she was in charge of care planning for Resident #37. S1DON stated the resident or a representative did not attend the care planning meeting on 08/10/2023. S1DON further stated that the resident never attended a care planning meeting and that she had no evidence that the resident or a family representative were invited and refused to attend. S1DON confirmed that Resident #37 or a representative should have been invited to attend care planning meetings but were not invited.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure hospice agencies communicated with facility s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure hospice agencies communicated with facility staff, and maintained and updated the residents' medical record that reflected the services provided for 1 (#20) of 1 (#20) resident that were provided Hospice Services. This deficient practice had the potential to affect the 2 hospice residents who resided in the facility.
Findings:
Record review of the Hospice and Nursing Facility Residential Agreement between the facility and Hospice dated [DATE], read in part, III. Services/ Responsibility to be provide by Hospice: 3.1 (a) .Hospice shall perform an assessment of such resident and shall notify the nursing facility . Hospice shall maintain adequate records of each authorization of Hospice admission.
3.2 Design and Maintenance of Plan of Care: (a) in accordance with applicable Federal and state laws and regulations, Hospice shall coordinate with the nursing facility to develop a Plan of Care for each new residential hospice patient. Hospice shall furnish nursing facility with a copy of the Plan of Care.
V. Records: 5.1 (a) Preparation. Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving nursing facility services and hospice services under the agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state laws and regulations . Each clinical record shall completely, promptly and accurately document all services provided to and events concerning, each residential hospice patient (including evaluations, treatments, progress notes .) Nursing facility and hospice shall cause each entry made for services provided hereunder to be signed by the person providing the services.
Record review of Resident #20's electronic record revealed she was admitted to the facility on [DATE] with an order dated [DATE] to admit to --- hospice for terminal Chronic Obstructive Pulmonary Disease. Her cumulative diagnoses were in part, Anxiety Disorder, Atrial Fibrillation and Unspecified Heart Failure.
Review of Resident #20's Quarterly MDS (Minimum Data Set) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident had intact cognition.
Record review of Resident #20's hospice medical record revealed a Hospice Recertification Statement for the second 90 day period had a benefit period from [DATE] to [DATE], signed by the hospice medical director on [DATE] which Indicated the resident was still considered terminally ill with a life expectancy of 6 months or less if the terminal illness runs it normal course. There was no recertification statement in medical records after [DATE].
Review of the physician's order/plan of care revealed the following: [DATE] SN (Skilled Nurse) visits 2 times a week for 5 weeks and 10 PRN (as needed) for a decline in patient status or crisis, [DATE] SN visit 1 time a week for 1 week, [DATE] SN visit 2 times a week for 4 weeks, [DATE] SN visit 1 time a week for 1 week, and [DATE] SN visits 2 times a week for 2 weeks There were no documentation of an updated care plan for SN visits in the facility's hospice medical binder.
Review of SN routine visit documentation revealed the last documented routine SN visit was dated [DATE].
On [DATE] at 4:00 p.m., an interview was conducted with S1DON, she reviewed the hospice medical records and confirmed the hospice recertification had expired on [DATE] and there was no updated recertification. She confirmed the hospice records in the residents chart were not current.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received services consistent with accepted p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident received services consistent with accepted professional standards by failing to document that a resident's dialysis shunt was assessed daily prior to and after dialysis treatments for 1 (#17) out of 2 residents (#17, #28) investigated for dialysis.
Findings:
Review of the facility's policy titled Arteriovenous Fistula Post Dialysis Care of Internal Access- General Care read in part .Check the fistula for a bruit .or a thrill .Assess for bleeding every day and especially when the resident returns from dialysis. Documentation: Document .thrill or bruit, circulation check of extremity, assessment of site (intact, bleeding, redness, etc.) and any other particular signs/symptoms you note.
Resident #17 was admitted to the facility on [DATE] with diagnoses including but not limited to: End Stage Renal Disease, Type 2 Diabetes, and Essential Hypertension.
Review of Resident #17's August 2023 Physician's Orders revealed an order that read in part: Dialysis on MWF (Monday Wednesday Friday) .Further review of Resident #17's Physician's Orders failed to reveal an order for monitoring or assessment of the resident's dialysis access site.
Review of Resident #17's August 2023's eMAR (Electronic Medication Administration Record) and eTAR (Electronic Treatment Administration Record) failed to reveal evidence that the resident's dialysis access site was assessed.
Review of Resident #17's progress notes failed to reveal evidence that the resident's dialysis access site was assessed.
On 08/15/2023 at 2:45 p.m., an interview and record review was conducted with S10LPN (Licensed Practical Nurse). S10LPN was asked if the nurses documented when they assess the resident's dialysis access site or if they document on the dialysis access site anywhere in the chart. She stated if there were any assessments or documentation, it would be in the weekly skin assessments. S10LPN proceeded to review Resident #17's weekly skin assessments and could not provide any evidence that the nurses documented an assessment of the resident's dialysis access site. S4WC (Wound Care) was asked if an assessment of the access site was performed before and after the resident went to dialysis. S4WC stated that they did not assess or monitor Resident #17's dialysis access site or document on it daily. S4WC and S10LPN provided Resident #17's dialysis communication sheets which did not address the status of the resident's dialysis access before or after dialysis treatment.
On 08/15/2023 02:50 p.m., an interview was conducted with S1DON (Director of Nursing) who confirmed that the nurses did not document assessments or monitoring of the resident's dialysis access site
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, record review and interview the provider failed to post the nurse staffing data at the beginning of each shift, which would reflect current daily totals of the number of hours wo...
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Based on observation, record review and interview the provider failed to post the nurse staffing data at the beginning of each shift, which would reflect current daily totals of the number of hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care.
Findings:
On 08/16/2023 at 10:35 a.m., an observation of the facility walls was conducted for posting of the facility's current daily totals of number of hours worked by categories of licensed and unlicensed nursing staff directly responsible for resident care. There were no postings observed.
On 08/16/2023 at 10:40 a.m., an interview was conducted with S9WC (Ward Clerk), she stated she had the facility's current daily totals of nursing hours lying on the desk at the nurses' station. She reported she is responsible for filling out the daily staff nursing hours. She stated the information for today is not recorded on the form until tomorrow, as they don't know who will call in, so they can't get the actual hours for today.
On 08/16/2023 at 1:22 p.m., an interview was conducted with S8ADMSec (Administrative Secretary). She reported the ward clerk is responsible for documenting the daily nursing staffing hours. She confirmed the hours documented on the form are from the previous day, because they are not able to know what the current staffing hours are until the end of the night, because they don't know if someone will call in.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to maintain a safe, sanitary environment evidenced by:
1.
Failure to ensure cookware was stored in a sanitary manner.
2.
Failure to verify d...
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Based on observations and interviews, the facility failed to maintain a safe, sanitary environment evidenced by:
1.
Failure to ensure cookware was stored in a sanitary manner.
2.
Failure to verify dishwasher temperature and chemical concentration every shift.
The deficient practice had the potential to affect a total of 43 out of 43 residents that were served a meal tray from the kitchen.
Findings:
1. A walk through observation of the kitchen on 08/14/2023 at 8:20 a.m., revealed 2 large pot lids and 1 oven rack on the floor.
An immediate interview on 08/14/2023 at 8:20 a.m., with S2DM (Dietary Manager) who confirmed the pot lids and oven rack were on the floor and should not have been.
2. Further observation of the kitchen on 08/14/2023 revealed an log titled, Dishwasher Temperature/Chemical Record .Month: August 2023. The Lunch temperature and chemical readings were missing 11 days out of 13 days. The Dinner temperature and chemical readings were missing for 9 days out of 9 days.
An immediate interview was conducted with S2DM who confirmed the temperature and chemical readings were not done and verified they should be done for every meal.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure Agency CNA's (Certified Nursing Assistant's) completed annual in-service training including Dementia, Resident Rights, HIPPA (Heal...
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Based on record reviews and interviews, the facility failed to ensure Agency CNA's (Certified Nursing Assistant's) completed annual in-service training including Dementia, Resident Rights, HIPPA (Health Insurance Portability and Accountability Act), Infection Control, and Abuse/Neglect Prevention for 3 (S5CNA, S6CNA, S7CNA) out of 3 (S5CNA, S6CNA, S7CNA) sampled Agency CNA's personnel files reviewed.
Findings:
Review of S5CNA's personnel file revealed no start date. Further review of personnel file revealed S5CNA had not completed Abuse/neglect or HIPAA training since on 09/20/2016. Further review revealed no education verification provided for Dementia training, infection control or resident rights.
Review of S6CNA's personnel file revealed no start date. Further review of personnel file revealed no education verification provided for Dementia training, infection control or resident rights.
Review of S7CNA's personnel file revealed no start date. Further review of personnel file revealed S5CNA had not completed HIPAA training since 05/28/2010. Further review revealed no education verification provided for Dementia training, infection control or resident rights.
Review of in-service training for Infection Control and Dementia: a signage sheet of in-service dated 03/23/2023, did not have a signature for S5CNA, S6CNA or S7CNA.
On 08/16/2023 at 12:48 p.m., an interview was conducted with S1DON, she reported the agency providing staff to facility was responsible for ensuring the staff are trained and competencies are completed, prior to the agency staff working at the facility. She also reported S8ADMSec is responsible for agency staff personnel files.
On 08/16/2023 at 1:22 p.m., an interview was conducted with S8ADMSec, she confirmed she is responsible agency staff personnel files. She reported the agency provided the education/training to the agency staff. She confirmed the agency staff did not have documented required trainings of Dementia training, HIPAA, resident Rights and Infection training in their personnel files and they should have had the required annual trainings in their personnel files.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
- • 33% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Gueydan Memorial Guest Home's CMS Rating?
CMS assigns GUEYDAN MEMORIAL GUEST HOME an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Gueydan Memorial Guest Home Staffed?
CMS rates GUEYDAN MEMORIAL GUEST HOME's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 33%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Gueydan Memorial Guest Home?
State health inspectors documented 26 deficiencies at GUEYDAN MEMORIAL GUEST HOME during 2023 to 2025. These included: 26 with potential for harm.
Who Owns and Operates Gueydan Memorial Guest Home?
GUEYDAN MEMORIAL GUEST HOME is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 66 certified beds and approximately 52 residents (about 79% occupancy), it is a smaller facility located in GUEYDAN, Louisiana.
How Does Gueydan Memorial Guest Home Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, GUEYDAN MEMORIAL GUEST HOME's overall rating (2 stars) is below the state average of 2.4, staff turnover (33%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Gueydan Memorial Guest Home?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Gueydan Memorial Guest Home Safe?
Based on CMS inspection data, GUEYDAN MEMORIAL GUEST HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Gueydan Memorial Guest Home Stick Around?
GUEYDAN MEMORIAL GUEST HOME has a staff turnover rate of 33%, 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 Gueydan Memorial Guest Home Ever Fined?
GUEYDAN MEMORIAL GUEST HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Gueydan Memorial Guest Home on Any Federal Watch List?
GUEYDAN MEMORIAL GUEST HOME 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.