Does St Joseph of Harahan have any serious inspection findings?

Yes, St Joseph of Harahan has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 52 total deficiencies from recent inspections.

What are the staffing levels at St Joseph of Harahan?

St Joseph of Harahan has a one-star staffing rating from CMS with 0.09 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is St Joseph of Harahan located?

St Joseph of Harahan is located in Harahan, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does St Joseph of Harahan have?

St Joseph of Harahan has 206 certified beds.

Who owns St Joseph of Harahan?

St Joseph of Harahan is a for profit - limited liability company facility and is part of the PLANTATION MANAGEMENT COMPANY chain.

What questions should families ask when visiting St Joseph of Harahan?

Families visiting St Joseph of Harahan should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does St Joseph of Harahan compare to other nursing homes?

St Joseph of Harahan has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

St Joseph of Harahan

Name: St Joseph of Harahan
Address: 405 Folse Drive, Harahan, LA, 70123, US
Telephone: (504) 738-7676
Rating: 1.0

405 Folse Drive, Harahan, LA 70123 · (504) 738-7676

For profit - Limited Liability company 206 Beds PLANTATION MANAGEMENT COMPANY Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

8/100

#249 of 264 in LA

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Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

St. Joseph of Harahan has received a Trust Grade of F, indicating significant concerns about its care and quality, which places it among the poorest-rated facilities. It ranks #249 out of 264 nursing homes in Louisiana and #10 out of 12 in Jefferson County, meaning it is in the bottom tier of options available. While the facility's issues are improving, with problems decreasing from 28 in 2024 to 8 in 2025, there are still serious concerns, including $274,845 in fines, which is higher than 87% of Louisiana facilities. Staffing is a weakness, with only 1 out of 5 stars and a 56% turnover rate, suggesting that staff may not stay long enough to build strong relationships with residents. Specific incidents of concern include a resident with dementia who fell and fractured her femur due to inadequate supervision and meals being served late or at improper temperatures due to insufficient dietary staffing. Additionally, there was a failure to report an allegation of abuse within the required timeframe, which raises serious concerns about resident safety.

Trust Score: F
In Louisiana: #249/264
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $274,845 in fines. Lower than most Louisiana facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 5 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 52 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 28 issues

2025: 8 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: 56%

10pts above Louisiana avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $274,845

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: PLANTATION MANAGEMENT COMPANY

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (56%)

8 points above Louisiana average of 48%

The Ugly 52 deficiencies on record

1 life-threatening

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

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Based on interviews, and record review, the facility failed to provide the resident representative (RR) with the facility's written bed-hold policy at the time of transfer to the hospital as required for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for discharge rights. Findings: Review of the facility's Resident Leave and Bed-Hold Policy and Procedure effective 04/27/2020 revealed, in part, the bed-hold policy must be issued at the time of the transfer from the facility. Further review revealed in cases of emergency transfer, notice at time of transfer meant family, surrogate, or representative were provided with written notification within 24 hours of the transfer. In an interview on 05/20/2025 at 12:08PM, S2Social Services (SS) indicated Resident #2 had an emergency transfer to the hospital due to behaviors on 02/27/2025. S2SS further indicated she mailed the facility's bed-hold policy to Resident #2's RR. S2SS indicated she did not call Resident #2's RR to see if Resident #2's RR received the mailed bed-hold policy. There was no documented evidence, and the facility was unable to present any documented evidence, the facility provided Resident #2's RR the written bed-hold policy within 24 hours of Resident #2's emergent transfer to the hospital. In an interview on 05/20/2025 at 12:39PM, S1Administrator indicated the bed- hold policy was included in Resident #2's transfer packet which was given to the behavioral health hospital. S1Administrator further indicated Resident #2 would probably not be able to understand the facility's bed-hold policy.

Apr 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews, the facility failed to immediately notify the resident's representative of a resident's injury of unknown origin for 1 (Resident #1) of 2 (Resident #1, Resident #2) sampled residents investigated for injuries of unknown origin. Findings: In an interview on 04/16/2025 at 8:30AM, S5Licensed Practical Nurse (LPN) indicated on 04/02/2025 at 8:04AM she assessed Resident #1 with right arm immobility and pain, and administered a standing order of Tylenol. S5LPN indicated Resident #1 had complaints of pain later in the day, and an x-ray was ordered at 1:30PM by Resident #1's physician. S5LPN confirmed Resident #1's daughter who was Resident #1's Responsible Party (RP) was not notified of Resident #1's change in condition or of the new physician's orders. Review of Resident #1's record revealed no documented evidence, and the facility was unable to present any documented evidence Resident #1's RP was notified of Resident #1's change in condition or new physician's orders. In an interview on 04/15/2025 at 2:51PM, Resident #1's RP indicated she was informed of Resident #1's right arm fracture on 04/02/2025 at approximately 6:00PM. Resident#1's RP indicated she wondered why she was notified at 6:00PM when Resident #1's arm pain began at 8:00AM in the morning. In an interview on 04/16/2025 at 3:15PM, S3Director of Nursing (DON) indicated Resident #1's Representative was notified at 6:00PM, after the facility received the results of the x-ray and not when Resident #1 was assessed with right arm immobility and pain or when Resident #1's x-ray order was placed.

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews, the facility failed to implement its policy for Abuse Prevention and Prohibition by not thoroughly investigating an injury of unknown origin for 1 (Resident #1) of 2 (Resident #1, Resident #3) sampled residents investigated for injuries of unknown origin. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure dated 03/25/2023 revealed, in part, the facility's process following an injury of unknown origin was that the Administrator would complete a thorough investigation. In an interview on 04/14/2025 at 12:50PM, S1Administrator indicated she was made aware of the results of Resident#1's x-ray, which revealed a fractured right arm, at 5:20PM on 04/02/2025, and S1Administrator began an investigation due to Resident #1's identified injury of unknown origin. S1Administrator indicated her review of surveillance camera footage revealed on 04/02/2025 at 7:00AM Resident #1 was ambulating out of her room using a rollator with no apparent issues, assisted into shower room by S10Shower Aide at 7:00AM approximately. Further review revealed surveillance camera footage showed Resident #1 was assisted out of shower room at 7:45AM by S10Shower Aide and left seated on her rollator in hallway. In an interview on 04/16/2025 at 12:04PM, S1Administrator indicated she thought her investigation of the facility video surveillance footage was thorough because she used the facility's video surveillance footage to pinpoint a time when the resident showed a change in condition related to her right arm. S1Administrator further indicated during her investigation, she observed Resident #1 enter the shower room and exit the shower room. S1Administrator indicated she did not consider or had a reason to determine if Resident #1 could have been left alone in the shower room. S1Administrator indicated she only viewed Resident #1's condition upon entrance and exit of the shower room, but not when S10CNA entered and exited the shower room. S1Administrator indicated she viewed the surveillance camera video at 16 speed the normal video speed and may have missed if S10CNA left Resident #1 unattended in the shower room. S1Administrator indicated the video surveillance footage was no longer available, and S1Administrator was unable to determine if Resident #1 was left unattended in the shower room.

Mar 2025 5 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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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 each resident received adequate supervision to prevent accidents for 1 (Resident #115) of 2 (Resident #115, Resident #165) sampled residents reviewed for wandering behaviors. This deficient practice resulted in an Immediate Jeopardy (IJ) situation on 03/05/2025 at 8:46PM, when Resident #115, identified as a wanderer with dementia and cognitive communication deficits requiring supervision with walking, was unsupervised when she wandered into Resident #105's room and sustained a fall. Resident #115's fall resulted in an acute right femur fracture that required surgical intervention and rehabilitation. As a result of the fall, Resident #115 was required to use a wheelchair and experienced decreased mobility and independence. S1Administrator was notified of the Immediate Jeopardy on 03/26/2025 at 3:05PM. The Immediate Jeopardy was removed on 03/27/2025 at 10:35AM, after it was verified through observations, interviews, and record reviews, that the facility implemented an acceptable Plan of Removal prior to the exit of the survey. This deficient practice had the likelihood to cause more than minimal harm to the 12 residents who resided in the facility and were identified as wanderers. Findings: Review of Resident #115's hospital record dated 03/06/2025 revealed, in part, Resident #115 was diagnosed with a displaced fracture of right femoral neck. Further review revealed Resident #115 had a right hip hemiarthroplasty (partial hip replacement surgery) to repair fracture. Review of Resident #115's Electronic Medical Record (EMR) revealed, in part, Resident #115 was admitted to the facility on [DATE] with a diagnoses of dementia, and cognitive communication deficit. Review of Resident #115's Minimum Data Set with an Assessment Reference Date of 02/26/2025 revealed, in part, Resident #115's Brief Interview for Mental Status should not be conducted and Resident #115 is rarely or never understood. Further review revealed Resident #115 required staff supervision or touching assistance with walking 10 feet, 50 feet, and 150 feet. Review of Resident #115's care plan with a revision date of 01/09/2025 revealed, in part, Resident #115 was at risk for falls r/t confusion and poor communication/comprehension. Review of Resident #115's Long Term Care Evaluation dated 01/23/2025 revealed, in part, Resident #115 wanders at night. Review of Resident #115's progress note dated 03/05/2025, revealed, in part, on 03/05/2025 at 8:46PM, revealed Resident #115 wandered into another residents (Resident #105) room and when he (Resident #105) was trying to get her (Resident #115) out of his room she (Resident #115) fell on the ground. Review of the facility's incident report submitted on 03/10/2025 revealed, in part, Resident #115 had a fall on 03/05/2025 and returned to the facility with a fracture to the right hip. Further review revealed, in part, S1Administrator wrote: Resident #115 was found on the floor in Resident #105's room. S11CNA reported that Resident #105 pushed Resident #115 to the floor, but S11CNA did not see this happen. Resident #115 does have behavior of wandering throughout the day. Further review revealed after the fall, Resident #115 was noted to have pain to the right leg and back upon initial assessment and was sent to the Emergency Department. Resident #115 was not able to state what occurred. S11CNA stated that she observed Resident #115 walking in and out of resident's rooms about 30 minutes prior to incident. S11CNA said she saw Resident #105 walking toward Resident #115 with his hands up, when he was close enough he put his hands on her shoulder. The amount of force, if any, that Resident #105 used when he touched Resident #115's shoulder cannot be determined. Review of S11CNA's written and signed fall investigation questionnaire revealed, in part: -What was Resident #115 doing? Resident #115 was walking in and out of rooms. Review of S15Licensed Practical Nurse (LPN) written and signed fall investigation questionnaire revealed, in part: -What time did you last see Resident #115 before the fall? The last time I saw Resident #115 before she fell, Resident #115 was walking down towards the end of the hall. -What was Resident #115 doing? Resident #115 was walking into different resident rooms. In an interview on 03/24/2025 at 10:28AM, S22Rehab Director indicated Resident #115 had a right hip fracture after a fall. S22Rehab Director further indicated since the fall rehab staff have been working on Resident #115's gait (refers to the manner or style of a person's walking or movement), balance, transfers and bed mobility. In a telephone interview on 03/25/25 at 3:33PM, S11CNA indicated that she tried to redirect Resident #115 several times but she did not stop wandering in other residents rooms. S11CNA further indicated while doing rounds she heard Resident #105 telling Resident #115 to get out of his room. S11CNA indicated when she arrived to Resident #105's room, she observed Resident #105's hands extended in front of him out towards Resident #115 while she was falling to the floor. S11CNA indicated she did not witness Resident #105 push Resident #115 to the floor. S11CNA indicated Resident #115 wandered into other resident's rooms most times she has worked with her. In a telephone interview on 03/25/25 at 10:06AM, S15LPN indicated on 03/05/2025 prior to Resident #115's fall, Resident #115 was re-directed a few times from walking into other resident's room. S15LPN indicated later in the shift S11CNA informed her that Resident #115 fell inside Resident #105's room. S15LPN indicated Resident #115 was guarding and grimacing after the fall and had to be sent to the hospital. S15LPN indicated it was hard to supervise Resident #115 because she wandered a lot. In interview on 03/25/2025 at 1:39PM, S1Administrator stated staff was redirecting and providing activities to Resident #115 to keep her from wandering, but Resident #115 continued to walk the halls and go into other resident's rooms. S1Administrator further indicated they did everything they possibly could short of 1:1 supervision to keep the resident safe. In interview on 03/26/25 at 11:27AM, S3DON stated that the fall occurred after supper and staff were rounding and getting residents ready for bed. S3DON also indicated Resident #115 can be redirected and put in her bed, but would still wander. S3DON further indicated the next level of supervision would be 1:1 supervision but we don't provide 1:1 supervision at the facility, and there were a lot of residents that wander. A Plan of Removal was accepted on 03/27/2025 at 10:35AM, which included the following actions to correct the deficient practice: The facility identified those who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: -12 Residents have been identified as wanderers, identified as Residents 1-12. One of these residents is currently in the hospital. Date completed 03/26/2025. Actions that the facility will take: -Photos taken of all residents and made available at nurses' stations and the reception desk to identify residents 1-12 who are at risk for wandering. Date completed 03/26/2025. -Additional staff, hall monitor, added to stay on the 2nd floor hall and visually observe and document observation of residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. During meal times, the monitoring of residents 1-12 will be handed off to CNA's and LPNs assigned to monitor the dining room and the hall monitor will remain on the hall to continue monitoring any of residents 1-12 that remain in their room for meals. Date begun 03/26/2026 and ongoing. Education/Training Plan: -Staff will be in-serviced on who the 12 residents are that are at risk for wandering, the need to visually observe residents 1-12 to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls, and methods for cueing, redirection, offering activities/snacks, and for what to do if a resident cannot be redirected. Date begun 03/26/2025 and ongoing until all staff are in-serviced. -Hall monitor will be trained on residents 1-12 at risk for wandering. How to monitor residents 1-12 every 30 minutes to prevent the likelihood of serious injury, serious harm, serious impairment, or death from falls. How to cue, redirect or offer activities/snacks, how to document on monitoring form, and how to handle meal time. Also trained on what to do if a resident cannot be redirected. Date begun 03/26/2025 and ongoing with each new hall monitor assigned. The facility asserts that the likelihood of serious harm to residents no longer exist as of 03/26/2025 at 6:00PM.

CONCERN (E) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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Based on interview and record reviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency within the required two hour timeframe for 2 (Resident #105, Resident #115 ) of 4 (Resident #51, Resident #105, Resident #115, Resident #187) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure dated 03/25/2023 revealed, in part, the administrator shall immediately initiate a Statewide Incident Management System (SIMS) report to the Louisiana Department of Health, but not less than 2 hours after forming a suspicion of a crime if the alleged violation involves abuse (physical abuse) or results in serious bodily injury. Review of the Louisiana Department of Health (LDH) Health Standards Incident Report #272956 revealed, in part, an allegation of physical abuse involving Resident #115 and Resident #105: -Occurred on 03/05/2025 at 11:14 PM; -Was entered into the SIMS reporting system on 03/10/2025 at 4:40PM. In an interview on 03/25/2025 at 10:48AM, S1Administrator confirmed the facility did not report an allegation of physical abuse involving Resident #115 and Resident #105 to the State Survey Agency within two hours and should have.

CONCERN (E) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure Resident #47's care planned fall interventions were implemented; and 2. Ensure Resident #115 a known wanderer, had a care plan developed for wandering. This deficient practice was identified 2 (Resident #47, Resident #115) of 5 (Resident #30, Resident #47, Resident #51, Resident #115, Resident #187) sampled residents reviewed for accidents. Findings: 1. Resident #47 Review of Resident #47's medical record revealed, in part, Resident #47 had an unwitnessed fall on 03/05/2025 while transferring from her bed to her wheelchair unassisted. Further review revealed Resident #47's fall on 03/05/2025 resulted in a left hip fracture. Review of Resident #47's Significant Change Minimum Data Set (MDS) and State Optional Assessment with an Assessment Reference Date (ARD) of 03/18/2025 revealed, in part, Resident #47 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated Resident #47 was cognitively intact, required extensive assistance with two person physical assistance for transfers, toileting, and had a hip fracture. Review of Resident #47's physician orders revealed, in part, an order for a fall mat every shift with a start date of 03/07/2025. Review of Resident #47's care plan revealed, in part, a plan of care was initiated 09/30/2024 for risk for falls related to deconditioning, and gait/balance problems. The plan of care was revised on 03/05/2025 due to an unwitnessed fall which included an intervention for bright colored tape to #47's wheelchair brakes. Observation on 03/25/2025 at 4:00PM revealed, in part, there was no fall mat in Resident #47's room. Observation on 03/26/2025 at 8:40AM revealed, in part, Resident #47 was sitting in wheelchair there was no fall mat in Resident #47's room, and there was no bright colored tape on the brakes of Resident #47's the wheelchair. Observation on 03/27/2025 at 10:00AM revealed, in part, Resident #47 was lying in bed. Further observations revealed no fall mat in Resident #47's room, and there was no bright colored tape on the brakes of Resident #47's wheelchair. In an interview on 03/26/2025 at 8:45AM, S10Certified Nursing Assistant indicated she was not aware Resident #47 required a fall mat in her room or bright colored tape to her wheelchair to decrease the risk of falls. In an interview on 03/27/2025 at 10:00AM, Resident #47 indicated she never had a fall mat next to her bed, or bright colored tape to the brakes on her wheelchair to decrease the risk of falls with injury. In an interview on 03/27/2025 at 10:10AM, S8Licensed Practical Nurse (LPN) indicated he was not aware Resident #47 had orders for a fall mat, or required bright colored tape to the brakes on her wheelchair to decrease the risk of falls with injury. In an interview on 03/27/2025 at 10:20AM, S3Director of Nursing (DON), confirmed Resident #47 did not have a fall mat in her room, and did not have bright colored tape to the brakes of Resident #47's wheelchair. S3DON furthered indicated Resident #47 should have had a fall mat and bright colored tape to the brakes of her wheelchair as specified in the physician's orders and care plan. 2. Resident #115 Review of Resident #115's medical record revealed, in part, Resident #115 had an unwitnessed fall on 03/05/2025 while wandering in another resident's (Resident #105) room. Further review revealed Resident #115 had a fall in Resident #105's room on 03/05/2025 that resulted in a right hip fracture. Review of Resident #115's medical record revealed, in part, Resident #115 was admitted to the facility on [DATE] with a diagnoses of dementia, and cognitive communication deficit. Review of Resident #115's Minimum Data Set with an Assessment Reference Date of 02/26/2025 revealed, in part, Resident #115's Brief Interview for Mental Status should not be conducted and Resident #115 is rarely or never understood. Review of Resident #115's Long Term Care Evaluation dated 01/23/2025 revealed, in part, Resident #115 wanders at night. Review of Resident #115's care plan revealed no documented evidence and the facility did not present any documented evidence Resident #115 had a care plan developed to address the risks and interventions for wandering. In an interview on 03/26/2025 at 11:27AM, S3DON indicated Resident #115 was a known wanderer and was not care planned for wandering but should have been. In an interview on 03/27/2025 at 3:01 PM, S18Minimum Data Set (MDS) Nurse indicated Resident #115 was not care planned for wandering and should have been.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on record reviews and interviews, the facility failed to administer a medication as ordered by the physician for 1 (Resident #116) of 4 (Resident #97, Resident #116, Resident #177, Resident #204) sampled residents reviewed for hospitalization. Findings: Review of the facility's policy and procedure on Medication Administration with an effective date of 10/04/2024, revealed, in part, nursing personnel shall ensure the safe and effective administration of medications. Further review revealed, prior to administration, the nursing staff member administering the medication shall ensure medications match the physician's orders and label, and that the proper dose was administered. Review of Resident #116's medical record revealed he had the following diagnoses, in part, of Congestive Heart Failure, Hypertensive Heart Disease with Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident #116's physician orders dated 11/12/2024, revealed, in part, to increase Digoxin (medication used to treat congestive heart failure) to 250 micrograms (mcg) to three times a day and repeat Digoxin level (a blood test to determine the amount of digoxin in your body at a certain time) on 11/21/2024. Record review revealed on 11/20/2024, revealed Resident #116 was transferred to a local hospital per physician orders for an elevated Digoxin Level of 4.2 nanograms per milliliter (ng/ml). Further review revealed the normal range was 0.9-2.0 ng/ml. In an interview on 03/27/2025 at 11:22AM, S3Director of Nursing (DON) indicated Resident #116 did not receive the correct dose of Digoxin as ordered by the physician. S3DON also indicated on 11/12/2024 the physician wrote an order to increase Resident #116's Digoxin to 250mcg three times a day and the order for 125mcg three times a day should have been discontinued. S3DON indicated the order for Digoxin 125mcg three times a day was not discontinued, so Resident #116 received Digoxin 250mcg and Digoxin 125 mcg by mouth three times a day from 11/12/2024 at 8:00PM to 11/18/2024 at 2:00PM. In an interview on 03/27/2025 at 6:20PM, S24Licensed Practical Nurse (LPN) acknowledged Resident #116 did not get her Digoxin medication as ordered by the physician, and should have.

CONCERN (F)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

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Based on observations, interviews, and record review, the facility failed to maintain adequate dietary staffing levels to ensure the timely preparation and delivery of resident meals by failing to ensure: 1. breakfast was served in a timely manner; and 2. lunch was served at an appropriate palatable temperature. Findings: 1. Review of the facility's posted undated Meal Times form revealed the following, in part: Dining Room II: Breakfast 7:00AM, Lunch 12 noon, and Supper 5:00PM Dining Room I: Breakfast 7:00AM, Lunch 12 noon, and Supper 5:30PM West I : Breakfast 7:45AM, Lunch 12 noon, and Supper 5:45PM Observations in the kitchen on 3/24/25 at 8:40AM, revealed 2 staff preparing meals for hallway carts. In an interview on 03/24/2025 at 8:40AM, S7Assistant Dietary Manager indicated one staff member called in, the Dietary Manager was on her way back from an appointment, and the kitchen was already short staffed. Observations during dining facility task on 3/24/25 starting at 12:50PM, revealed some residents had not been served in both dining areas. Further observations revealed meal carts had arrived to the first and second floor hallways after 1:00PM. Observations on 03/24/2025 at 1:20PM, revealed 2 staff members started to pass trays on the second floor east hall. S9Certfied Nursing Assistant (CNA) indicated meals had just been passed on the second floor west hall. When asked about meal times, S9CNA answered that for the last month or two the breakfast carts have arrived on the floor around 9:00AM on most days, and the lunch carts have arrived around 12:45PM. Observations were continued until 1:54PM when the last tray remained and the surveyor requested the tray for further observation. In an interview on 3/24/25 at 1:40PM, Resident #164 indicated he eats in his room and breakfast and lunch are always late. Resident #164 indicated breakfast was after 930AM and lunch is after 1:45PM at least 3 days per week. Observation on 03/24/25at 1:29PM, revealed, in part, food cart for 100 hall arrived and trays were passed out to Residents in their rooms by S25CNA. In an interview on 3/24/25 at 2:10PM, Resident #134 indicated breakfast and lunch were always late. Resident #134 stated he ate in the dining area so he could get his meals faster. Resident #134 indicated if he ate in his room, breakfast would not get to him until 9:30AM-9:45AM and it would be cold and the grits would be hard as a rock; and lunch would definitely be served closer to 2:00PM at least 2-3 days per week. Observation on 03/25/2025 at 8:20AM, revealed breakfast trays were placed on hall carts and sent out from the kitchen by kitchen staff. In an interview on 03/26/2025 at 7:25AM, S6Dietary Manager acknowledged that breakfast was not served in the dining areas by 7:45AM and on the halls by 8:30AM. S6Dietary Manager further indicated lunch was not served by 12:45PM on 03/24/2025. S6Dietary Manager also indicated the kitchen has had daily call-ins from staff, and the kitchen was already not sufficiently staffed. Observation on 03/26/25 at 8:20AM, revealed breakfast trays were placed on hall carts and sent out from the kitchen by kitchen staff. In an interview on 03/27/2025 at 3:45PM, S7Assistant Dietary Manager indicated the posted meal time form times were correct, and [NAME] 1 represented the hallways. S7Assistant Dietary Manager acknowledged that breakfast was not served at 7:00AM, and lunch was not served at 12:00PM, the times listed on the Meal Time form. S7Assistant Dietary Manager further indicated that breakfast has been served after 8:30AM and lunch has been served after 1:00PM for the past few weeks. In an interview on 03/27/2025 at 4:10PM, S2Assistant Administrator indicated the meal time form presented at entrance has not been changed or modified, so the breakfast times were 7:00AM for dining rooms, 7:45AM for [NAME] 1 and halls, and lunch was 12:00Pm everywhere. 2. Observation on 03/24/2025 at 1:42PM of last tray passed on hall b, delivered by S25CNA, for room a, revealed the food was not at a palatable temperature. Observation on 03/24/2025 at 1:45PM revealed in part, S6Dietary Manager performed temperature checks to the above mentioned tray. Further observation revealed the macaroni temperature was 90 degrees Fahrenheit and the okra temperature was 88 degrees Fahrenheit. In an interview on 03/24/2025 at 1:45PM, S6Dietary Manager indicated the macaroni and the okra temperatures were not palatable and the temperatures should be maintained between 160 degrees Fahrenheit - 165 degrees Fahrenheit until served. In an interview on 03/24/25 at 2:10PM, Resident #134 indicated if he ate in his room, breakfast would not get to him until 9:30AM-9:45AM and it would be cold and the grits would be hard as a rock.

Oct 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to ensure maintenance staff secured electrical wall sockets in 3 (Room a, Room b, and Room c) of 4 (Room a, Room b, Room c, and Room d) rooms; and 2 (Hall X and Hall Y) of 4 (Hall W, Hall X, Hall Y, and Hall Z) halls observed for physical environment. Findings: Observation on 10/28/2024 at 9:15 a.m., revealed an electrical wall socket located in Room a was not secured to the wall. Observation on 10//28/2024 at 10:15 a.m. of the Hall W, Hall X, Hall Y, and Hall Z revealed the following: - Hall X had one electrical wall socket not secured to the wall; and - Hall Y had three electrical wall sockets not secured to the wall. Observation of Room b on 10/28/2024 at 10:15 a.m., revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further observation revealed there were two electrical plugs which were plugged into the electrical socket. Observation on 10/28/2024 at 10:25 a.m. of Room c revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further observation revealed there were two electrical plugs which were plugged into the electrical socket. Further observation revealed on the wall opposite the head of the bed revealed an electrical wall socket not secured to the wall. Observation of Room b on 10/28/2024 at 2:30 p.m. revealed the electrical wall socket located at the head of the bed was not secured to the wall. Further observation revealed there were two electrical plugs which were plugged into the electrical socket. Observation on 10/28/2024 at 2:40 p.m. of Room c revealed the electrical wall socket located at the head of the bed was not secured to the wall. Observation also revealed there were two electrical plugs which were plugged into the electrical socket. Further observation revealed on the wall opposite the head of the bed revealed an electrical wall socket not secured to the wall. In an interview on 10/28/2024 at 3:30 p.m., S3Maintenance Supervisor indicated the electrical wall sockets in Hall X, Hall Y, Room a, Room b, and Room c were not secured to the wall, and should have been. In an interview on 10/29/2024 at 9:50 a.m., S4CNA indicated she had noted electrical wall sockets in the hallways were not secured to the wall when plugging and unplugging the microwave during meal service. In an interview on 10/29/2024 at 9:45 a.m., S7Licensed Practical Nurse (LPN) indicated he noted an electrical wall socket in Hall X was not secured to the wall. In an interview on 10/29/2024 at 10:30 a.m., S2Administrator indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been. In an interview on 10/29/2024 at 10:31 a.m., S5Regional Maintenance Director indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been. In an interview on 10/29/2024 at 10:33 a.m., S6Electrical Contractor indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been. In an interview on 10/29/2024 at 10:35 a.m., S1Regional Administrator indicated the above mentioned electrical wall sockets were not secured to the wall, and should have been.

Sept 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident received care and services to prevent falls as much as possible by failing to develop new individualized interventions after a resident sustained a fall. This deficient practice was identified for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for falls. Findings: A review of the facility's incident reports for the past 60 days revealed, in part, a fall by Resident #1 on 08/06/2024; falls by Resident #2 on 08/12/2024, 08/22/2024, and 08/30/2024; and falls by Resident #3 on 07/26/2024, 08/02/2024, and 09/01/2024. Review of the facility's Fall Prevention Program Policy and Procedure (10/22/2014) revealed, in part, the fall prevention program is an individualized daily plan to promote safety of residents who have been identified as high risk for Falls via interdisciplinary team determination. All residents will be assessed upon readmit, quarterly, annually, if significant change occurs, and as needed; residents on the program will have care plan addressing goals and approaches. Review of the facility's Care Plan Policy and Procedure (05/22/2017) revealed, in part, the care plan will be revised on an on-going basis to reflect changes in the resident and the care that the resident is receiving; interventions are to be implemented to prevent avoidable declines, and to reserve and build resident strengths. Resident #1 Resident #1, a [AGE] year old English-speaking African American female, was admitted [DATE] with readmission on [DATE], with diagnoses which included hypertensive heart disease without heart failure and dementia. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 revealed, in part; Resident #1 had a Brief Mental Status exam score of (BIMS) 4, which indicated severe cognitive impairment, with no signs or symptoms of delirium; Patient Health Questionnaire (PHQ9) of 0, which indicated there were no symptoms of depression; no hallucinations, delusions, or potential indicators of psychosis. Resident #1 did not reject care or wander. Resident #1 was able to make her needs known, although she was confused about actual events occurring. Resident #1 had a fall on 08/06/2024, which resulted in hospital admission. She was readmitted to the facility on [DATE]. New interventions were not implemented on Resident #1's care plan to prevent future falls. Review of Resident #1's medical record revealed a fall risk assessment dated [DATE] with a score of 10; resident was added to the fall program due to her recent fall. On 09/04/2024 at 1:09 p.m., S5LPN indicated Resident #1 mostly takes care of herself, ambulates, changes herself, feeds herself, and doesn't need much assistance from staff. In an interview on 09/04/2024 at 1:20 p.m., S4CNA stated Resident #1 was pretty independent, and was trying to move herself into her own wheelchair when she fell to the floor. She was sent to the hospital for evaluation. Resident #2 Resident #2 is a [AGE] year-old African American English-speaking male, admitted on [DATE], with admitting diagnosis of Pneumonia. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/2024 revealed, in part; Resident #2 had a BIMS of 10, PHQ9 of 00, with no hallucinations, delusions, or indications of psychosis. Resident #2 did not reject care or wander. Resident #2 is able to make his needs known. Resident #2 had falls on 07/05/2024, 07/10/2024, 07/26/2024, 08/02/2024, and 09/01/2024. New interventions were not implemented on Resident #2's care plan after each fall to prevent future falls. Review of Resident #2's medical record revealed a fall risk assessment dated [DATE] with a score of 12; resident was not added to the fall program. In an interview on 09/04/2024 at 1:24 p.m., S6LPN stated Resident #2 falls often because he tries to go to the bathroom unassisted, not calling for help; he thinks he can do it alone. S6LPN stated Resident #2 has left sided weakness s/p CVA, that his expectations are not realistic. Resident #3 Resident #3 is a [AGE] year-old English-speaking white female of Hispanic/Latin/Spanish origin who was admitted to the facility on [DATE], with readmission on [DATE]; with diagnoses which include acute on chronic diastolic heart failure, schizophrenia, sepsis, shortness of breath. Review of Resident #3's Minimum Data Set (MDS) Assessment Reference Date (ARD) 08/24/2024 revealed, in part; Resident #3 had a BIMS of 10, and a PHQ9 of 0; No hallucinations or delusions, no potential indicators of psychosis; no physical, verbal, or other behavioral symptoms exhibited; no rejection of care; no wandering exhibited. Resident #3 is able to make her needs known, although she is often confused about events occurring and will at times exhibit behaviors (e.g. throwing herself on the floor). Resident #3 had falls on 07/07/2024, 08/22/2024, 08/23/2024, and 08/30/2024. New interventions were not implemented on Resident #3's care plan after each fall to prevent future falls. Review of Resident #3's medical record revealed a fall risk assessment dated [DATE] with a score of 7; resident was not added to the fall program. In an interview on 09/04/2024 at 1:36 p.m., S7LPN stated resident #3 is always confused. For her recent fall, the care manager said she needed help to reposition her, because she said she would throw herself on the floor - and then she did throw herself on the floor, within 1 minute of making the statement. She did the same the next day. In an interview on 09/06/2024 2:30 p.m. S3Assistant Director of Nursing stated the facility had recently begun implementing new procedures regarding interventions for falls in June. She acknowledged that not all the falls listed on the care plans since June had appropriate individualized interventions for each fall sustained, and they should. In an interview on 09/06/2024 2:33 p.m. S2DON acknowledged not all the falls listed on the care plans since June had appropriate individualized interventions for each fall sustained, and they should.

Jul 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was free from verbal abuse for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents. Findings: Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure revealed, in part, each resident has the right to be free from abuse. Further review revealed verbal abuse was defined as the use of oral, written or gestural language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance or sight, regardless of the resident's age, ability to comprehend, or disability and examples included name calling, cursing, or yelling at a resident in anger. Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnosis, in part of Alzheimer's Dementia. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 06/12/2024 revealed, in part, he had a Brief Interview Mental Status Score of 7 which indicated moderate cognitive impairment. Review of S5Certified Nursing Assistant's (CNA) separation notice dated 06/21/2024 revealed, in part, the reason for separation was verbal abuse towards a resident. Further review revealed the Director of Nursing (DON) overhead S5CNA telling a resident to Shut the F*** up and when the DON questioned her, S5CNA indicated the resident cursed her so she told him to Shut the F*** up. In an interview on 07/02/2024 at 12:21 p.m., S2DON indicated she overheard S5CNA tell Resident #3 to Shut the F*** up when she was passing by the room. S2DON further confirmed this was considered verbal abuse and it should not have occurred.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene prior to providing catheter care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's Catheter Care, Indwelling Catheter Policy and Procedure dated 08/24/2016 revealed, in part, hand hygiene should be performed and gloves put on prior to the procedure. Further review the next step was to inspect the catheter at the urinary meatus and not any problems, then cleanse the perineal area with soap and water or a perineal wipe taking care to wash from front to back. Cleanse the area well at the insertion site and remove all debris form the insertion site. Further review revealed to then rinse well with warm water and pat dry. Further review revealed to then empty, clean and store bedpan or measuring device properly and then ensure the catheter is secured to the resident's thigh as appropriate. Further review revealed to then remove gloves into an appropriate container and then perform hand hygiene. Review of Resident #1's record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis, in part, of neuromuscular dysfunction of the bladder (a condition in which a person lacks control of the bladder). Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 06/05/2024, revealed, in part, Resident #1 had an indwelling catheter for urinary elimination. Further review revealed Resident #1 was always incontinent of bowel. Review of Resident #1's Physician's Orders revealed, in part, an order for catheter care , which included cleaning the insertion site with soap and water and rinse well every shift starting on 01/25/2023. Observation on 07/02/2024 at 10:20 a.m., revealed S6Certified Nursing Assistant (CNA) and S7CNA providing Resident #1 after having a bowel movement. Further observation revealed after Resident #1 was cleaned, S6CNA removed her gloves used to perform incontinent care and applied a new pair of gloves without performing hand hygiene. Observation then revealed S6CNA perform catheter care for Resident #1. In an interview on 07/02/2024 at 10:28 a.m., S6CNA confirmed that she changed her gloves but did not perform hand hygiene in between cleaning Resident #1 and performing catheter care for Resident #1. S6CNA further indicated she should have performed hand hygiene when she changed her gloves. In an interview on 07/02/2024 at 10:30 a.m. S4Wound Care Nurse confirmed the above mentioned observation and then indicated hand hygiene should have been performed after cleaning resident from having a bowel movement and before providing catheter care. In an interview on 07/02/2024 at 10:42 a.m., S8CNA Supervisor confirmed hand hygiene should be performed when changing gloves between incontinent care and catheter care. In an interview on 07/02/2024 at 1:30 p.m., S9Infection Control Nurse confirmed hand hygiene should be performed when changing gloves between incontinent care and catheter care.

May 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident was provided with restorative services for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of Resident #5's Physical Therapy Discharge summary dated [DATE] revealed, in part, Resident #5 was discharged from physical therapy with restorative nurse program to facilitate Resident #5 maintaining current level of performance and in order to prevent a decline with ambulation, bed mobility, and transfers. Review of Resident #5's Occupational Therapy Discharge summary dated [DATE] revealed a discharge recommendation for 24 hour care and participation in the restorative nurse program. In an interview on 05/16/2024 at 11:26 a.m., S7Restorative CNA indicated Resident #5 was not on the restorative CNA program at this time, and had not been since admit. In an interview on 05/16/2024 at 12:19 p.m., S2DON confirmed Resident #5 was not provided restorative series as recommended by therapy staff.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to identify and/or implement interventions to prevent falls. This deficient practice was identified for 2 (Resident #4 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for falls. Findings: Resident #4 Review of the facility's Incident/Accident Log for the last 3 months revealed, in part, Resident #4 had an unobserved fall on 03/18/2024 in Resident #4's room with no injury apparent upon assessment. Review of Resident #4's Nurses Notes dated 03/18/2024 at 5:00 p.m. revealed Resident #4 was screaming out, and when the Certified Nursing Assistant (CNA) entered the room, found Resident #4 on the floor. Further review revealed Resident #4 indicated he was trying to get out of the bed by himself and fell. Review of Resident #4's Care Plan revealed problems of, in part, Resident #4 was assessed as being at risk for falls related to impaired mobility and weakness with falls on 03/17/2024 and 04/29/2024. Further review revealed no documented evidence and the facility did not present any documented evidence that the care plan was updated after the fall on 03/18/2024. In interview on 05/15/2024 at 12:45 p.m., S3Minimum Data Set (MDS) Nurse/Licensed Practical Nurse (LPN) indicated she did not identify and include new approaches on the care plan to prevent falls after the fall on 03/18/2024. In an interview on 05/16/2024 at 11:34 a.m., S2Director of Nursing indicated the care plan should have been revised after every fall with new interventions to prevent future falls. Resident #5 Review of Resident #5's Care Plan revealed problem of, in part, Resident #5 had an actual fall from her bed on 04/18/2024, with a goal date of 07/31/2024. Further review revealed interventions to include putting Resident #5's bed was in the lowest position, and for Resident #5 to be screened for therapy. Observation on 05/15/2024 at 2:46 p.m. revealed Resident #5 was in bed with the bed approximately halfway between the lowest and highest position of the bed. In an interview on 05/15/2024 at 2:49 p.m., S4CNA Supervisor indicated the bed was not in the lowest position and staff should ensure the bed was always in the lowest position. Observation on 05/16/2024 at 9:59 a.m. revealed Resident #5 was in bed with the bed approximately halfway between the lowest and the highest position of the bed. In an interview on 05/16/2024 at 10:05 a.m., S5LPN confirmed Resident #5's bed was not in the lowest position, but should have been in the lowest position due to her fall risk. In an interview on 05/16/2024 at 10:13 a.m., S6CNA indicated Resident #5 was a fall risk and her bed should be in the lowest position at all times. In an interview on 05/16/2024 at 12:19 p.m., S2DON indicated Resident #5's bed should have been in the lowest position.

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure a dependent resident was provided incontinence care as needed for 1(Resident #2) of 4(Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for incontinence care. Findings: Review of Resident #2's MDS (Minimum Data Set) with ARD (Assessment Reference Date) dated 03/20/2024 revealed, in part: Resident #2 had a BIMS (Brief Interview for Mental Status) score of 06 (which indicated severe cognitive impairment), was always incontinent of bowel and bladder, and substantial/maximum assistance for toileting. Review of Resident #2's Potential for Bowel and Bladder Retraining assessment dated [DATE] revealed, in part, Resident #2 was incontinent of bladder and staff were to provide pericare after each one of Resident #2's incontinent episodes. Review of the facility's camera footage on 04/24/2024 at 4:51 a.m. through 04/24/2024 at 8:41 a.m. revealed, S8CNA exited Resident #2's room at approximately 4:55 a.m. with a blue brief in a clear garbage bag. Further review revealed S4CNA entered Resident #2's room to pass ice at 6:25 a.m. and then exited Resident #2's room without evidence Resident #2 was provided incontinence care. Further review revealed S4CNA re-entered Resident #2's room at approximately 7:13 a.m. and then exited Resident #2's room approximately 20 seconds later without evidence Resident #2 was provided incontinence care. Observation on 04/23/2024 at 8:12 a.m. revealed Resident #2 lying in his bed with a strong urine smell noted to his room. Observation on 04/24/2024 at 8:41 a.m. revealed Resident #2 lying in his bed with his eyes open. Further observation revealed Resident #2's blue brief was heavily saturated and his white sheet was visibly soiled. Further observation revealed a strong smell of urine in Resident #2's room. Observation on 04/24/2024 at 9:00 a.m. revealed S6CNASupervisor exited Resident #2's room with a heavily saturated blue brief in a clear trash bag. In an interview on 04/24/2024 at 10:00 a.m., S4CNA confirmed she was responsible for Resident #2's activities of daily living and she had not provided Resident #2 incontinence care since she arrived at 6:00 a.m. In an interview on 04/24/2024 at 10:30 a.m., S6CNA Supervisor stated the expectation of S4CNA was to ensure every resident was clean and dry when she arrived to the facility and began her shift. S6CNA Supervisor further stated Resident #2's brief would not have been saturated if he had been changed every 2 hours. In an interview on 04/24/2024 at 11:00 a.m., S1Administrator confirmed he reviewed the facility's camera footage for 04/24/2024 from 12:00 a.m. through 8:00 a.m. and there was no evidence Resident #2 had been provided incontinence care by S4CNA.

Mar 2024 20 deficiencies

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview the facility failed to ensure medications were not left unattended on a resident's bedside table for 1(Resident #481) of 34 (Resident #1, Resident #4, Resident #34, Resident #67, Resident #68, Resident #69, Resident #72, Resident #78, Resident #82, Resident #91, Resident #92, Resident #95, Resident #103, Resident #105, Resident #112, Resident #129, Resident #139, Resident #158, Resident #160, Resident #164, Resident #165, Resident #174, Resident #184, Resident #191 Resident #203, Resident #221, Resident #223, Resident #477, Resident #478, Resident #479, Resident #480, Resident #481, Resident #579, and Resident #581) sampled resident included in the initial pool. Findings: Review of Resident #481's March 2024 Physician's Orders revealed, in part, no evidence of an order for Ultra Lubricating eye drops. Review of Resident #481's record revealed no documentation of an assessment that Resident #481 could self-administer medications. Observation on 03/10/2024 at 9:45 revealed, Resident #481 had a bottle of Ultra Lubricating eye drops on his bedside table. In an interview on 03/10/2024 at 9:45 a.m., Resident #481 stated he had dry eyes and administered his own eye drops throughout the day. Observation on 03/12/2024 at 10:20 a.m., Resident #481 had a bottle of Ultra Lubricating eye drops on his bedside table. Observation on 03/13/2024 at 10:00 a.m., Resident #481 had a bottle of Ultra Lubricating eye drops on his bedside table. In an interview on 03/13/2024 at 2:30 p.m., S3Assistant Director of Nursing confirmed Resident #481 had a bottle of Ultra Lubricating eye drops on his bedside table and should not have. S3ADON further confirmed she could find no documentation that Resident #481 had been assessed for self-administration of medication and no documentation Resident #481 had an order for Ultra Lubricating eye drops in his record. There was no evidence, and the facility failed to present any evidence, Resident #481 had been assessed for self-administration of medication or that Resident #481 had an order in his record for Ultra Lubricating eye drops.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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Based on interview, observations, and record review the facility failed to allow a resident who is their own responsible party a choice to leave the facility on pass/leave for 1 resident (Resident #180) of 4 residents (Resident #103, Resident #95, and Resident #72) investigated for choices. Findings: Review of facility policy and procedure titled Pass/Leave of Absence with an effective date of 11/17/2015 revealed, in part facility residents may leave out on pass. Further review revealed a physician's order is needed if the facility resident is on skilled services at the time of pass/leave request and should include reason for leave, if resident can go on pass/leave alone and/or with a responsible party. Review of Resident #180's face sheet revealed, in part an admit date of 02/12/2024. Further review revealed Resident #180 is her own responsible party. In a phone interview on 03/12/2024 at 8:22 a.m., Resident #180's son stated he made a pass/leave request to S4Assistant Director of Nursing (ADON) to take his mother, Resident #180 out of the facility for pass/leave and was denied his request by S4ADON. Resident #180's son further stated the reason he could not take Resident #180 out the facility on pass/leave because Resident #180 was on skilled services at the time of pass/leave request. In an interview on 03/12/2024 at 9:15 a.m., S1Administrator stated Resident #180's son requested to take Resident #180 out of the facility for pass/leave. S1Administrator further stated he cannot take Resident #180 out of the facility for a pass/leave. In an interview on 03/12/2024 at 2:40 p.m., S4ADON stated Resident #180's son requested to take Resident #180 out of the facility for a pass/leave. S4Assistant Director of Nursing further stated she told Resident #180's son he could not take Resident #180 on pass/leave because Resident #180 was still on facility skilled services. In an interview on 03/12/2024 at 3:05 p.m., Resident #180 stated she would go on pass/leave with her son if he asked to take her on pass/leave. In an interview on 03/13/2024 at 9:31 a.m., S2DON stated she could not produce any evidence that would deny or prevent Resident #180 from going on a pass/leave. In an interview on 03/13/2024 at 10:07 a.m. S1Administrator stated according to Resident #180's face sheet dated 02/12/2024, Resident #180 is her own responsible party.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's code status was consistent with the resident's wishes for 1 (Resident #478) of 34 (Resident #1, Resident #4, Resident #34, Resident #67, Resident #68, Resident #69, Resident #72, Resident #78, Resident #82, Resident #91, Resident #92, Resident #95, Resident #103, Resident #105, Resident #112, Resident #129, Resident #139, Resident #158, Resident #160, Resident #164, Resident #165, Resident #174, Resident #184, Resident #191 Resident #203, Resident #221, Resident #223, Resident #477, Resident #478, Resident #479, Resident #480, Resident #481, Resident #579, and Resident #581) sampled resident included in the initial pool. Findings: Review of Resident #478's electronic medical record revealed, in part, Resident #478 was admitted to the facility on [DATE]. Review of Resident #478's March 2024 Physician's Orders revealed, in part, an order dated 02/29/2024 which indicated Resident #478 was a Full Code (which indicated in the event he presented with no pulse or no breath, medical interventions would take place). Review of Resident #478''s Louisiana Physician Orders For Scope of Treatment (LaPOST) dated 02/29/2024 revealed, in part, Resident #478's request was a Do Not Resuscitate (DNR). In an interview on 03/10/2024 at 3:00 p.m., S12Licensed Practical Nurse (LPN) confirmed there was an order for Resident #478 to be a Full Code in Resident #478's March 2024 Physician's Orders. S12LPN further confirmed that Resident #478's LaPOST dated 02/29/2024 indicated Resident #478 was a DNR. S12LPN further indicated there should not be a discrepancy in Resident #478's code status orders. In an interview on 03/11/2024 at 3:15 p.m., S2Director of Nursing (DON) agreed there should not have been a discrepancy in Resident #478's code status orders.

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

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Based on record review and interviews the facility failed to notify the provider (Physician or Nurse Practitioner) a resident refused blood collection as ordered by Nurse Practitioner for 1 (Resident #182) of 5 (Resident #72, Resident #182, Resident #184, Resident #203, Resident #478 ) sampled residents investigated for unnecessary medication. Findings: Review of Resident #182's record revealed, in part, a physician's telephone order dated 02/16/2024 to obtain blood samples for a complete blood count (a blood test that counts the cells that make up your blood), comprehensive metabolic panel (a blood test is used to measure liver and kidney functions and nutrient levels), lipid panel (a blood test that measures fat molecules called lipids in your blood), thyroid stimulating hormone (a blood test used to diagnosis and monitor thyroid disorders) and a glycated hemoglobin (a blood test used to measure average blood sugar levels over the past 3 months). Review of Resident #182's record revealed, in part, an Advanced Laboratory order sheet dated 2/20/2024 indicating Resident #182 refused blood collection for completed blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH) and glycated hemoglobin (A1C. Further review revealed no documented evidence of provider notification or review of the order sheet. Review of Resident #182's progress notes for February 2024 revealed no documented evidence provider was notified Resident #182 refused blood collection. In an interview on 03/13/2024 at 03:03 p.m. S2Director of Nursing (DON) stated the providers are notified if a resident refused a blood collection. S2DON further stated if the order sheet is not signed by the provider, there is no process in place to ensure the order sheet was placed in the provider's mailbox for review. S2DON stated there was no documented evidence that the provider was notified Resident #182 refused blood collection on 02/20/2024. In an interview on 03/13/2024 at 03:11 p.m. S3Assistant Director of Nursing (ADON) stated there was no documented evidence the provider was notified Resident #182's refused blood collection on 2/20/2024. S3ADON further stated nurse should make a note in the progress notes when a resident refuses labs and when the provider is notified.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to report an injury of unknown origin following the discovery of a resident's unexplainable wrist fracture for 1 (Resident #69) of 3 (Resident #69, Resident #92, Resident #481) sampled residents investigated for accidents. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure revealed, in part, the facility employee who becomes aware of an injury of unknown source shall immediately report the matter to the facility administrator. Further review revealed the injury of unknown origin shall be reported not less than 2 hours if the incident involves serious bodily injury. Review of Resident #69's Minimum Data Set with an Assessment Reference Date of 12/20/2023 revealed, in part, Resident #69 had a Brief Interview for Mental Status score of 6, which indicated Resident #69 had severe cognitive impairment. Further review revealed Resident #69 had a diagnosis of cognitive communication deficit Review of Resident #69's Fall Risk assessment dated [DATE] revealed, in part, Resident #69 was not a fall risk. Observation on 03/10/2024 at 1:22 p.m. revealed Resident #69 had a blue cast on his left upper extremity. In an interview on 03/10/2024 at 1:23 p.m., Resident #69 stated he fell and fractured his arm. Review of the facility's incident and accident log dated 12/01/2023 through 03/10/2024 revealed no documented evidence Resident #69 sustained a fall. Review of Resident #69's progress note from 12/22/2024 revealed Resident #69 was seen for a chief complaint of fall. Further review revealed Resident #69's present illness was documented as seen today after mechanical fall this morning while taking a shower. Review of Resident #69's handwritten physician's orders dated 12/22/2023 revealed, in part, an order for an x-ray of Resident #69's left wrist. Review of Resident #69's Radiology Interpretation dated 12/22/2023 revealed, in part, Resident #69 had a left wrist 2 view x-ray obtained, which revealed an age-indeterminate scaphoid (a bone in the wrist) fracture. In an interview on 03/11/2024 at 3:08 PM, S6Licensed Practical Nurse (LPN) stated Resident #69 had informed the physician during rounds that Resident #69 fell and hurt his wrist. S6LPN stated an x-ray was completed and Resident #69 had a scaphoid fracture. S6LPN further stated Resident #69 had not fallen on her shift and she was unsure when or if Resident #69 had fallen. In an interview on 03/12/2024 at 10:31 a.m., S2Director of Nursing (DON) stated on 12/22/2023 Resident #69 complained of pain to his left wrist, and Resident #69's physician ordered an x-ray, which showed a left wrist fracture. S2DON confirmed the facility was unaware how Resident #69's fracture occurred. S2DON confirmed Resident #69's injury was an injury of unknown origin. In a telephone interview on 03/12/2024 at 12:13 p.m., S19Certified Nursing Assistant stated Resident #69 had not fallen on her shift on 12/21/2023 or 12/22/2023. In an interview on 03/12/2024 at 3:48 p.m., S13LPN stated Resident #69 had not fallen on any shifts with her. S13LPN stated Resident #69 had never mentioned a fall to her. S13LPN confirmed a fracture with an unexplainable cause was an injury of unknown origin. S13LPN stated if a resident had come back with a new found fracture without an identifiable cause, nursing administration should have been notified. In an interview on 03/12/2024 at 11:10 a.m., S1Administrator confirmed Resident #69's fracture without an identifiable cause was an injury of unknown origin because it was unable to be determined if Resident #69 had fallen. S1Adminsitrator confirmed Resident #69's left wrist fracture was not reported.

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on record reviews, observations, and interviews, the facility failed to investigate an injury of unknown origin following the discovery of a resident's unexplained wrist fracture for 1 (Resident #69) of 3 (Resident #69, Resident #92, Resident #481) sampled residents investigated for accidents. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure revealed, in part, an injury of unknown origin must be thoroughly investigated, including interviews of employees who were working in resident's room during the time in question and obtaining signed statements from these employees. Review of Resident #69's Minimum Data Set with an Assessment Reference Date of 12/20/2023 revealed, in part, Resident #69 had a Brief Interview for Mental Status score of 6, which indicated Resident #69 had severe cognitive impairment. Further review revealed Resident #69 had a diagnosis of cognitive communication deficit Observation on 03/10/2024 at 1:22 p.m. revealed Resident #69 had a blue cast on his left upper extremity. In an interview on 03/10/2024 at 1:23 p.m., Resident #69 stated he fell and fractured his arm. Review of the facility's incident and accident log dated 12/01/2023 through 03/10/2024 revealed no documented evidence Resident #69 sustained a fall. Review of Resident #69's progress note from 12/22/2024 revealed Resident #69 was seen for a chief complaint of fall. Further review revealed Resident #69's present illness was documented as seen today after mechanical fall this morning while taking a shower. Review of Resident #69's handwritten physician's orders dated 12/22/2023 revealed, in part, an order for an x-ray of Resident #69's left wrist. Review of Resident #69's Radiology Interpretation dated 12/22/2023 revealed, in part, Resident #69 had a left wrist 2 view x-ray obtained, which revealed an age-indeterminate scaphoid (a bone in the wrist) fracture. In an interview on 03/11/2024 at 3:08 p.m., S6Licensed Practical Nurse (LPN) stated Resident #69 had informed the physician during rounds that Resident #69 fell and hurt his wrist. S6LPN stated an x-ray was completed and Resident #69 had a scaphoid fracture. S6LPN further stated Resident #69 had not fallen on her shift and she was unsure when or if Resident #69 had fallen. In an interview on 03/12/2024 at 10:31 a.m., S2Director of Nursing (DON) stated on 12/22/2023 Resident #69 complained of pain to his left wrist, and Resident #69's physician ordered an x-ray, which showed a left wrist fracture. S2DON confirmed the facility was unaware how Resident #69's fracture occurred. S2DON further confirmed Resident #69's injury was an injury of unknown origin. S2DON stated an investigation should have been completed to determine the cause of Resident #69's fracture. In a telephone interview on 03/12/2024 at 12:13 p.m., S19Certified Nursing Assistant stated Resident #69 had not fallen on her shift on 12/21/2023 or 12/22/2023. In an interview on 03/12/2024 at 3:48 p.m., S13LPN stated Resident #69 had not fallen during any shifts she had worked. S13LPN stated Resident #69 had never mentioned a fall to her. S13LPN confirmed a fracture with an unexplainable cause was an injury of unknown origin. S13LPN confirmed if the resident had claimed he had fallen, but staff were unaware when the fall occurred, an investigation should have been completed. In an interview on 03/12/2024 at 11:10 a.m., S1Administrator confirmed Resident #69's fracture without an identifiable cause was an injury of unknown origin because it was unable to be determined if Resident #69 had fallen. S1Administrator stated an investigation should have been completed in order to identify the validity or cause of Resident #69's fall. S1Administrator confirmed an investigation was not done and should have been.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observations, interview, and record review, the facility failed to develop a plan of care that addressed a resident's pain for 1 (Resident #165) of 1 (Resident #165) sampled residents investigated for pain. Finding; Review of Resident #165's Plan of Care revealed, in part, no documented evidence of measurable goals or interventions for the management of Resident #165's pain. Further review revealed no documented evidence of timeframes or approaches for monitoring the effectiveness of interventions managing Resident #165's pain. In an interview on 03/10/2024 at 9:30 a.m., Resident #165 complained of pain to the left knee rated a 10 on a scale of 0 to 10 with 0 being no pain and 10 being the worse pain. Observation on 03/11/2024 at 9:43 a.m. revealed Resident #165 was not participating in his physical therapy exercises. In an interview on 03/11/2024 at 9:53 a.m., Resident #165 indicated that the pain to his left knee was keeping him from participating in physical therapy. In an interview on 03/11/2024 at 10:21 a.m., Resident #165 stated he was experiencing pain in his left thigh, just above the knee rated 6 out of 10. In an interview 03/11/2024 at 3:40 p.m., S8Minimum Data Set Licensed Practical Nurse (MDSLPN) confirmed there was no documented evidence of measurable goals or interventions for the management of Resident #165's pain and no documented evidence of timeframes or approaches for monitoring the effectives of interventions managing Resident #165's pain. S8MDSLPN further indicated, if Resident #165 was experiencing pain, goals and interventions related to management of his pain should have been developed for his Plan of Care.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure: 1. A resident that required dialysis had an order for hemodialysis (a procedure that filters waste and fluid from the blood in people whose kidneys can no longer function) frequency for 1 (Resident #477) of 1 (Resident #477) sampled residents investigated for dialysis services; 2. Ongoing communication regarding a resident's condition was completed with the dialysis facility for 1 (Resident #477) of 1 (Resident #477) sampled residents investigated for dialysis services; and 3. A dialysis resident's condition was assessed upon return from dialysis for 1 (Resident #477) of 1 (Resident #477) sampled residents investigated for dialysis services. Findings: Review of the facility's policy titled Dialysis Resident's Care Policy and Procedure, most recently revised on 10/09/2014, revealed, in part, the facility must obtain a physician's order for dialysis services that specified the days the resident was to go to dialysis. Further review revealed, the facility must assess and monitor a resident's dialysis site for bleeding or abnormalities. Further review revealed, the facility must review the dialysis communication form upon a resident's return from the dialysis clinic. #1 Review of Resident #477's March 2024 Physician's Orders, revealed, in part, no documentation of an order for the frequency of Resident #477's hemodialysis treatment. In an interview on 03/13/2024 at 11:20 a.m., S3Assistant Director of Nursing (ADON) confirmed there was no order in Resident #477's record for hemodialysis treatments. In an interview on 03/13/2024 at 11:45 a.m., S2Director of Nursing (DON) stated there should have been a Physician's Order for hemodialysis treatments in Resident #477's record. #2 Review of Resident #477's Dialysis Communication Record dated 03/08/2024 revealed, in part, no signature that Resident #477's communication form was reviewed by a nurse. In an interview on 03/13/2024 at 11:45 a.m., S2DON indicated that nurses are required to review a resident's Dialysis Communication Record upon a resident's return from dialysis. There was no documented evidence, and the facility failed to produce any documented evidence, that Resident #477's Dialysis Communication Record was reviewed by a nurse upon Resident #477's return from dialysis on 03/08/2024. #3 Review of Resident #477's facility progress note dated 03/08/2024 revealed, in part, Resident #477 had a Brief Interview for Mental Status score of 14, which indicated Resident #14 was cognitively intact. Review of Resident #477's vital sign log revealed, in part, no documentation that Resident #477's blood pressure was assessed on 03/11/2024. Review of Resident #477's Dialysis Communication Record dated 03/11/2024 revealed, in part, Resident #477 was hypotensive and the dialysis center was unable to remove fluid from Resident #477. Further review revealed, Resident #477 was at risk for fluid overload. In an interview on 03/11/2024 at 10:47 a.m., Resident #477 stated his blood pressure was not taken by any staff member on 03/08/2024 when he returned from dialysis. In an interview on 03/12/2024 at 8:57 a.m., Resident #477 stated that his blood pressure was low at dialysis on 03/11/2024 and he could not finish his hemodialysis session. Resident #477 further stated the facility's staff had not checked his blood pressure since he returned to the facility on [DATE] after completing dialysis. In an interview on 03/13/2024 at 11:20 a.m., S3ADON stated in cases where a resident had complications during dialysis, the nurse should have assessed the resident when they returned to the facility by taking a set of vitals. In an interview on 03/13/2024 at 11:45 a.m., S2DON indicated Resident #477's blood pressure should have been assessed upon his return to the facility on [DATE], when Resident #477 was noted to be hypotensive at the dialysis center. There was no evidence, and the facility failed to provide any evidence, Resident #477's blood pressure was assessed on 03/11/2024 when Resident #477 returned to the facility with a Dialysis Communication record that indicated he was hypotensive during hemodialysis treatment.

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not greater than 5%. This deficient practice was identified for 2 (Resident #583 and Resident #584) of 4 (Resident #180, Resident #583, Resident #584, and Resident #600) residents observed during medication administration. Findings: Observation on 03/12/2024 at 8:41 a.m. revealed S10Licensed Practical Nurse (LPN) administered one tablet of Metoprolol Succinate Extended Release (a medication to lower blood pressure) 100 milligrams (mg) 1 tablet by mouth to Resident #583. Further observation on 03/12/2024 at 9:04 a.m. revealed S10LPN administered Vitamin B12 (a vitamin required for metabolism) 500 micrograms (mcg) 1 tablet by mouth to Resident #584. Review of Resident #583's March 2024 Physician's orders revealed, in part, an order dated 02/29/2024 to administer 1 tablet of Toprol XL (a medication used to lower blood pressure) 50 mg by mouth twice daily. Review of Resident #584's March 2024 Physician's orders revealed, in part, an order dated 03/07/2024 to administer 1 tablet of Vitamin B12 1000 mcg by mouth once daily. In an interview on 03/13/2024 at 11:20 a.m., S10LPN confirmed she administered one tablet of Metoprolol Succinate Extended Release 100 mg to Resident #583. S10LPN further confirmed she administered one tablet of Vitamin B12 500 mcg to Resident #584. S10LPN indicated she should have verified whether Resident #583's and Resident #584's Physician's Orders matched the medications she administered to Resident #583 and Resident #584 and she did not. In an interview on 03/13/2024 at 12:50 p.m., S2Director of Nursing confirmed S10LPN should have followed Resident #583's and Resident #584's Physician's orders noted on their electronic Medication Administration Records (eMAR) before administering Resident #583's and Resident #584's medications.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure food available for use was properly stored, dated, and labeled in the dry food pantry and walk-in kitchen refrigerator. Findings: Review of the facility's Food Storage Labeling Policy dated October 2018 revealed, in part, the facility will store and label all foods to ensure safety and quality. Further review of the policy revealed food is routinely monitored in storage to identify and discard foods that have passed the expiration or use by date. Observation on 03/10/2024 at 9:15 a.m. of the kitchen's dry food pantry revealed an undated box with 7 bunches of overripe bananas that were black with brown bruises. Observation on 03/10/2024 at 9:20 a.m. revealed, in the facility's walk-in refrigerator 8 chef salads in plastic containers with soggy brown lettuce. Further observation revealed the containers were dated 03/04/2024. In an interview on 03/10/2024 at 9:16 a.m., S16Culinary [NAME] stated the bananas were for resident use. [NAME] further acknowledged the bananas and expired salads should have been discarded. In an interview on 03/10/2024 at 12:00 p.m., S15Culinary Supervisor acknowledged expired salads should not have been in the facility's refrigerator. S15Culinary Supervisor further confirmed the black bananas with brown bruises should have been discarded.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure: 1. Documentation of a resident's wound assessment and treatment for 1 (Resident #477) of 4 (Resident #92, Resident #184, Resident #191, and Resident #477) sampled residents investigated for wound care; and 2. Documentation of a resident's antibiotic administration was recorded for 1 (Resident #91) of 3 (Resident #68, Resident #69, and Resident #91) sampled residents investigated for urinary tract infections. Findings: #1 Review of Resident #477's Electronic Medical Record (EMR) revealed, in part, Resident #477 was admitted to the facility on [DATE]. Review of Resident #477's admission Order Sheet dated 03/07/2024 revealed, in part, orders for Resident #477's right lower leg wound and right heel wound were noted. Review of Resident #477's March 2024's Physician's Orders revealed, in part, no documentation of a wound care order for Resident #477's right lateral shin wound or right heel wound on 03/07/2024 and/or 03/08/2024. Review of Resident #477's electronic Treatment Administration Record revealed, in part, no documentation that Resident #477 received wound care treatment on 03/07/2024 or 03/08/2024. Review of Resident #477's EMR revealed, in part, no documentation a wound assessment was completed and resident's wounds were measured for Resident #477's right lateral shin wound and right heel wound on 03/07/2024 and/or 03/08/2024 Review of Resident #477's nurse's notes dated 03/07/2024 and/or 03/08/2024 reveled, in part, no documentation Resident #477 right heel wound was assessed, measured, or treated. Further review revealed no documentation Resident #477's right lateral shin wound was assessed, measured or treated. In an interview on 03/13/2024 at 11:45 a.m., S2Director of Nursing (DON) stated there should be documentation Resident #477's right lateral shin wound and right heel would were assessed, measured, and treated on 03/07/2024 and/or 03/08/2024. There was no documented evidence, and the facility failed to provide any documented evidenced, Resident #477's right lateral shin wound and right heel wound were assessed, measured, and treated on 03/07/2024 and/or 03/08/2024. #2 Review of Resident #91's EMR revealed, in part, Resident #91 was admitted to the facility on [DATE]. Review of Resident #91's February 2024 Physician's Orders revealed, in part, an order for Keflex 500 milligrams (mg) capsule (an antibiotic used to treat urinary tract infections) take 1 capsule by mouth 4 times a day for 5 days starting on 02/12/2024 and ending on 02/16/2024. Review of Resident #91's February 2024 Electronic Medication Administration Record revealed in part, Keflex 500 mg capsule was not administered for 2 of 4 doses on 02/14/2024. Further review revealed Keflex 500 mg was not administered for 1 of 4 doses on 02/16/2024. Review of Resident #91's nurse's notes on 02/14/2024 and 02/16/2024, revealed, in part, no documented evidence, and the facility did not present any documented evidence, Resident #91 received all doses of Keflex 500 mg as ordered on 02/14/2024 and 02/16/2024. In an interview on 03/13/2024 at 3:57 p.m., S2Director of Nursing confirmed the above findings. S2Director of Nursing further indicated Resident #91 should have had documentation of all doses of Keflex 500 mg capsule being administered.

CONCERN (E)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure: 1. A resident had a physician's order to maintain an indwelling urinary catheter; 2. A resident was assessed every shift for adverse signs and symptoms related to an indwelling urinary catheter; and, 3. A resident with an indwelling urinary catheter received catheter care every shift. This deficient practice was identified for 1 (Resident #69) of 3 (Resident #68, Resident #69, and Resident #91) sampled residents investigated for urinary catheters. Findings: Observation on 03/10/2024 at 1:22 p.m. revealed Resident #69 had a urinary catheter drainage bag attached to his wheelchair with rust colored urine in the drainage tubing. Review of Resident #69's hospital discharge records revealed, in part, Resident #69 had an emergency room visit on 03/08/2024 and was diagnosed with hematuria (blood in the urine), urinary retention (the inability to pass urine), and a urinary tract infection. Further review revealed Resident #69 was discharged from the emergency room with a urinary catheter in place due to urinary retention. Review of Resident #69's March 2024 physician's orders revealed no physician's order to maintain Resident #69's urinary catheter. Review of Resident #69's record revealed no documented evidence and the facility was unable to present any documented evidence Resident #69 was monitored for adverse signs and symptoms related to Resident #69's urinary catheter every shift. Review of Resident #69's record revealed no documented evidence and the facility was unable to present any documented evidence Resident #69 was provided urinary catheter care every shift. In an interview on 03/11/2024 at 3:08 p.m., S6Licensed Practical Nurse (LPN) stated Resident #69 had returned from the hospital with a diagnosis of hematuria and a urinary tract infection. S6LPN further stated Resident #69 had a urinary catheter placed at the emergency room due to urinary retention. S6LPN stated a resident's urinary catheter needed to be assessed every shift, for any symptoms of a urinary tract infection. S6LPN further stated catheter care needed to be completed every shift. In an interview 03/11/2024 at 3:29 p.m., S2Director of Nursing (DON) confirmed Resident #69 had a urinary catheter. S2DON stated a resident with a urinary catheter needed a physician's order. In an interview on 03/12/2024 at 10:31 a.m., S2DON stated Resident #69 went to the emergency room on [DATE] and had a urinary catheter placed. S2DON confirmed Resident #69 did not have a physician's order for his urinary catheter upon returning from the emergency room. S2DON stated the nurse should assess a resident's the urinary catheter every shift. S2DON further stated the nurse should clean a resident's urinary catheter insertion site every shift and as needed. S2DON stated it was especially important to monitor Resident #69's urine characteristics since Resident #69 had an active urinary tract infection.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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Based on record reviews, observations, and interviews, the facility failed to administer a resident's oxygen per physician's orders for 2 (Resident #67 and Resident #129) of 4 (Resident #34, Resident #67, Resident #112, and Resident #129) sampled residents investigated for respiratory care. Findings: Resident #67 Review of Resident #67's record revealed diagnoses, in part, of Respiratory Failure and Hypoxia (low levels of oxygen in the blood). Review of Resident #67's physician's orders for March 2024 revealed, in part, an order for Oxygen 2 liters per nasal cannula for low oxygen saturation. Observation on 03/10/24 at 10:24 a.m. revealed Resident #67 receiving oxygen at 3 liters per nasal cannula via an oxygen concentrator. Observation on 03/11/2024 at 1:00 p.m. revealed Resident #67 receiving oxygen at 3 liters per nasal cannula via an oxygen concentrator. In an interview on 03/12/2024 at 1:45 p.m., S17LPN acknowledged Resident #67's orders indicated Resident #67 should have received oxygen at 2 liters per nasal cannula. Resident #129 Review of Resident #129's record revealed, in part, Resident #129 had diagnoses of acute and chronic respiratory failure with hypercapnia (high levels of carbon dioxide), shortness of breath, and chronic obstructive pulmonary disease. Review of Resident #129's electronic March 2024 physician's orders revealed, in part, an order for continuous oxygen at 5 liters per minute via nasal cannula with a start date of 01/30/2024. Review of Resident #129's written order from 03/07/2024 at 12:00 p.m. revealed, in part, an order for oxygen at 2.5 liters per minute via nasal cannula or face mask. Review of Resident #129's care plan for continuous oxygen with an onset date of 02/19/2021 revealed, in part, interventions to administer oxygen as ordered. Review of Resident #129's March 2024 eMAR revealed documentation Resident #129 was administered oxygen at 5 liters per minute via nasal cannula from 03/08/2024 through 03/12/2024. Observation on 03/10/2024 at 11:33 a.m. revealed Resident #129 was receiving oxygen via nasal cannula connected to the oxygen concentrator. Further observation revealed Resident #129's oxygen concentrator was set at 5 liters per minute. Observation on 03/11/2024 at 3:04 p.m. revealed Resident #129 was receiving oxygen via nasal cannula connected to the oxygen concentrator. Further observation revealed Resident #129's oxygen concentrator was set at 5 liters per minute. Observation on 03/12/2024 at 12:02 p.m. revealed Resident #129 was receiving oxygen via nasal cannula connected to the oxygen concentrator. Further observation revealed Resident #129's oxygen concentrator was set at 5 liters per minute. In an interview on 03/13/2024 at 9:43 a.m., S5Licensed Practical Nurse stated Resident #129 had an order for oxygen at 5 liters per minute, but the oxygen order was changed to 2.5 liters per minute at some time last week. In an interview on 03/12/2024 at 10:04 a.m., S3Assistant Director of Nursing (ADON) confirmed Resident #129 had an order placed on 03/07/2024 at 12:00 p.m. for oxygen at 2.5 liters per minute via nasal cannula. S3ADON stated Resident #129's oxygen order should have been changed in the electronic record at the time Resident #129's oxygen order was received. S3ADON confirmed Resident #129 should have had oxygen administered as ordered. In an interview on 03/12/2024 at 11:42 a.m., S2Director of Nursing (DON) stated Resident #129's oxygen order should have been entered into the electronic record and carried out when it was placed on 03/07/2024. S2DON confirmed Resident #129's oxygen should have been administered as ordered.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to ensure expired medications and dressings were not available for resident use for 3 (Medication Cart V, Medication cart X, Medication Cart Z) of 5 (Medication Cart V, Medication cart W, Medication Cart X Medication Cart Y, and Medication Cart Z) medication carts and 1 (Medication Room C), of 2 (Medication Room B and Medication Room C) medication rooms observed for medication storage. Findings: Observation on 03/13/2024 at 11:30 a.m. with S10Licensed Practical Nurse (LPN) of Medication Cart Z revealed a bottle of Fish Oil 500 milligram (mg) caplets with an expiration date of 07/2023. Further observation revealed one 30 ounce (oz) bottle of Uti-stat (a supplement to aid in the prevention of bladder infections) with an expiration date of 02/28/2024. Observation on 03/13/2024 of Medication Room C at 11:40 a.m. with S10LPN revealed two 30 ounce bottles of Uti-stat with expiration dates of 2/28/2024. In an interview on 03/13/2024 at 11:31 a.m., S10LPN stated the expired bottle of Fish Oil 500 mg caplets and the three 30 oz bottles of UTI-Stat should not have been in Medication Cart Z and Medication Room C and available for resident use. Observation of Medication Cart X on 03/13/2024 at 12:15 p.m. with S14Infection Preventionist (IPNurse) revealed a container of CeraVe anti-itch cream with an expiration date of 1/2024. In an interview on 03/13/2024 at 12:16 p.m., S14IPNurse stated the expired anti-itch cream should not have been in Medication Cart X and available for resident use. Observation of Medication Cart V on 03/13/2024 at 12:25 p.m. with S11Wound Care Nurse (WCNurse) revealed one bottle of Hydrogen Peroxide 3% with an expiration date of 02/2021 and Curad Iodoform Packing Strips with an expiration date of 05/2022. In an interview on 03/13/2024 at 12:28 p.m., S11WCNurse stated the Hydrogen Peroxide and Iodoform Packing Strips should not have been in Medication Cart V and available for resident use. In an interview on 03/13/2024 at 12:50 p.m., S2Director of Nursing (DON) confirmed that the expired Fish Oil, Uti-Stat, CeraVe, Curad iodoform packing strips, and hydrogen peroxide should not have been on the medication carts and in the medication room available for resident use.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on record review, observations and interviews, the facility failed to: 1. Ensure a nurse did not administer a contaminated supplement to a resident for 1 (Resident #583) of 5 (Resident #79, Resident #180, Resident #583, Resident #584, and Resident #600) residents observed during medication administration; 2. Ensure a resident's continuous positive airway pressure (a machine that delivers a constant stream of air pressure to prevent airway closure during sleep) mask was contained in a sanitary manner for 1 (Resident #34) of 4 (Resident #34, Resident #67, Resident #112, and Resident #129) sampled residents reviewed for respiratory care; and, 3. Ensure the nurse completed hand hygiene during medication administration for 1 (S10Licensed Practical Nurse) of 2 (S6Licensed Practical Nurse and S10Licensed Practical Nurse) Licensed Practical Nurses observed during medication administration. Findings: 1. Observation on 03/12/2024 at 8:41 a.m. revealed S10Licensed Practical Nurse (LPN) poured 30 milliliters of Pro-Stat (a supplement to promote wound healing) in a medication cup. Further observation revealed S10LPN's bare finger touched the surface of Resident #583's Pro-Stat, and a drop of Pro-Stat dripped off of S10LPN's finger. Further observation revealed S10LPN administered the Pro-Stat she had touched with her bare finger to Resident #583. In an interview on 03/12/2024 at 9:25 a.m., S10LPN acknowledged she had contaminated Resident #583's Pro-Stat. S10LPN stated she should have discarded Resident #582's Pro-Stat and not administered it to Resident #583. 2. Review of the facility's Continuous Positive Airway Pressure (CPAP) Machine Cleaning policy and procedure revealed, in part, a resident's CPAP will be kept clean when in the resident's room by storing the mouthpiece and mask in a plastic bag while the CPAP was not in use. Review of Resident #34's record revealed Resident #34 had a diagnosis of obstructive sleep apnea (a disorder that causes people to stop breathing for short periods during sleep). Review of Resident #34's March 2024 physician's orders revealed an order for CPAP with a setting of 18 centimeters of water every night. Review of Resident #34's care plan revealed Resident #34 utilized a CPAP machine and required assistance from staff with CPAP equipment. Observation on 03/10/2024 at 12:48 p.m. revealed Resident #34 CPAP mask was uncontained and lying on the floor. Observation on 03/11/2024 at 2:51 p.m. revealed Resident #34's CPAP mask was uncontained and lying on top of the CPAP machine. Observation on 03/12/2024 at 12:01 p.m. revealed Resident #34's CPAP mask was uncontained and lying on top of the CPAP machine. Observation on 03/12/2024 at 5:02 p.m. revealed Resident #34's CPAP mask was uncontained and lying on top of the CPAP machine. Observation on 03/13/2024 at 9:41 a.m. revealed Resident #34's CPAP mask was uncontained and lying on top of the CPAP machine. In an interview on 03/13/2024 at 9:45 a.m., S6LPN stated if Resident #34 did not contain her CPAP mask, facility nurses usually contained the mask for Resident #34. S6LPN confirmed Resident #34's CPAP mask should have been contained. In an interview on 03/13/2024 at 11:39 a.m., S2Director of Nursing (DON) confirmed that a resident's CPAP mask should be contained to prevent infection. S2DON stated if a resident did not place their CPAP mask in a bag, the resident's nurse should ensure that the CPAP mask was contained. 3. Observation on 03/12/2024 at 9:04 a.m. revealed, S10LPN did not perform hand hygiene after administering Resident #583's medication, and before administering Resident #584's medications. In an interview on 03/12/2024 at 9:25 a.m., S10LPN acknowledged she failed to perform hand hygiene after administering Resident #583's medications and before administering Resident #584's medications. S10LPN stated she should have performed hand hygiene while administering medications

CONCERN (E)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to implement protocols and processes to identify the types of organisms/bacteria which caused infections, and/or the types of antibiotics those organisms were susceptible and resistant to. Findings: Review of the facility's Surveillance: Infection Prevention and Control Program with reviewed date of 08/16/2023 revealed, in part, outcome surveillance included reviewed of relevant data which may include laboratory antibiograms (antibiotic susceptibility profiles). Review of the facility's Antibiotic Stewardship Program Policy and Procedure revealed, in part, the Director of Nursing (DON)/designee would maintain a facility Antibiotic Stewardship Program to promote commitment to safe and appropriate antibiotic use. Further review revealed the DON/designee would monitor the antibiotic resistance based on laboratory data as appropriate. Further review revealed the DON/designee would utilize the Laboratory Vendor Antibiogram report or the Facility Antibiogram Form. In an interview on 03/13/2024 at 1:08 p.m., S14Infection Preventionist stated the facility did not have an antibiogram report due to lack of data to have a report generated. S14Infection Preventionist stated she reviews the infection report but unless the culture was already completed she did not investigate if a culture was completed, what type of organism was identified or the susceptibility of the bacteria/organism to antibiotics. S14Infection Preventionist stated the facility had no documented evidence of tracking the types of organisms which caused infections, or the susceptibility of organisms to antibiotics. In an interview on 03/13/2024 at 1:34 p.m., S2Director of Nursing (DON) stated she but did not think the facility tracked and trended the type of bacteria/organism which caused the infections. In an interview on 03/13/2024 at 1:35 p.m., S4Assistant Director of Nursing (ADON) stated she but did not think the facility tracked and trended the type of bacteria/organism which caused the infections, and was not aware of any report with this information being present in the facility. Review of the facility's Antibiotic Utilization Report for January 2024 through March 2024 revealed listing of residents with antibiotics prescribed with all residents' organism section listed as none. Review of the facility's January 2024 Laboratory Organism Report revealed, in part: -Resident #90 had Escherichia Coli (bacteria most commonly found in the intestines) bacteria identified from a urine culture on 01/02/2024; and -Resident #183 had Proteus Mirabilis (bacteria that commonly causes bladder infections) bacteria identified from a urine culture on 01/18/2024. Review of the facility's February 2024 Laboratory Organism Report revealed, in part: -Resident #191 had enterococcus species (bacteria which commonly causes infections) and pseudomonas aeruginosa (bacteria that commonly causes bladder infections) bacteria identified from a culture of Resident #191's sacral wound on 01/31/2024; -Resident #26 had a klebsiella pneumoniae (bacteria commonly found in the intestines) bacteria identified from a urine culture on 01/31/2024; -Resident #176 had an Escherichia Coli and Proteus Mirabilis bacteria from urine culture on 02/15/2024; and -Resident #32 had an Escherichia Coli bacteria identified from urine culture on 02/20/2024. Review of the facility's Antimicrobial Susceptibilities Percent Susceptible Report for February 2024, which was a cumulative 12 month rolling antibiogram for urines revealed the susceptibility for Escherichia Coli bacteria with the bacteria being most susceptible to the following antibiotics, in part, Imipenem, Meropenem, Entapenem, and Nitrofurantoin. In an interview on 03/13/2024 at 3:15 p.m., S14Infection Preventionist stated she had just received the antibiogram reports, today 03/13/2024, and the laboratory staff said the antibiogram reports were faxed monthly, and the number she faxed to was to S2DON. S14Infection Preventionist stated she had never seen the antiobiogram report prior to the fax today, 03/13/2024. S14Infection Preventionist further stated she was not reviewing the culture reports, antibiogram reports, and was not compiling the data on the types of organisms identified and the susceptibility of infection to bacteria. In an interview on 03/13/2024 at 3:17 p.m., S4ADON stated she had never seen the antibiogram report before and only sees the labs as they are faxed, but she was not gathering and combining the data to identify common organisms and/or the susceptibility of those organisms to antibiotics. In an interview on 03/13/2024 at 3:20 p.m., S2DON stated she had seen the antiobiogram reports but thought they were sent to S14Infection Preventionist for review and trending of infections and organisms. S2DON further stated she did not realize S14Infection Preventionist was not receiving the antiobiogram reports or reviewing the culture and sensitivity reports. S2DON confirmed the facility did not maintain the antibiotic stewardship program.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected multiple residents

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Based on observation, record review, and interviews, the facility failed to post the most recent survey results in an area available to the public. Findings: Review of the facility's survey history revealed a complaint survey conducted with an exit date of 02/05/2024. Review of the facility's survey binder on 03/12/2024 at 3:30 p.m. revealed the last survey available for review had an exit date of 11/29/2023. Further review, revealed the complaint survey conducted with an exit date of 02/05/2024 was not available for review. In an interview on 03/12/2024 at 3:40 p.m., S1Administrator confirmed the above findings and indicated the complaint survey with an exit date of 02/05/2024 should have been available for review.

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

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Based on record reviews and interviews, the facility failed to ensure residents' Minimum Data Set (MDS) assessments were transmitted within 14 days of completion for 7 (Resident #76, Resident #50, Resident #106, Resident #64, Resident #183, Resident #116, and Resident #197) of 9 (Resident #76, Resident #50, Resident #106, Resident #64, Resident #183, Resident #116, Resident #197, Resident #77, and Resident #40) residents reviewed for resident assessment. Findings: Review of the facility's Final Validation Report dated 03/12/2024 revealed the following: -Resident #76's Discharge MDS with an Assessment Reference Date (ARD) of 11/02/2023 was submitted more than 14 days after the completion date of 11/08/2023; -Resident #50's Quarterly MDS with an ARD of 01/10/2024 was submitted more than 14 days after the completion date of 01/10/2024; -Resident #106's Discharge MDS with an ARD of 11/21/2023 was submitted more than 14 days after the completion date of 11/21/2023; -Resident #64's Quarterly MDS with an ARD 01/31/2024 was submitted more than 14 days after the completion date of 01/31/2024; -Resident #183's Quarterly MDS with an ARD of 01/31/2024 was submitted more than 14 days after the completion date of 02/01/2024; -Resident #116's Discharge MDS with an ARD of 12/01/2023 was submitted more than 14 days after the completion date of 12/04/2023; and, -Resident #197's Discharge MDS with an ARD of 12/08/2023 was submitted more than 14 days after the completion date of 12/18/2023. In an interview on 03/12/2024 at 11:37 a.m., S8MDS Licensed Practical Nurse stated the transmission of a resident's MDS assessment should be done within 14 days of the completion date. S8MDS Licensed Practical Nurse confirmed the above mentioned residents' assessments were not transmitted within 14 days of the completion date. In an interview on 03/13/24 11:43 a.m., S2Director of Nursing confirmed a resident's MDS assessment should be transmitted within 14 days of the completion date.

MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

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Based on record reviews and interviews, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment reflected the resident's oxygen use for 1 (Resident #129) of 4 (Resident #34, Resident #67, Resident #112, and Resident #129) sampled residents investigated for respiratory care. Findings: Review of Resident #129's record revealed, in part, Resident #129 had diagnoses of acute and chronic respiratory failure with hypercapnia (high levels of carbon dioxide), shortness of breath, and chronic obstructive pulmonary disease. Review of Resident #129's electronic March 2024 physician's orders revealed, in part, an order for continuous oxygen at 5 liters per minute via nasal cannula (a device that delivers supplemental oxygen into the nose) with a start date of 01/30/2024. Review of Resident #129's written order from 03/07/2024 at 12:00 p.m. revealed, in part, an order for oxygen at 2.5 liters per minute via nasal cannula or face mask. Review of Resident #129's care plan for continuous oxygen revealed, in part, interventions to administer oxygen as ordered and ensure oxygen was available at all times. Review of Resident #129's January 2024 electronic Medication Administration Record (eMAR) revealed documentation Resident #129 was administered oxygen at 5 liters per minute via nasal cannula from 01/26/2024 through 01/31/2024. Review of Resident #129's February 2024 eMAR revealed documentation Resident #129 was administered oxygen at 5 liters per minute via nasal cannula from 02/01/2024 through 02/29/2024. Review of Resident #129's March 2024 eMAR revealed documentation Resident #129 was administered oxygen at 5 liters per minute via nasal cannula from 03/01/2024 through 03/06/2024 and 03/08/2024 through 03/12/2024. Review of Resident 129's Significant Change MDS with an Assessment Reference Date (ARD) of 01/31/2024 revealed, in part, Resident #129 was assessed to not have utilized oxygen while a resident in the facility. Further review revealed Resident #129's assessment was completed by S7MDS Licensed Practical Nurse (LPN). Review of Resident #129's Discharge MDS with an ARD of 03/06/2024 revealed, in part, Resident #129 was assessed to not have utilized oxygen while a resident in the facility. Further review revealed Resident #129's assessment was completed by S7MDS LPN. In an interview on 03/12/2024 at 11:31 a.m., S7MDS LPN stated she had completed Resident #129's MDS assessments. S7MDS LPN confirmed Resident #129 had an order dated 01/30/2024 for oxygen at 5 liters per minute via nasal cannula and an order dated 03/12/2024 for oxygen at 2.5 liters per minute via nasal cannula. S7MDS LPN acknowledged Resident #129's above mentioned MDS assessments did not reflect Resident #129's oxygen administration. In an interview on 03/13/24 at 11:55 a.m., S2Director of Nursing confirmed Resident #129's above mentioned MDS assessments should have reflected Resident #129's use of oxygen.

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on observation and interview, the facility failed to ensure the facility posted the daily census, total number of staff, and actual hours worked for licensed nurses and certified nurse aides. Findings: Observation on 03/10/2024 at 1:08 p.m. at Nursing Station A revealed the posted nursing staff data was dated 03/04/2024. Observation on 03/12/2024 at 5:04 p.m. at Nursing Station A revealed the posted nursing staff data was dated 03/11/2024. In an interview on 03/13/2024 at 2:35 p.m., S2Director of Nursing stated nursing staff data and facility census should be updated and posted daily.

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to report an allegation of neglect timely to the State Survey Agency and Certification Agency as required for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure, effective 03/25/2023, revealed, in part, neglect means the failure of the facility, its employees or service provider to provide adequate medical care or goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress. Further review revealed, in part, the administrator shall immediately initiate a SIMS (Statewide Incident Management System) report to the Louisiana Department of Health no later than 24 hours after forming the suspicion if the alleged violation involves neglect and does not result in serious bodily harm. Review of Resident #1 record revealed he was admitted to the facility on [DATE]. Review of Resident #1's baseline care plan dated 01/19/2024 revealed, in part, Resident #1 required extensive assistance with activities of daily living and was at risk for falls. Review of Resident #1's nurses notes dated 01/19/2024 at 8:30 p.m. revealed, in part, S2Certified Nursing Assistant (CNA) reported to the nurse Resident #1 was in the Hoyer lift and she left the room and when she returned Resident #1 was on his back on the floor. Further review revealed the Hoyer lift was in the highest position with the Hoyer pad attached. Resident #1 was assessed and transferred to the hospital for evaluation. In an interview on 02/01/2024 at 2:05 p.m., S2CNA confirmed she was the CNA for Resident #1 on 01/19/2024. S2CNA stated Resident #1 was in the bed and the mattress needed to be changed to a low air loss mattress. S2CNA stated the low air loss mattress was in the hallway outside of Resident #1's room. S2CNA stated she asked the floor nurse to assist her with the transfer using the Hoyer lift because you are supposed to have 2 people for mechanical transfers. S2CNA stated the nurse told her she would help when she finished what she was doing. S2CNA stated she went to Resident #1's room and provided incontinence care because she thought that would give the nurse enough time to come to the room but when the nurse did not come to the room she chose to transfer Resident #1 with the Hoyer lift on her own. S2CNA stated she took the existing mattress off the bed and brought it into the hallway and when she bent down to unplug the low air loss mattress, which was in the hallway, she heard Resident #1 fall. S2CNA stated she made a mistake when she chose to transfer Resident #1 on her own using the Hoyer lift and when she left him in the room unattended while on the Hoyer lift. In an interview on 02/01/2024 at 12:40 p.m., S1Administrator confirmed he did not report Resident #1's fall from the Hoyer lift on 01/19/2024 to the state. S1Administrator confirmed Hoyer lifts should have 2 staff present at all times and a resident should not be left unattended while in the Hoyer lift. S1Administrator stated a review of video footage from 01/19/2024 confirmed S2CNA used the Hoyer lift on her own and left Resident #1's room to bring out the existing mattress and to get the low air loss mattress. S1Administator stated when S2CNA was out of the room was when Resident #1 fell from the Hoyer lift.

Aug 2023 6 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interview, the facility failed to ensure the facility staff treated a resident with respect and dignity by failing to respond to residents' request for a bedpan and was told to urinate in a diaper for 1(Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents sampled. Findings: In an interview on 08/28/2023 at 10:33 a.m., Resident #2 stated she was usually continent of her bowel and bladder, but had to go in a diaper a couple of times because facility staff could not find a bed pan. In an interview on 08/29/2023 at 8:35 a.m., Resident #2 stated she asked for the bed pan this morning, but the staff took too long to bring her the bedpan and she wetted on herself. In an interview on 08/30/2023 at 8:45 a.m., Resident #2 stated she did not have a good night last night. Resident #2 stated she asked to use the bedpan around 11:30 p.m. last night and S5Certified Nursing Assistant (CNA) told her to pee in the bed. In an interview on 08/30/2023 at 9:42 a.m., S4CNA Supervisor stated S5CNA was the CNA taking care of Resident #2. S4CNA Supervisor spoke to S5CNA who stated to S4CNA supervisor, Resident #2 asked to use a bedpan and she could not find a bed pan. S4CNA Supervisor stated S5CNA told Resident #2 she could not find a bed pan and Resident #2 asked her if she should just urinate in her diaper and S5CNA responded yes. In an interview on 08/30/2023 at 10:40 a.m., S5CNA stated Resident # 2 had asked for the bed pan last night and S5CNA could not find the bed pan. S5CNA stated she told Resident #2 she could not find the bed pan and Resident #2 asked her if she should just urinate in her diaper. S5CNA stated she responded to Resident #2, I don't know.

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to notify a resident representative of a change in tube feeding formula and new medication orders. This deficient practice was identified for 2 (Resident #1 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents sampled for failure to notify. Findings: Resident #1 Review of Resident #1's physician orders revealed, in part, a telephone order dated 06/25/2023 stating it was okay to use Isosource (a nutritional formula) 1.5 until Peptemen (a nutritional formula) comes in. In an interview on 08/29/2023 at 11:40 a.m., Resident #1's husband stated Resident #1's tube feeding was changed on 06/25/2023 from Peptamen to Isosource and facility did not notify him of the change in tube feeding. In an interview on 08/30/2023 at 1:42 p.m., S2Director of Nursing (DON) confirmed there was no documentation to indicate Resident #1's husband was made aware of the tube feeding change on 06/25/2023. S2DON stated staff should have documented they notified Resident #1's family representative of tube feeding change on 06/25/2023. Resident #4 Review of Resident #4's physician orders revealed, in part, an order written on 06/09/2023 for Flonase Allergy 50 micrograms/spray use in bilateral nostril for 7 days, and Mucinex Extended Release 600 mg give 1 tablet by mouth twice daily for 7 days. Review of Resident #4's nurses notes dated 06/01/2023 through 08/27/2023 revealed, in part, there was no documentation that Resident #4's responsible party was notified of the new orders for Flonase and Mucinex on 06/09/2023. In an interview on 08/29/2023 at 3:00 p.m., S2DON confirmed new orders for Flonase and Mucinex were written on 06/09/2023 and there was no documented evidence that Resident #4's responsible party was notified of the new orders. S2DON stated the nurses should have notified Resident #4's responsible party and documented that notification.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure pain medication was available for resident use as ordered by the Physician for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents. Findings: Review of Resident #2's August 2023 physician orders revealed Oxycodone 15 milligrams (mg) by mouth every 6 hours as needed for pain. In an interview on 08/28/2023 at 10:33 a.m., Resident #2 stated she had been having pain but had not been able to receive her pain medication since last Thursday. Resident #2 stated she received her pain medication the first two days she was in the facility, but has not had it over the weekend because staff stated the medication was not available. In an interview on 08/28/2023 at 1:15 p.m., Resident #2 stated she was in pain and her pain level was a 12 (pain scale of 8 or more indicated severe pain). Resident #2 stated she had to go through the weekend without her pain medication because the facility did not have her pain medication in stock. In an interview on 08/28/2023 at 1:20 p.m., S7Licensed Practical Nurse (LPN) stated Resident #2 has an order for Oxycodone 15 mg every 6 hours as needed, but the Oxycodone was not available in the facility at this time. S7LPN stated Resident #2's oxycodone had been out of stock since early Saturday morning on 08/26/2023. In an interview on 08/28/2023 at 3:00 p.m., S2Director of Nursing (DON) confirmed Resident #2 had been without her Oxycodone since Saturday, 08/26/2023, because the medication was not available in the facility. S2DON stated the facility was waiting for Resident #2's Oxycodone to arrive today.

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 F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to ensure adequate monitoring was completed after the initiation of new medications. This deficient practice was identified for 2 (Resident #4 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents sampled. Findings: Resident #4 Review of Resident #4's physician orders revealed, in part, new physician orders written on 06/09/2023 for Flonase Allergy RLF 50 microgram/spray use in both nostrils daily for 7 days and Mucinex extended release 600 mg by mouth twice daily for 7 days. Review of Resident #4's Nurses notes dated 06/01/2023 through 08/27/2023 revealed, in part, no adequate monitoring for efficacy and adverse consequences while these medication were being administered. Resident #5 Review of Resident #5's physician orders revealed, in part, new physician orders written on 06/09/2023 for Potassium extended release 10 milliequivalent (mEq) 1 tablet by mouth every day and on 07/01/2023 Pataday 0.2% once daily 1 drop to each eye every morning indefinitely. Review of Resident #5's nurses notes dated 06/01/2023 through 08/27/2023 revealed, in part, no adequate monitoring for efficacy and adverse consequences while these medications were being administered. In an interview on 08/30/2023 at 10:45 a.m., S2Director of Nurses (DON) stated the intake nurse transcribes the orders after they are written by the physician and the floor nurses follow through with those orders. S2DON further stated the initiation of new medication was a change in the resident's care and monitoring for efficacy and adverse reactions should have been documented. In an interview on 08/30/2023 at 1:50 p.m., S1Administrator stated he could not produce a policy on the required nursing documentation.

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview the facility failed to ensure a medication administration error rate was not equal to or greater than 5 percent. The facility had a medication administration error rate of 24%. This deficient practice was identified for 1 (S6 License Practical Nurse) of 1 nurse observed during medication administration for 2 (Resident #3 and Resident #4) of 2 (Resident #3 and Resident #4) sampled residents with 25 administration opportunities observed. Findings: Resident #3 Review of Resident #3's active physician orders revealed orders for Lexapro 5 milligrams (mg) give 1 tablet by mouth once daily; Hydrocortisone 1% cream - chest/trunk lesion - apply mixture of Bactroban and 1% hydrocortisone daily until resolved; Calcium +D soft chewable tablet give one tablet by mouth once daily; Oxybutynin 5 mg take 1 tablet by mouth once daily; and Potassium Chloride 20 milliequivalent (mEq) tablet give one tablet by mouth once daily. Observation on 08/29/2023 at 9:05 a.m. revealed S6Licensed Practical Nurse did not administer Calcium +D soft chewable tablet, Oxybutynin 5 mg tablet, and Potassium Chloride 20 mEq tablet to Resident #3 as ordered. Further observation of the medication card revealed S6LPN administered Lexapro 10 milligram tablet to Resident #3 instead of ordered Lexapro 5 milligram tablet. In an interview on 08/29/2023 at 1:25 p.m., S6LPN confirmed she had not been back into Resident #3's room since medication administration that morning and had not given any other medication to Resident #3. S6LPN confirmed she signed off as administered for Resident #3's hydrocortisone 1% cream to chest/trunk lesion, Calcium +D soft chewable tablet, Oxybutynin 5mg tablet, and Potassium CL ER 20mEq tablet, but did not give them as ordered. S6LPN further confirmed she administered Lexapro 10 milligram tablet to Resident #3 instead of the ordered Lexapro 5 milligram tablet. In an interview on 08/29/2023 at 3:00 p.m., S2Director of Nursing (DON) stated S6LPN should have been more careful when she administered Resident #3's medications in order to avoid any medication errors. Resident #4 Review of Resident #4's active physician orders revealed an order for Biofreeze 10% cream apply three times daily to bilateral knees. Observation on 08/29/2023 at 9:27 a.m. revealed S6LPN did not apply Biofreeze cream to Resident #4's bilateral knees as ordered. In an interview on 08/29/2023 at 1:25 p.m., S6LPN confirmed she had not been back into Resident #4's room since medication administration that morning and had not given any other medication to Resident #4. S6LPN confirmed she signed off as administered on administration of Resident #4's Biofreeze cream to bilateral knees for the 8:00 a.m. and 12:00 p.m. administrations, but did not apply as ordered. In an interview on 08/29/2023 at 3:00 p.m., S2Director of Nursing (DON) stated S6LPN should have been more careful when she administered Resident #4's medications in order to avoid any medication errors.

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to accurately document administration of medications for 2 (Resident #3 and Resident #4) of 3 (Resident #3, Resident #4, and Resident #5) residents reviewed for medication administration task. Findings: Resident #3 Review of Resident #3 active physician orders revealed, in part, medication orders for Hydrocortisone 1% cream, chest/trunk lesion, apply mixture of Bactroban and 1% hydrocortisone daily until resolved; Calcium +D soft chewable tablet give one tablet by mouth once daily; Oxybutynin 5 milligram (mg) TR24 take 1 tablet by mouth once daily; Potassium Chloride extended release 20 milliequivalent (mEq) tablet give one tablet by mouth once daily. Observation of medication administration on 08/29/2023 at 9:05 a.m. revealed, in part, S6LPN did not administer Resident #3's Calcium +D soft chewable tab, Oxybutynin 5mg tablet, and Potassium CL ER 20mEq tablet as ordered; however, S6Licensed Practical Nurse (S6LPN) signed off medication as administered. In an interview on 08/29/2023 at 1:25 p.m., S6LPN confirmed she had not been back into Resident #3's room since medication administration that morning and had not given any other medication to Resident #3. S6LPN confirmed she signed off on administration of Resident #3's hydrocortisone 1% cream to chest/trunk lesion, Calcium +D soft chewable tablet, Oxybutynin 5mg tablet, and Potassium CL ER 20mEq tablet but did not give them as ordered. In an interview on 08/29/2023 at 3:00 p.m., S2Director of Nursing (DON) stated S6LPN should have been more careful when she administered Resident #3's medications in order to avoid any medication errors. Resident #4 Review of Resident #4's active physician orders revealed, in part, medication order to apply Biofreeze 10% three times daily to bilateral knees. Observation of medication administration on 08/29/2023 at 9:27 a.m. revealed, in part, S6LPN did not administer Biofreeze to Resident #4 bilateral knees as ordered. In an interview on 08/29/2023 at 1:25 p.m., S6LPN confirmed she had not been back into Resident #4's room since medication administration that morning and had not given any other medication to Resident #4. S6LPN confirmed she signed off on administration of Biofreeze 10% to Resident #4's bilateral knees as ordered at 8:00 a.m. and 12:00 p.m., but did not apply as ordered. In an interview on 08/29/2023 at 3:00 p.m., S2DON stated S6LPN should have been more careful when she administered Resident #4's medications in order to avoid any medication errors.

May 2023 7 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility the facility failed to ensure residents were free from restraints for 2 (Resident #24 and Resident #279) of 2 residents investigated for restraints. Findings: Review of the facility's Restraint/Safety Device Policy and Procedure revealed, in part, physical restraints were defined as any manual methods or physical or mechanical device, matter, or equipment attached or adjacent to a resident's body that the resident cannot remove easily and restricts the resident's freedom of movement Further review revealed physical restraints include lap trays and lap belts. Review also revealed the facility must: assesses the resident's need for a restraint safety device; obtain a physician order for restraints; obtain a signed consent for the restraint; monitor restraint every shift on the medication administration record; and, ensure care plans reflect the restraint. Resident #24 Review of Resident #24's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/19/2023 revealed, in part, Resident #24 had a BIMS (Brief Interview for Mental Status) score of 11, which indicated mild cognitive impairment. Further review revealed no indication of restraint use for Resident #24. Review of Resident #24's care plan revealed, in part, Resident #24 did not have goals or interventions related to restraint use. Review of Resident #24's May 2023 physician orders revealed, in part, an order for lap tray for wheelchair use dated 04/11/2023. Review of Resident #24's April and May 2023 electronic Medication Administrator Records (eMARs) revealed, in part, order for lap tray for wheelchair use was documented on as ordered except on 05/01/2023 at 6:00 a.m. Review of Resident #24's physician progress note dated 04/11/2023 reveled, in part, lap buddy ordered, with no indication for use noted. Review of Resident #24's medical record revealed, in part, a handwritten piece of paper with a statement signed by Resident #24's responsible party indicating consent for use of lap tray with no date or further documentation noted. Observation on 05/15/2023 at 11:43 a.m., revealed Resident #24 in wheelchair that has a lap tray attached to it. In an interview on 05/15/2023 at 11:43 a.m., Resident #24 stated that she did not like the lap tray attached to her wheelchair and that she was being locked up like a damn dog. In an interview on 05/17/2023 at 10:05 a.m. S20CertifiedNursingAssistant (CNA) stated Resident #24 did not like the lap tray that was attached to Resident #24's wheelchair. S20CNA further stated that she was not sure why Resident #24 had the lap tray, and that she applied lap tray to Resident #24's wheelchair each time she got Resident #24 up into her wheelchair. In an interview on 05/17/2023 at 12:35 p.m., S15Licensed Practical Nurse (LPN) stated Resident #24's lap tray was used because she had frequent falls. Observation on 05/27/2023 at 12:45 p.m. revealed Resident #24 was sitting in the dining room with her lap tray attached to her wheelchair. Observation on 05/28/2023 at 9:38 a.m., revealed Resident #24 was sitting in her room with her lap tray attached to her wheelchair. In an interview on 05/18/2023 at 9:40 a.m., S21CNA stated Resident #24 did not like the lap tray on her wheelchair. In an interview on 05/18/2023 at 9:42 a.m., Resident #24 stated the facility put her the lap tray on her wheelchair because she kept falling out of her wheelchair. Resident #24 further stated she was not falling anymore, and did not feel she needed lap tray. Resident #24 also stated she was unable to remove her lap tray. In an interview on 05/18/2023 at 10:05 a.m., S10MDS Coordinator stated in order for a resident to have restraints, an order must be obtained, a restraint assessment should be completed, and the resident with the restraint need to be monitored. In an interview on 05/18/2023 at 1:26 p.m., S11MDS Coordinator stated she did not complete a restraint assessment for Resident #24. In an interview on 05/18/2023 at 2:10 p.m., S3Director of Nursing (DON) stated she did not realize the lap tray Resident #24 had on her wheelchair needed to be assessed. S3DON further stated she thought that in order to use a restraint on a resident, the facility only needed an order for the restraint and a consent.S3DON further stated she had not realized that Resident #24's consent was not dated. Resident #279 Review of Resident #279's open MDS with ARD of 05/12/2023 revealed, in part, Resident #279 had a BIMS score of 4, which indicated severe cognitive impairment. Further review reveled no indication of restraint use for Resident #279. Review of Resident #279's May 2023 physician orders revealed, in part, no order for use of lap belt. Review of Resident #279's baseline care plan dated 05/03/2023 revealed, in part, not applicable was marked for restraint use. Review of Resident #279's nurse's notes from admission on [DATE] to 05/16/2023 revealed no documentation regarding use of Resident #279's lap belt. Observation on 05/16/2023 at 10:30 a.m., revealed Resident #279 was in his wheelchair in the doorway of his room. Resident #279 appeared agitated and had a lap belt secured across his lap. Observation further revealed that Resident #279 was pulling at his lap belt. In an interview on 05/16/2023 at 10:30 a.m., Resident #279 stated that he did not want the lap belt on and asked the surveyor to unclasp the lap belt for him. Observation on 05/16/2023 at 10:20 a.m. revealed Resident #279 was sitting in his wheelchair with the lap belt secured across his lap. Observation further reveled Resident #279 was pulling at the lap belt and asked the surveyor to unclasp it. In an interview on 05/16/2023 at 10:20 a.m., Resident #279 stated that he could not unclasp the lap belt. Observation on 05/16/2023 at 11:16 a.m. revealed Resident #279 was sleeping in the hallway in his wheelchair with the lap belt in place. In an interview on 05/16/2023 at 11:32 a.m., S20CNA stated that she uses lap belt in order to prevent Resident #279's from falling while up in wheelchair. S20CNA further stated that Resident #279 cannot get lap belt unclasped. In an interview on 05/16/2023 at 11:36 a.m., S17LPN stated Resident #279 had a lap belt because he was a fall risk. S17LPN confirmed there was no physician's order for use of Resident #279's lap belt. S17LPN further stated that a physician's order was required for the use of a lap belt because a lap belt is considered a restraint. Observation on 05/16/2023 at 11:40 a.m. revealed Resident #279 was in dining room with the lap belt secured across his lap. Further observation revealed S17LPN asked Resident #279 to remove the lap belt. Observation revealed Resident #279 became agitated and was unable to remove the lap belt. In an interview on 05/16/2023 at 11:45 a.m., S17LPN confirmed that Resident #29 could not remove his lap belt. In an interview on 05/26/2023 at 11:50 a.m., S3DON stated that Resident #279 should not have had a lap belt on because it was a restraint. S3DON further stated if restraints were used, a physician's order was needed to be obtained and a restraint consent needed to be signed. In an interview on 05/16/2023 at 12:44 p.m., S3DON stated that the facility did not have a signed consent or a physician's order for Resident #279's lap belt.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to report an allegation of physical abuse to the State Survey Agency within two hours after the allegation was made for 1( Resident #68) of 3 Residents ( Residents #68, Resident #100 and Resident #77) that were investigated for abuse. Findings: Resident #68 was admitted to the facility on [DATE] with a diagnosis, in part, Cerebrovascular Accident (CVA) Minimum Data Set (MDS) with an Assessment Reference Date of 04/26/2023 revealed, in part, Section C- Cognitive patterns- Brief Interview for Mental Status (BIMS) 15 which means cognitively intact. Section G- Functional status- Bed mobility- extensive assistance, two person physical assist, In an interview on 05/16/2023 at 9:29a.m., Resident #68 stated on 05/09/2023 Resident #100, her roommate, hit her on the head with a shoe while she was asleep. Resident #68 stated she told S6Receptionist on 05/09/2023 in the morning hours. Resident #68 further stated she was visited by S1Administrator on 05/09/2023 and reported the physical abuse to him in person. Resident #68 stated S1Administrator did not follow-up with her or offer any help to prevent further abuse. Review of Statewide Incident Management System (SIMS) reports the facility provided revealed no report was filed for the allegation of abuse that happened on 05/9/2023 between Resident #68 and Resident #100. In an interview on 05/16/2023 at 10:18a.m., S1Administrator stated he did not file a Statewide Incident Management Systems (SIMS) report on the allegation of physical abuse made by Resident #68 because he did not feel like it was abuse since Resident #100 only tapped Resident #68 lightly. Record review revealed, in part, S6Receptionist phone call log dated 05/09/2023 at 9:15a.m., Resident #68 reported Resident #100 hit her in the head with a shoe on 05/09/2023 at 4:00a.m.

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

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Based interview and record review the facility failed to thoroughly investigate an allegation of physical abuse and prevent further potential abuse for 1( Resident #68) of 3 Residents ( Residents #68, Resident #100 and Resident #77) that were investigated for abuse. Findings: In an interview on 05/16/2023 at 9:29a.m., Resident #68 stated on 05/09/2023 Resident #100, her roommate, hit her on the head with a shoe while she was asleep. Resident #68 stated she told S6Receptionist on 05/09/2023 in the morning hours. Resident #68 further stated she was visited by S1Administrator on 05/09/2023 and reported the physical abuse to him in person. Resident #68 stated S1Administrator did not follow-up with her or offer any help to prevent further abuse. In an interview on 05/18/2023 at 10:29a.m., S6Receptionist stated she received a message from Resident #68 on 05/09/2023 at 09:15a.m. that her roommate Resident #100 hit her on the head with a shoe on 05/09/2023 at 4:00a.m. S6Receptionist further stated she gave the written message Resident #68 left stating her roommate had hit her on the head with a shoe to S2Assistant Administrator immediately after it was reported by Resident #68. In an interview on 05/16/2023 at 10:17a.m., S2Assistant Administrator stated that he vaguely recalled the allegation of abuse that occurred on 05/09/2023 between Resident #68 and Resident #100. Review of Incident/Accident Log for May2023 revealed, in part, the allegation of resident to resident abuse between Resident #68 and Resident #100 was not on the incident log. Record review revealed, in part, S6Receptionist phone call log dated 05/09/2023 at 9:15a.m., Resident #68 reported Resident #100 hit her in the head with a shoe on 05/09/2023 at 4:00a.m. In an interview on 05/16/2023 at 10:18a.m., S1Administrator stated Resident #68 told him that her roommate resident #100 touched her with a shoe. S1Administrator stated he did not notify the Provider for Resident #68 or Resident #100 of the alleged physical abuse allegation. S1Administrator stated he did not write any investigation documentation about the incident between Resident #68 and Resident #100. In an interview on 05/17/23 at 01:39p.m., S1Administrator stated the allegation of physical abuse between resident #68 and #100 should have been properly investigated. S1Administrator further stated he thought he could handle the situation without doing a written investigation.

CONCERN (D)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly. Findings: A review of the facility's Quarterly Quality Assurance Report revealed meeting date of 01/31/2023. In an interview on 05/18/2023 at 2:25 p.m., S3Director of Nursing (DON) stated the last Quality Assurance (QA) meeting was held on January 31, 2023. S3DON stated the facility had not completed the quarterly QA that was due in April 2023 because state was in the building.

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to administer hypertensive (high blood pressure) medication as prescribed for 1 (Resident #164) of 6 (Resident #57, Resident #84, Resident #89, Resident #105, and Resident #138) residents reviewed for medication administration. This deficient practice have the potential the affect any of the 172 residents on the Resident Census and Conditions of Residents (CMS-672). Findings: Review of Resident #164's medical record revealed, in part, a diagnosis of essential hypertension. Review of Resident #164's nurse's notes dated 05/02/2023 at 11:14 p.m., revealed in part, Resident #164 returned to the facility on [DATE] at 3:07 p.m. from the hospital. Review of an After Visit Summary dated 05/01/2023-05/02/2023 for Resident #164 revealed, in part, a diagnosis of hypertensive urgency. Further review revealed, in part, change Spironolactone (a diuretic that also can treat high blood pressure) 25 milligram (mg), take 1 tablet by mouth daily; continue Losartan (a medication used to treat high blood pressure) 100 mg, take 100 mg in the morning by mouth; and Carvedilol (a medication used to treat high blood pressure) 25 mg tablet, take a 25 mg tablet in the morning and a 25 mg tablet in the evening by mouth. Review of Resident #164's Medication Administration Record for May of 2023 revealed, in part the following: Carvedilol (a medication used to treat high blood pressure) 25mg tablet, take 25 mg in the morning and 25 mg in the evening by mouth not administered from 05/02/2023 to 05/11/2023; Losartan (a medication used to treat high blood pressure) 100 mg, take 100 mg in the morning by mouth not administered from 05/02/2023 to 05/12/2023; and Spironolactone 25 (a diuretic that also can treat high blood pressure) milligram (mg), take 1 tablet by mouth daily not administered from 05/02/2023 to 05/12/2023. In an interview 5/18/2023 at 1:20 p.m., S4 Assistant Director of Nursing (ADON) stated Resident #164 medication was not given as ordered from 05/02/2023 to 05/11/2023. S4ADON further stated Resident #164 should have started her new medications upon her return to the facility on [DATE]. In an interview on 05/18/2023 at 2:13 p.m., S2Assistant Administrator and S3Director of Nursing (DON) stated the staff should have called for new orders when Resident #164 return from a hospitalization on 05/02/2023. S1Administrator and S3DON further stated Resident #164 should have started her new medications upon her return to the facility on [DATE].

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on record reviews, observations, and interviews, the facility failed to ensure: 1. Expired medications were not available for administration to residents for 1 (Medication Room a) of 1 medication storage room observed and; 2. Expired medications were not available for administration to residents for 3 (Medication Cart w, Medication Cart x, and Medication Cart z) of 5 medication carts (Medication Cart u, Medication Cart w, Medication Cart x, Medication Cart y, and Medication Cart z) observed. Findings: Review of the facility's medical room guidelines revealed, in part, multi-dose vials are dated when opened and insulin vials are dated once removed from the refrigerator. Further review revealed, discontinued and expired drugs are removed from medication cart, medication room, and refrigerator. Review of the facility's medication administration policy and procedure revealed, in part, all multi-dose vials shall be labeled with an expiration date that is 28 days after the vial was opened and opened multi-dose vials that lack dates shall be discarded. #1 Observation on 05/18/2023 at 11:27 a.m., revealed Medication Room a contained a bottle of Acidophilus (a probiotic supplement) with an expiration date of 02/2023. In an interview on 05/18/2023 at 11:28 a.m., S5ADON, confirmed the bottle of Acidophilus was expired and available for use. Observation of 05/18/2023 at 11:23 a.m., revealed Medication Room a contained 3 bottles of Nutra-UTI Stat supplement with an expiration date of 02/16/2023. Observation on 05/18/2023 at 11:39 a.m., revealed Medication Room a contained 1 syringe of Heparin with an expiration date of 03/2023. In an interview on 05/18/2023 at 11:29 a.m., S3Director of Nursing (DON) confirmed the Heparin syringe in Medication Room a was expired. Observation on 05/18/2023 at 11:44 a.m., revealed an opened and punctured Novolog vial in the Medication Room a without an opened date. Observation on 05/18/2023 at 11:45 a.m., revealed an opened and punctured Lantus vial in the Medication Room a opened on 03/30/2023. In an interview on 05/18/2023 at 11:46 a.m., S5ADON stated insulin vials are good for 28 days after being opened. S5ADON further stated the vial should have been labeled with the date it was opened. #2 Observation on 05/18/2023 at 12:15 p.m., revealed Medication Cart w contained an opened Lantus pen and an opened Victoza pen without an opened date. In an interview on 05/18/2023 at 12:17 p.m., S12Licensed Practical Nurse (LPN) confirmed the Lantus and Victoza pens were opened and did not have an opened date. S12LPN confirmed the Lantus and Victoza pens should have been labeled with the date they were opened. Observation on 05/28/2023 at 12:27 p.m., revealed Medication Cart w contained a bottle of Latanoprost eye drops did not have an opened date. In an interview on 05/18/2023 at 12:27 p.m., S13LPN confirmed there was no opened date on the Latanoprost eye drops. S13LPN also confirmed the Latanoprost eye drops should have been labeled with the date they were opened. Observation on 05/18/2023 at 12:33 p.m., revealed Medication Cart x contained a bottle of Latanoprost with no opened date and a bottle of Timolol eye drops with no opened date. In an interview on 05/18/2023 at 12:34 p.m., S14LPN confirmed there were no opened dates on the bottle of Latanoprost eye drops and the bottle of Timolol eye drops. In an interview on 05/18/2023 at 12:56 p.m., S4ADON stated opened eye drops are good for 30 days on the cart and insulin pens are good for 28 days. S4ADON also stated medications should be labeled with the opened date so that the nurse knows when the medications are expired. Observation on 05/18/2023 at 12:58 p.m., revealed Medication Cart z contained Brimonidine eye drops and Dorzolamide-Timolol eye drops were not dated. In an interview on 05/18/2023 at 12:59 p.m., S16LPN stated eye drops were supposed to be labeled with an opened date and confirmed no opened date on Brimonidine eye drops and Dorzolamide-Timolol eye drops.

CONCERN (E) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations, records review and interviews, the facility failed to store and distribute food in a sanitary manner. This deficient practice had the potential to affect the 167 residents who received food from the facility's kitchen. Findings: Observation of the kitchen on 05/15/23 at 10:15 a.m. revealed the following: 1.) Roast beef on a tray on the bottom shelf of the refrigerator with a brownish- red substance which leaked on to the tray. The Roast beef was dated 04/25/2023. The refrigerators interior fan had a buildup of dust and leaked water which had dripped to the items below it in the refrigerator. The items below the fan included a box of pancakes, a 10 pound (lb) box of sausage, 3-15lb boxes of bacon, 15 dozens of pasteurized eggs. All the tops of the packages were saturated with water; and 2.) On the floor near the refrigerator was 2 boxes of 96 cups of juice and the tops of the box were saturated with water. In an interview on 05/15/2023 at 10:15 a.m., S7Dietary Manager stated the roast beef should have been discarded within 7 days of the date it was opened. S7Dietary Manager confirmed the refrigerator had leaked water on to multiple food items. On 05/15/2023 at 10:45 a.m., S8Dietary Aide tested the sanitizer solution in the three compartment sink and the results were 10 parts per million. In an interview on 05/15/2023 at 10:45 a.m., S7Dietary Manager stated the sanitizer should have been at least 50 parts per million. Observation on 05/17/23 at 11:20 a.m. revealed S7Dietary Manager and S8Dietary Aide checked the temperatures on the steam table. Observation revealed S7Dietary manager wiped the thermometer with a paper towel and then inserted the thermometer into the lasagna to obtain a temperature. The thermometer was laid on top of the lasagna. The temperatures were checked for each food item and was wiped with a paper towel in between each food item. S7Dietary Manager checked the temperature of the pureed vegetables and the thermometer fell into the container of pureed vegetables. . In an interview on 05/17/2023 at 12:05 p.m., S8Dietary Aide stated an alcohol wipe should have been used to clean the thermometer before the temperatures were checked and in between each food item. In an interview on 05/17/2023 at 12:05 p.m., S7Dietary Manager confirmed the thermometer was not cleaned with an alcohol wipe prior to and in between food items when temperatures were obtained. S7Dietary Manager confirmed the uncleaned thermometer may have cross contaminated the foods.

Apr 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and interview, the facility failed to: 1.) Ensure linen was properly contained while being transported by the Certified Nursing Assistant (CNA) for 1(S13CNA) of 1 CNAs observed who transported linen; 2.) Ensure the Certified Nursing Assistant (CNA) removed gloves and completed hand hygiene during incontinent care for 4 (S9CNA, S10CNA, S12CNA, S13CNA) of 5 (S9CNA, S10CNA, S11CNA, S12CNA, S13CNA) CNAs observed for incontinence care; and 3.) Ensure the Licensed Practical Nurse (LPN) disinfected the glucometer machine between residents when blood glucose monitoring was performed for 1 (S7LPN) of 3 (S7LPN, S8LPN, S14LPN) LPNs observed for blood glucose monitoring. Findings: 1. Review of facility Linen Handling, Storage, and Transport Policy and Procedure revealed, in part, clean linen shall be covered and transported away from the staff workers body when being transported. Resident #3's MDS(Minimum Data Sheet) with ARD(Assessment Reference Data) dated 03/15/2023 revealed, in part, Section G-Functional Status- Bed mobility extensive assistance, one person physical assist, Transfer- extensive assistance, two person physical assist, Dressing-extensive assistance, one person physical assist, Toilet use-extensive assistance, two person physical assist. Personal hygiene- Limited assistance one person physical assist. In an observation on 04/25/2023 at 8:54a.m. S13Certified Nursing Assistant (S13CNA) removed linen from the clean linen cart and placed the linen against her clothing then carried the linen into a resident's room. In an interview on 04/25/2023 at 9:06a.m., S13CNA acknowledged she placed clean linen against her clothing and use the linen to change a random resident's incontinence bed pad. In an interview on 4/26/2023 at 2:02p.m., S2DON acknowledged staff should not place linen against their clothing. 2. Review of the facility's Hand Hygiene Policy and Procedure with an effective date of 07/01/2022 revealed, in part, hand hygiene should be performed before and after direct resident contact, before and after assisting a resident with personal care, before and after assisting a resident with toileting, and before and after completing a duty. In an observation on 4/25/2023 at 9:00a.m. S13CNA provided perineal care to Resident #3. S13CNA did not perform hand hygiene before she applied gloves and provided perineal care to Resident #3. Further observation revealed S13CNA removed soiled gloves after she performed perineal care for Resident #3 and did not perform hand hygiene. In an interview on 04/25/2023 at 9:06a.m., S13CNA acknowledged she did not perform hand hygiene before or after she provided perineal care to Resident #3. In an interview on 4/26/2023 at 2:02 p.m., S2Director of Nursing (DON) acknowledged staff should have performed hand hygiene before gloves were applied. S2DON further acknowledged staff should have performed hand hygiene before and after perineal care was provided to Resident #3. Observation on 04/25/2023 at 9:09 a.m. revealed S9CNA entered Resident R8's room to provide incontinence care. Observation further revealed S9CNA donned clean gloves, opened Resident R8's soiled brief, and cleaned the top of Resident R8's genital area and down Resident R8's left and right groin area. Observation further revealed S9CNA placed a new diaper on Resident R8, covered Resident #1 with her linens, and placed Resident R8's bedside table within his reach and did not change gloves or perform hand hygiene. Observation on 04/25/2023 at 9:15 a.m. revealed S9CNA donned clean gloves, removed Resident R7's visibly soiled brief, wiped Resident R7's genital area, turned Resident R7 onto his right side, placed a new brief on Resident R7, rearranged the items on his bedside table and did not change gloves or perform hand hygiene. In an interview on 04/25/2023 at 9:20 a.m., S9CNA stated she should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident R7 and Resident R8 and before she touched personal items in Resident R7 and Resident R8's room. Observation on 04/25/2023 at 9:25 a.m. revealed S12CNA donned gloves, removed Resident R9's visibly soiled brief, wiped Resident R9's genital area, left, and right groin, turned Resident R9 onto her right side, placed a new brief on Resident R9, and did not change gloves or perform hand hygiene. In an interview on 04/25/2023 at 9:34 a.m., S12CNA stated she should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident R9. Observation on 04/25/2023 at 9:43 a.m. revealed S10CNA entered Resident R2's room to provide incontinence care. Observation revealed S10CNA donned gloves, opened Resident R2's soiled diaper, and cleaned the top of Resident R2's genital area and down Resident R2's left and right groin area. Observation revealed S10CNA proceeded to clean Resident R2 and did not change gloves or complete hand hygiene. Observation further revealed S6CNA then continued to complete Resident R2's incontinent care area, placed a clean brief on Resident R2, removed Resident R2's soiled linen, and replaced Resident R2's bed linen and did not change her gloves or perform hand hygiene. In an interview on 04/25/2023 at 9:55 a.m., S10CNA stated she should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident R2 and before she touched Resident R2's clean bed linen. In an interview on 04/25/2023 at 10:20 a.m., S5CNASupervisor stated S9CNA, S10CNA, and S12CNA should have changed their gloves and completed hand hygiene after incontinence care was provided to Resident R2, Resident R7, Resident R8, and Resident R9 and before they touched personal items in Resident R2, Resident R7 and Resident R8's room. In an interview on 04/25/2023 at 2:30 p.m., S2Director of Nursing (DON) stated S9CNA, S10CNA, and S12CNA should have changed their gloves and completed hand hygiene after incontinence care was provided to Resident R2, Resident R7, Resident R8, and Resident R9 and before they touched personal items in Resident R2, Resident R7 and Resident R8's room. 3. Review of the facility's Blood Glucose Monitoring Policy and Procedure with an effective date of 08/24/2016 revealed, in part, all surfaces of the glucometer should be disinfected with a disinfectant wipe after use. Observation on 04/24/2023 at 11:44 a.m. revealed S7LPN performed Resident R5's blood glucose assessment with the blood glucose monitor, returned to the medication cart, and did not disinfect the blood glucose monitor. Observation on 04/24/2023 at 11:52 a.m. revealed S7LPN performed Resident R6's blood glucose assessment with the blood glucose monitor previously mentioned in the above observation, returned to the medication cart, and did not disinfect the blood glucose monitor. Observation on 04/24/2023 at 11:57 a.m. revealed S7LPN performed Resident R4's blood glucose assessment with the same blood glucose monitor previously mentioned in the above observation, returned to the medication cart, and did not disinfect the blood glucose monitor. Observation on 04/24/2023 at 12:03 p.m. revealed S7LPN performed Resident R8's blood glucose assessment with the same blood glucose monitor previously mentioned in the above observation, returned to the medication cart, and did not disinfect the blood glucose monitor. In an interview on 04/24/2023 at 1:33 p.m., S7LPN confirmed she did not disinfect the blood glucose monitor when she performed blood glucose monitoring on Resident R4, Resident R5, Resident R6, and Resident R8. S7LPN further stated she should have disinfected the blood glucose monitor after each use. In an interview on 04/25/2023 at 2:30pm, S2DON stated the blood glucose monitor should be cleaned after each use with disinfectant wipes and allowed to sit for 3 minutes before being used on the next resident. In an interview on 04/26/2023 at 12:30pm, S6Infection Preventionist stated the blood glucose monitor should be cleaned after each use with disinfectant wipes and allowed to sit for 3 minutes before being used on the next resident.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the nursing staff failed to clarify, follow physician orders, and report blood pressures readings out of normal range. This deficient practice was identified for 2 (Resident #1 and Resident #5) of the 5 sampled residents, and had the potential to affect any of the 174 residents residing in the facility as documented on the Resident Census and Conditions of Residents form (CMS-672). Findings: Resident #1 Review of Resident #1 electronic record revealed admission to the facility on [DATE] from a local hospital. Review of Resident #1's hospital discharge orders titled Continue these medications which have NOT CHANGED . telmisartan (Micardis) 40mg take 20mg by mouth every evening. Take ½ tablet by mouth at bedtime. Review of Resident #1's electronic physician orders revealed, in part, an order dated 03/14/2023 for Telmisartan (a medication to lower blood pressure) 40 mg (milligrams) tablet take ½ tablet by mouth at bedtime; and discontinued on 03/15/2023. Further review of Resident #1's electronic physician orders revealed, in part, an order dated 03/15/2023 for Telmisartan 20mg tablet take half tab (10mg) total by mouth nightly. Review of Resident #1's electronic Medication Administration Record (eMAR) revealed Telmisartan was not administered on 03/14/2023 or 03/15/2023. Review of Resident #1's electronic record revealed documentation dated 03/14/2023, in part; an entry at 7:42 p.m. of blood pressure of 185/96, and a note at 8:08 p.m. of feeling weak. In an interview on 04/04/2023 at 12:40 p.m., S1Director of Nursing (DON) stated the Telmisartan order was confusing, and should have been clarified by the Licensed Practical Nurse (LPN) on admission. S1DON stated the order was clarified by S2Clinical Data Coordinator/LPN (LPN) on 03/15/2023, and was not administered. S1DON stated she received LPN's reports of Resident #1's blood pressures on admission, but the pressures were not documented. S1DON further acknowledged that Resident #1's blood pressure should have been assessed and documented at least twice daily with administration of the blood pressure medications. S1DON stated she was unable to provide any documented evidence of blood pressure readings. Resident #5 Review of Resident #5's electronic physician orders revealed, in part, an order dated 03/28/2023 for Nifedipine Extended Release/(ER) (a medication to lower blood pressure) 30 mg (milligrams) tablet every day for a Systolic Blood Pressure (SBP) (measures the pressure in your arteries when you heart beats) greater than 170 mmHg (millimeters of mercury) and a Diastolic Blood Pressure (DBP)(measures the pressure in your arteries when your heart rests between beats) less than 90 (millimeters of mercury). Review of Resident #5's handwritten orders revealed, in part an ordered dated 03/27/2023 for Nifedipine ER 30 mg tablet every day for a SBP greater than 170 mmHg and a DBP greater than 90 mmHg. In an interview on 04/05/2023 at 10:12 a.m., S3LPN stated the order for Nifedipine 30 mg ER tablet every day was entered into computer system incorrectly by S2LPN. S3LPN further stated she was administering Nifedipine ER 30 mg tablet every day to Resident #5 based on the incorrect blood pressure readings that were listed in the electronic order. In an interview on 04/05/2023 at 10:46 a.m., S2LPN stated the order for Nifedipine 30 mg tablet every day was entered incorrectly when trying to revise a nurse practitioner order entry error. S2LPN further stated the correct order for administration was for Nifedipine ER 30 mg every day for a SBP greater than 170 mmHg and a DBP greater than 90 mmHg. In an interview on 04/05/2023 at 1:00 p.m., S1DON stated Resident #5's order for Nifedipine ER 30 mg tablet every day was entered incorrectly into computer system by S2LPN. S1DON further stated Nifedipine ER 30 mg was administered when blood pressure readings did not meet the original handwritten order.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure (Resident #2) of 5 (Resident #1, #2, #3, #4 and #5) sampled residents with a suprapubic catheter had an individualized care plan implemented for monthly catheter change and to secure the suprapubic catheter to the abdomen. This deficient practice had the ability to affect 6 residents with indwelling catheters according to the Resident Census and Condition of Residents Form (CMS-672) provided by the facility. Findings: Review of Resident#2's Clinical record revealed, in part, admission to the facility on [DATE] with a history of chronic suprapubic catheter. On 09/30/2022 Resident #2 was day1, status post suprapubic catheter placement. Review of the facility's Suprapubic Catheter Care Policy and Procedure revealed, in part: Policy: Suprapubic catheter care will be provided as ordered by the physician. Procedures 9: Secure catheter to abdomen with tape or tube holder to reduce tension. Observations on 01/03/2023 at 02:50 pm and 1/4/2023 at 02:10pm, Resident#2 had a suprapubic catheter to the lower abdomen. Further observation revealed the suprapubic catheter was not secured with tape or tube holder to Resident #2's abdomen. In an interview on 01/03/2022 at 02:47 pm, Resident #2 stated the suprapubic catheter had not been secured or changed since returning to the facility on 9/30/2022. Review of physician orders dated: October 2022, November 2022, and December 2022 revealed, in part, no physician orders for a suprapubic catheter. In an interview on 01/04/2023 at 02:00pm, S3Licened Practical Nurse (LPN) acknowledged Resident #2 had a suprapubic catheter and it should be secured to the abdomen. S3LPN further stated there was no documentation Resident#2's suprapubic catheter was changed out for October 2022, November 2022, or December 2022. In an interview on 01/05/2023 at 03:00 pm, S2DON acknowledged Resident#2 did not have current physician orders specific to provide appropriate care for a resident with a suprapubic catheter. S2DON further acknowledged Resident #2 should have had physician orders specific for a suprapubic catheter. S2DON acknowledged the facility had no documentation of Resident #2's suprapubic catheter being changed out for October 2022, November 2022 or December 2022.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), $274,845 in fines, Payment denial on record. Review inspection reports carefully.
• 52 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $274,845 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
• Grade F (8/100). Below average facility with significant concerns.

Bottom line: Trust Score of 8/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is St Joseph Of Harahan's CMS Rating?

CMS assigns St Joseph of Harahan 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 St Joseph Of Harahan Staffed?

CMS rates St Joseph of Harahan's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at St Joseph Of Harahan?

State health inspectors documented 52 deficiencies at St Joseph of Harahan during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 47 with potential for harm, and 4 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates St Joseph Of Harahan?

St Joseph of Harahan 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 PLANTATION MANAGEMENT COMPANY, a chain that manages multiple nursing homes. With 206 certified beds and approximately 175 residents (about 85% occupancy), it is a large facility located in Harahan, Louisiana.

How Does St Joseph Of Harahan Compare to Other Louisiana Nursing Homes?

Compared to the 100 nursing homes in Louisiana, St Joseph of Harahan's overall rating (1 stars) is below the state average of 2.4, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting St Joseph Of Harahan?

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

Is St Joseph Of Harahan Safe?

Based on CMS inspection data, St Joseph of Harahan has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 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 St Joseph Of Harahan Stick Around?

Staff turnover at St Joseph of Harahan is high. At 56%, the facility is 10 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was St Joseph Of Harahan Ever Fined?

St Joseph of Harahan has been fined $274,845 across 1 penalty action. This is 7.7x the Louisiana average of $35,827. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is St Joseph Of Harahan on Any Federal Watch List?

St Joseph of Harahan is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 206
Avg. Residents: 175
Occupancy: 85.4%
Ownership: For profit - Limited Liability company
Chain: PLANTATION MANAGEMENT COMPANY
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
52 Deficiencies: -10
Fines ($274,845): -15
Final Score: 8/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 195374