Jefferson Healthcare Center
For profit - Limited Liability company
222 Beds
PLANTATION MANAGEMENT COMPANY
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#214 of 264 in LA
Photo by Jefferson Healthcare
Photo by Jefferson Healthcare
Photo by Jefferson Healthcare
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Jefferson Healthcare Center has received a Trust Grade of F, indicating poor performance with significant concerns about care quality. It ranks #214 out of 264 in Louisiana, placing it in the bottom half of facilities in the state, and #8 out of 12 in Jefferson County, suggesting there are better local options available. The facility is experiencing a worsening trend, with issues increasing from 12 in 2024 to 16 in 2025. Staffing is a major concern, rated at 1 star, with a high turnover rate of 60%, significantly above the state average, meaning staff may not stay long enough to build relationships with residents. Additionally, the facility has incurred $70,651 in fines, which is an average amount, but indicates ongoing compliance issues. There are also serious safety concerns, such as a failure to secure oxygen cylinders, which led to an incident where an oxygen cylinder was knocked over, creating a potential hazard for residents. Another critical issue involved residents identified as unsafe smokers who were not properly supervised, leading to situations where they could smoke unsafely without staff oversight. While the facility does have some RN coverage, it is lower than 94% of state facilities, which raises concerns about adequate oversight of resident care. Overall, families should weigh these serious weaknesses against any strengths the facility may have.
- Trust Score
- F
- In Louisiana
- #214/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $70,651 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 6 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 19%
Review needed
12 → 16 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 16 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 60%
14pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $70,651
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: PLANTATION MANAGEMENT COMPANY
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Louisiana average of 48%
The Ugly 52 deficiencies on record
4 life-threatening
May 2025
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure residents were able to access and manage their funds at all times for 3 (Resident #17, Resident #56, Resident #67) of 3 (Resident ...
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Based on interviews and record reviews, the facility failed to ensure residents were able to access and manage their funds at all times for 3 (Resident #17, Resident #56, Resident #67) of 3 (Resident #17, Resident #56, and Resident #67) sampled residents reviewed for personal funds.
Findings:
Review of the facility's Resident Trust Fund policy and procedure, undated, revealed, in part, residents or family members may deposit funds into the resident trust fund account for resident's personal spending. Further review revealed just like a bank the facility had banking hours, and to please see the facility business office specialist for a listing of the resident's banking hours.
Review of the facility's Resident Trust Fund Policy and Procedure, effective date of 01/23/2023, revealed, in part, residents who have authorized the facility to manage their personal funds must have reasonable access to those funds. Further review revealed the facility was expected to maintain amounts of petty cash on hand that may be required by the residents, and a request for fifty dollars or less would be honored the same day.
Resident #17
Review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 (score of 13-15 indicated Resident #17 was cognitively intact).
In an interview on 04/28/2025 at 10:21AM, Resident #17 indicated he could not access his funds on the weekends.
Resident #56
Review of Resident #56's MDS with an ARD of 03/21/2025 revealed a BIMS score of 12 (score of 08-12 indicated Resident #56 had a moderate cognitive impairment).
In an interview on 04/28/2025 at 10:46AM, Resident #56 indicated he could not access his funds on the weekends.
Resident #67
Review of Resident #67's MDS with an ARD of 01/29/2025 revealed a BIMS score of 14 (score of 13-15 indicated Resident #67 was cognitively intact).
In an interview on 04/28/2025 at 11:39AM, Resident #67 indicated she could not access her funds on the weekends. Resident #67 further indicated she was informed the money dispersal was closed on Saturdays and Sundays.
In an interview on 04/29/2025 at 11:30AM, S26Business Office Specialist (BOS) indicated Resident #17, Resident #56, and Resident #67 had personal funds accounts with the facility. S26BOS further indicated the process for the residents to access their funds was the facility's bank was open from 1:00PM through 3:00PM Monday through Friday. S26BOS further indicated she only opened Monday through Friday, and on the weekends she would leave a petty cash box with the weekend registered nurse, usually S2Director of Nursing (DON).
In an interview on 04/29/2025 at 11:47AM, S2DON indicated she was given a petty cash box on the weekends for residents with personal funds accounts. S2DON further indicated she can dispense funds, but she never publicized this information. S2DON further indicated the funds would only be available for the 8 hours she was working at the facility.
In an interview on 05/01/2025 at 12:20PM, S26BOS indicated the facility did not have anything documented which identified the facility's banking hours. S26BOS further indicated the facility did not have documented evidence that residents were provided with banking hours or it was discussed with residents during care plan meetings and/or resident council meets as to how to access funds on the weekends. S26BOS further indicated the facility did not have any documented evidence that any resident had accessed their funds on the weekends.
There was no documented evidence, and the facility presented no documented evidence, the facility had resident's personal funds available on the weekends and that residents were made aware that their personal funds could be accessed on weekends.
In an interview on 05/01/2025 at 1:19PM, S1Administrator indicated personal funds were available to residents on the weekends; however, the facility had no documented evidence personal funds were available on weekends, that the facility had notified residents on how to access their funds on the weekends, and/or that residents were accessing funds on the weekends.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident with a facility initiated discharge with Medica...
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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 a resident with a facility initiated discharge with Medicare Part A skilled services days remaining was provided with a Notice of Medicare Non-Coverage (NOMNC) for 1 (Resident #227) of 3 (Resident #34, Resident #68, Resident #227) sampled residents reviewed for Beneficiary Notification requirements.
Findings:
Review of Resident #227's Skilled Nursing Facility (SNF) Beneficiary Notification Review revealed, in part, Resident #227 started Medicare Part A skilled services on 09/23/024 with the last covered day of Part A services on 11/03/2024. Further review revealed the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted.
Review of Resident #227's Social Service note dated 11/04/2024 revealed, in part, social services issued a local coverage of determination (LCD) for skilled services on 11/03/2024 with discharge home on [DATE]. Further review revealed no documented evidence a Notice of Medicare Non-Coverage (NOMNC) was provided to Resident #227 or Resident #227's responsible party prior to discharge and prior to non-covered days.
There was no documented evidence, and the facility presented no documented evidence, Resident #227 was provided with a NOMNC notice prior to Medicare Part A services being discontinued.
In an interview on 04/30/2025 at 10:09AM, S19Social Services Director indicated the facility had not been able to locate Resident #227's NOMNC that should have been completed by S21Prior Social Worker.
In an interview on 05/01/2025 at 12:57PM, S1Administrator indicated the facility had identified a problem with beneficiary notices, but had not implemented a Quality Assurance and Perform Improvement (QAPI) at this time. S1Administrator further indicated the facility should have a NOMNC for the facility initiated discharge with skilled days remaining; however, the facility was unable to provide documented evidence Resident #227 or Resident #227's family was provided with a NOMNC prior to Medicare Part A services discontinuing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to maintain a sanitary environment in a resident's room for 1 (Resident #36) of 1 (Resident #36) sampled residents investigate...
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Based on observations, interviews, and record review, the facility failed to maintain a sanitary environment in a resident's room for 1 (Resident #36) of 1 (Resident #36) sampled residents investigated for environment.
Findings:
Review of Housekeeper Aide Job Description, dated 04/15/2015, revealed, in part, the primary purpose of the Housekeeper Aide was to perform the day-to day activities of the housekeeping department in accordance with current federal, state, and local standards. Further review revealed the housekeeper aide was responsible for cleaning walls by washing, wiping, dusting, spot cleaning, disinfecting, and deodorizing.
Observation on 04/28/2025 at 10:25AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed.
Observation on 04/29/2025 at 10:31AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed.
Observation on 04/30/2035 at 10:42AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed.
Observation on 05/01/2025 at 11:53AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed.
In an interview on 05/01/2025 at 11:57AM, S8Housekeeper indicated she was responsible for ensuring she cleaned each resident's room. S8Housekeeper further indicated she had cleaned and wiped all unclean areas on Resident #36's wall.
Observation with S8Houskeeper on 05/01/2025 at 12:02PM, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed.
In an interview on 05/01/2025 at 12:02PM, S8Housekeeper indicated she noticed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed.
In an interview on 05/01/2025 at 12:05PM, S5Business Office Specialist confirmed Resident #36's wall was not maintained in a sanitary manner at this time, and should have been maintained in a sanitary manner.
In an interview on 05/01/2025 at 1:43PM, S1Administrator acknowledged she was aware of the above findings and had nothing to present to dispute the above mentioned deficient practice.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure:
1. An injury of unknown origin was reported to the State ...
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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:
1. An injury of unknown origin was reported to the State Survey Agency as required after discovery of a bruise to a resident's right eye (Resident #146); and,
2. An allegation of resident to resident physical abuse was reported to the State Survey Agency as required (Resident #154).
This deficient practice was identified for 2 (Resident #146, Resident #154) of 3 (Resident #56, Resident #146, Resident #154) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse Prevention and Prohibition policy and procedure, dated 09/30/2019, revealed, in part, the facility must ensure all alleged violations involving injuries of unknown origin and abuse were reported immediately, but no later than 2 hours after the allegation was made to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with state law through established procedures.
1.
Review of Resident #146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/16/2025 revealed, in part, Resident #146 had a Brief Interview for Mental Status (BIMS) score of 02 (00-07 indicated Resident #146 had a severe cognitive impairment). Further review revealed Resident #146 required supervision for transfers and was independent for ambulation.
Review of Resident #146's progress note dated 04/20/2025 at 10:48PM revealed, in part, Resident #146 was observed with a bruise of unknown origin to the right periorbital (area around the eye) area. Further review revealed the skin to the right periorbital area was reddish-blue in color. Review further revealed Resident #146 was unable to provide a history of the bruise.
In an interview on 04/29/2025 at 5:34PM, S1Administrator indicated she was aware of Resident #146's right periorbital bruising with no witnessed falls reported around 04/20/2025. S1Administrator further indicated due to Resident #146 having a habit of picking things up off the floor the facility assumed he must have hit his eye on something or had a fall. S1Administrator indicated she did not submit a SIMS report to the State Survey Agency.
In an interview on 04/29/2025 at 5:34PM, S29Regional Administrator indicated a SIMS report was not completed for Resident #146's right periorbital bruising. S29Regional Administrator acknowledged origin of Resident #146's right periorbital bruising was not identified.
In an interview on 05/01/2025 at 1:23PM, S1Administrator indicated Resident #146 was unable to explain the reason for the bruising, and the facility had no documented evidence Resident #146 had a witnessed fall. S1Administrator further indicated the facility was unable to prove the origin of Resident #146's right periorbital injury; however she did not believe she needed to complete a SIMS report to notify the State Survey Agency of Resident #146's injury of unknown origin. S1Administrator did not offer any further explanation for the reason why the facility felt the injury of unknown origin was not reportable.
2.
Review of Resident #154's medical record revealed Resident #154 was admitted to the facility on [DATE] with diagnoses, which included, vascular dementia and mood or anxiety disturbance.
Review of Resident #154's MDS with an ARD of 01/22/2025 revealed, in part, Resident #154 had a BIMS of 03 (score of 00-07 indicated severe cognitive impairment).
Review of the facility's Incident Log revealed, in part, on 03/24/2025 Resident #154 was listed as the recipient of physical aggression on 03/24/2025 at 12:00AM with Resident #91 listed as the aggressor.
Review of Resident #154's nurse's note dated 03/24/2025 at 2:52PM revealed, in part, the staff was notified by a Certified Nursing Assistant (CNA) that Resident #91 grabbed Resident #154 out of his wheelchair. Further review revealed Resident #91 was hovering over and yelling at Resident #154.
In an interview 04/30/2025 at 2:10PM, S2Director of Nursing (DON) indicated on 03/24/2025 Resident #91 pulled Resident #154 out of a wheelchair onto floor in response to Resident #154 extending his arm out to him. S2DON was unable to verify if the incident involving Resident #91 and Resident #154 on 03/24/2025 was an allegation of resident to resident abuse which required reporting to the State Survey Agency.
There was no documented evidence, and the facility presented no documented evidence, of the allegation of resident to resident abuse involving Resident #91 and Resident #154's on 03/24/2025 had been reported to the State Survey Agency.
In an interview on 04/30/2025 at 4:15PM, S1Administrator indicated the facility had not reported the allegation of a resident to resident altercation between Resident #91 and Resident #154 to the State Survey Agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure an injury of unknown origin was thoroughly investigated for 1 (Resident #146) of 3 (Resident #56, Resident #146, Resident #154) sa...
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Based on interviews and record reviews, the facility failed to ensure an injury of unknown origin was thoroughly investigated for 1 (Resident #146) of 3 (Resident #56, Resident #146, Resident #154) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse Prevention and Prohibition policy and procedure dated 09/30/2019, revealed, in part, for an allegation of abuse, the administrator was to complete a thorough investigation, including interviews of employees who were working in the resident's room during the time in question, and obtaining signed statements from these employees. Further review revealed the investigator would interview the resident if the resident was cognitively able to answer questions, and if not able to interview, the investigator would interview the resident's roommate.
Review of Resident #146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/16/2025 revealed, in part, Resident #146 had a Brief Interview for Mental Status (BIMS) score of 02 (00-07 indicated Resident #146 had a severe cognitive impairment). Further review revealed Resident #146 required supervision for transfers and was independent for ambulation.
Review of Resident #146's progress note dated 04/20/2025 at 10:48PM revealed, in part, Resident #146 was observed with a bruise of unknown origin to the right periorbital (area around the eye) area. Further review revealed the skin to the right periorbital area was reddish-blue in color. Review further revealed Resident #146 was unable to provide a history of the bruise.
In an interview on 04/29/2025 at 5:34PM, S1Administrator indicated she was aware of Resident #146's right periorbital bruising with no witnessed falls reported around 04/20/2025. S1Administrator further indicated due to Resident #146 having a habit of picking things up off the floor the facility assumed Resident #146 may have hit his eye on something or had a fall. S1Administrator further indicated she had spot checked the security footage but did not have any documented evidence of the dates and times reviewed or what was seen, and she was still waiting on the written statements from the staff S30Certified Nursing Assistant (CNA) Supervisor had interviewed.
In an interview on 04/29/2025 at 5:48PM, S30CNA Supervisor indicated she only conducted verbal interviews with staff regarding Resident #146's right periorbital bruising. S30CNA Supervisor further indicated she had only interviewed S31CNA and S32CNA. S30CNA Supervisor further indicated she did not have any documented evidence of S31CNA and S32CNA's verbal statements as she failed to write down their statements.
In an interview on 04/29/2025 at 5:55pm S31CNA indicated none of the staff had ever interviewed her regarding Resident #146's right periorbital bruising.
In an interview on 04/29/2025 at 5:59PM, S33Licensed Practical Nurse (LPN) indicated she had not been asked about the bruising to Resident #146's right eye.
In an interview on 04/29/2025 at 6:09PM, S32CNA indicated she had notified S33LPN of the bruise to Resident #146's right periorbital area on a Thursday. S32CNA indicated the area under Resident #146's eye was reddish purple, then became black and red. S32CNA further indicated neither S30CNA Supervisor nor S1Administrator had interviewed her or asked her to write a statement regarding the bruising to Resident #146's right periorbital area.
In an interview on 05/01/2025 at 1:23PM, S1Administrator indicated the facility had assumed Resident #146 had a fall which caused the bruising/discoloration to the right periorbital area; however, Resident #146 did not have any documented falls. S1Administrator further indicated she did not document the video surveillance footage review, nor did she interview any other shifts or staff other than S31CNA and S32CNA. S1Administrator further indicated she had no other documented evidence to present that the facility had completed a thorough investigation into the bruising on Resident #146's right periorbital area.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure:
1. A referral was made to the Louisiana Office of Behavio...
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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:
1. A referral was made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for a resident with a onset of mental illness since admission (Resident #121); and,
2. A referral was made to the Louisiana Office of Behavioral Health's PASRR program for a resident identified with a mental illness upon admission (Resident #17).
This deficient practice was identified for 2 (Resident #17, Resident #121 of 3 (Resident #17, Resident #57, Resident #121) sampled residents investigated for PASRR.
Findings:
1.
Review of Resident #121's Electronic Medical Record (EMR) revealed, in part, Resident #121 was admitted to the facility on [DATE]. Further review revealed Resident #121 had a diagnosis of moderate, recurrent, Major Depressive Disorder with an onset date on 09/02/2022. Further review revealed no documented evidence a PASRR Level II evaluation was completed for Resident #121 and/or a referral was made to the Louisiana Office of Behavioral Health's PASRR program for Resident #121 since admission.
Review of facility's Quality Improvement Corrective Action Plan regarding the facility not appropriately submitting Level II reviews to the Louisiana Office of Behavioral Health's PASRR program revealed, in part, a Re-Admit Screening for New Psychiatric Diagnosis and/or Psychotropic Medication Changes form was completed for Resident #121 on 03/28/2025 as part of the facility's auditing for the Quality Improvement Corrective Action Plan.
Review of Resident #121's Re-Admit Screening for New Psychiatric Diagnosis and/or Psychotropic Medication Changes form dated 03/28/2025 revealed, in part, no documentation staff identified a referral to the Louisiana Office of Behavioral Health's PASRR program needed to be completed due to Resident #121's diagnosis of Major Depressive Disorder since his admission.
In an interview on 04/30/2025 at 1:25PM, S24Corporate Nurse acknowledged Resident #121's Major Depressive Disorder diagnosis occurred after his admission, and was a diagnosis that would have required a referral to the Louisiana Office of Behavioral Health's PASRR Program. S24Corportate Nurse further indicated the staff should have identified during the facility auditing on 03/28/2025 that Resident #121 required a referral to the Louisiana Office of Behavioral Health's PASRR program.
There was no documented evidence, and the provider did not present any documented evidence, a referral was made to the Louisiana Office of Behavioral Health's PASRR program regarding Resident #121's diagnosis of Major Depressive Disorder that occurred after his admission.
In an interview on 04/30/2025 at 1:30PM, S4Administrator Assistant indicated the facility's staff should have identified Resident #121 required a Level II PASRR evaluation during the facility's 03/28/2025 PASRR audit of Resident #121's record.
2.
Review of Resident #17's EMR revealed, in part, Resident #17 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder and Bipolar II Disorder. Further review revealed no documented evidence a PASRR Level II evaluation was completed for Resident #17 and/or a referral was made to the Louisiana Office of Behavioral Health's PASRR Program for Resident #17.
In an interview on 04/30/2025 at 1:35PM, S4Administrator Assistant indicated Resident #17 was admitted with diagnoses of Major Depressive Disorder and Bipolar II Disorder. S4Administrator Assistant further indicated if a resident was admitted with a mental illness diagnosis, a referral for a Level II PASRR evaluation should have been submitted to the Louisiana Office of Behavioral Health's PASRR program.
There was no documented evidence, and the provider did not present any documented evidence, a referral was made to the Louisiana Office of Behavioral Health's PASRR program regarding Resident #17's diagnoses of Major Depressive Disorder and Bipolar II Disorder.
In an interview on 04/30/2025 at 1:39PM, S1Administrator confirmed a referral for a Level II PASRR evaluation should have been submitted to the Louisiana Office of Behavioral Health's PASRR program for a resident who was admitted with a mental illness diagnoses.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PAS...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASRR) was accurately completed to reflect a resident's mental illness for 1 (Resident #17) of 3 (Resident #17, Resident #57, Resident #121) sampled residents investigated for PASRR requirements.
Findings:
Review of Resident #17's medical record revealed, in part, Resident #17 was admitted to the facility on [DATE] with diagnoses, which included, major depressive disorder and bipolar II disorder.
Review of Resident #17's incomplete and undated Level I PASRR revealed, in part, Resident #17 was documented to not have been diagnosed with a mental illness. Further review revealed no psychiatric diagnosis was selected/identified on the above mentioned assessment.
In an interview on 04/30/2025 at 1:35PM, S4Administrator Assistant (AA) indicated Resident #17 was admitted with diagnoses of major depressive disorder and bipolar II disorder. S4AA further indicated Resident #17's undated preadmission Level I PASRR indicated Resident #17 did not have a mental illness diagnosis, and was inaccurate and incomplete.
There was no documented evidence, and the provider did not present any documented evidence a complete Level I PASRR was completed for Resident #17.
In an interview on 04/30/2025 at 1:39PM, S1Administrator confirmed Resident #17's Level I PASRR was not verified for accuracy and completeness and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure a dependent resident received nail care for 1 (Resident #22) of 2 (Resident #21, Resident #22) sampled residents inv...
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Based on observations, interviews, and record review, the facility failed to ensure a dependent resident received nail care for 1 (Resident #22) of 2 (Resident #21, Resident #22) sampled residents investigated for activities of daily living (ADLs).
Findings:
Review of Resident #22's April 2025 Care Task log revealed, in part, Resident #114's nail care task was documented as not applicable on 05/01/2025 at 5:59AM.
Observation on 05/01/2025 at 8:28AM revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half of an inch above the tips of Resident #22's fingers. Further observation revealed an unknown gray substance was visible underneath Resident #22's nails where they extended above Resident #22's fingertips.
In an interview on 05/01/2025 at 8:28AM, Resident #22 indicated that he would like his fingernails cut.
In an interview on 05/01/2025 at 8:39AM, S25CNA indicated Resident #22 required total assistance with ADLs.
Observation on 05/01/2025 at 10:40AM revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half of an inch above the tips of Resident #22's fingers. Further observation revealed an unknown gray substance was visible underneath Resident #22's nails where they extended above Resident #22's fingertips.
Observation on 05/01/2025 at 12:47PM, revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half of an inch above the tips of Resident #22's fingers. Further observation revealed an unknown gray substance was visible underneath Resident #22's nails where they extended above Resident #22 finger tips. Further observation revealed, when Resident #22 turned his hands over to present his palms, the nails on the middle three fingers of Resident #22's left hand had an unknown gray substance packed beneath the nail area that extended above Resident #22's fingertips.
In an interview on 05/01/2025 at 12:47PM, S9Assistant Director of Nursing (ADON) acknowledged Resident #22's nails needed to be cut, and staff should have cleaned the unknown gray substance from beneath Resident #22's fingernails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to ensure a carton of nutritional supplement was stored per a manufacturer's guideline and was not available for resident consu...
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Based on observation, interviews, and record review, the facility failed to ensure a carton of nutritional supplement was stored per a manufacturer's guideline and was not available for resident consumption.
Findings:
Review of Med Plus 2.0 nutritional supplement's directions revealed, in part, the product should be used within 4 hours of opening if not refrigerated.
Observation on 05/01/2025 at 8:30AM revealed an opened unrefrigerated carton of Med Plus 2.0 nutritional supplement on Medication Cart d. Further observation revealed the above mentioned carton had an opened date of 04/30/2025.
In an interview on 05/01/2025 at 8:45AM, S13Licensed Practical Nurse (LPN) confirmed the above mentioned supplement was opened on 04/30/2025, not refrigerated, and available for resident consumption. S13LPN further indicated he did not know the supplement should have been used within 4 hours of opening if not refrigerated.
In an interview on 05/01/2025 at 11:00AM, S2Director of Nursing (DON) confirmed nursing staff should have ensured the carton of Med Plus 2.0 nutritional supplement was discarded 4 hours after being opened if not refrigerated. S2DON confirmed an opened and unrefrigerated Med Pass 2.0 nutritional supplement dated 04/30/2025 should not have been on Medication Cart d and available for use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's electronic Medication Administration Record (...
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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 a resident's electronic Medication Administration Record (eMAR) was accurately documented for 2 (Resident #14, Resident #99) of 4 (Resident #14, Resident #17, Resident #67, Resident #99) sampled residents reviewed for accurate medical record documentation.
Findings:
Review of the facility's Employee Handbook Code of Conduct dated 10/01/2024 revealed, in part, all employees were required to be truthful in all communication and written records to ensure resident records were accurate.
Review of the facility's Licensed Practical Nurse (LPN) job description dated 10/2024 revealed, in part, it was the responsibility of the LPN to have knowledge of federal and state laws and regulations related to resident care and to carry out the assigned duties and responsibilities in accordance with current existing federal and state regulations.
Resident #14
Review of Resident #14's electronic medical record revealed, in part, Resident #14 was admitted to the facility on [DATE] with a diagnoses which included unhealed pressure ulcers (wounds on the body created by prolonged pressure).
Review of Resident #14's Minimum Data Set with an Assessment Reference Date of 04/10/2025
revealed, in part, a Brief Interview for Mental Status summary score of 14, which indicated Resident #14 was cognitively intact.
In an interview on 04/29/2025 at 3:40PM, Resident #14 indicated he was not seen by a wound care nurse on 04/28/2025.
Review of Resident #14's Wound Care assessment dated [DATE] revealed, in part, the following wounds were documented as evaluated by S18Registered Nurse/Treatment Nurse (RN/TN) on 04/28/2025:
- Unstageable (a full-thickness tissue injury where the depth is obscured by eschar and/or slough) left heel pressure injury;
-Rear left malleolus deep tissue pressure injury (damage under the skin's surface that usually appears as a bruise); and,
- Stage 2 (a shallow open wound) sacral pressure injury.
In an interview on 05/01/2025 at 11:45AM, S18RN/TN indicated she did not treat and/or evaluate Resident #14's pressure ulcer wounds on 04/28/2025. S18RN/TN could offer no further explanation as to why the above mentioned documented assessments were dated 04/28/2025.
In an interview on 05/01/2025 at 10:20AM, S2Director of Nursing (DON) was presented the above findings and could offer no further explanation as to why the above mentioned documentation was inaccurate.
In an interview on 05/01/2025 at 12:25PM, S24Corporate Nurse confirmed the above mentioned assessments for Resident #14's pressure ulcers were inaccurate and should not have been.
Resident #99
Review of Resident #99's medical record revealed, in part, Resident #99 was admitted to a local hospital on [DATE] and returned back to the facility on [DATE].
Review of Resident #99's progress note by S27Licensed Practical Nurse (LPN) dated 02/16/2025 at 8:31PM revealed, in part, Resident #99 was found unresponsive and transferred by Emergency Medical Services to a local Emergency Department.
Review of Resident #99's progress note by S28LPN dated 02/19/2025 at 9:31PM revealed, in part, resident arrived back to the facility.
Review of Resident #99's February 2025 electronic Medication Administration Record (eMAR) revealed, in part, the following orders were documented as having been completed and/or administered:
- Latanoprost Ophthalmic Solution (a medication used to treat glaucoma) 0.005% 1 drop instilled in both eyes on the evening shift on 02/17/2025 at 6:08PM by S15LPN;
- Turn/repositioned every 2 hours and monitored for incontinence and skin breakdown on 02/17/2025 on the evening shift by S15LPN and on the night shift by S11LPN;
- Flushed percutaneous endoscopic gastrostomy (PEG) tube (a tube that goes directly into the stomach to receive nutrition) with 250 milliliters (mL) of water every 6 hours on 02/17/2025 at 6:00PM by S15LPN and on 02/18/2025 at 12:00AM by S11LPN;
- Non pharmalogical interventions implemented during shift: resident checked for incontinence on 02/17/2025 during the evening shift by S15LPN and on the night shift by S11LPN;
- Enhanced barrier precautions were utilized for high contact activities with resident on 02/17/2025 during the evening shift by S15LPN and on the night shift by S11LPN;
- PEG tube placement was checked on 02/17/2025 during the evening shift by S15LPN and on the night shift by S11LPN;
- Observed resident for signs of dehydration, distention, and breath sounds on 02/17/2025 during the evening shift by S15LPN and on the night shift by S11LPN;
- Isosource 1.5 enteral feed (a nutritional formula given directly into the stomach) ran at 65 mL/hour continuously through PEG tube on 02/17/2025 during the evening shift by S15LPN and on the night shift by S11LPN;
- Amount of formula and water provided to Resident #99 during the evening shift on 02/17/2025 was 400 mL on 02/17/2025 by S15LPN; and,
- Elevated Resident #99's head of the bed while receiving tube feeding during the evening shift by S15LPN and on the night shift by S11LPN.
In an interview on 05/01/2025 at 10:01AM, S14LPN indicated a nurse should not have documented medications were given or tasks were completed on the resident's eMAR unless they were actually performed. S14LPN further indicated a checkmark on the resident's eMAR indicated a medication was given and/or a task was performed.
In an interview on 05/01/2025 at 10:20AM, S2DON confirmed all resident's eMARs should have been accurate. S2DON further confirmed nurses should not have documented medications were administered and/or tasks were completed if they were not actually completed and/or performed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's physician was notified of a resident's elevat...
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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 a resident's physician was notified of a resident's elevated blood glucose level for 1 (Resident #114) of 5 (Resident #36, Resident #67, Resident #104, Resident #105, Resident #114) sampled residents investigated for unnecessary medications.
Findings:
Review of Resident #114's April 2025 physician's orders revealed, in part, an order to administer Resident #114's Humalog Insulin Pen (a medication used to help control blood glucose levels) 100 units/milliliters as per a sliding scale before meals and at bedtime. Further review revealed, if Resident #114's blood glucose level was between [PHONE NUMBER] mg/dL (milligrams per deciliter), Resident #114's physician should be called.
Review of Resident #114's April 2025 electronic Medication Administration Record (eMAR) revealed, in part:
On 04/07/2025 at 4:00PM, Resident #114's blood glucose level was 433 mg/dL;
On 04/11/2025 at 4:00PM, Resident #114's blood glucose level was 360 mg/dL;
On 04/17/2025 at 4:00PM, Resident #114's blood glucose level was 389 mg/dL;
On 04/22/2025 at 4:00PM, Resident #114's blood glucose level was 384 mg/dL;
On 04/25/2025 at 4:00PM, Resident #114's blood glucose level was 394 mg/dL;
On 04/30/2025 at 4:00PM, Resident #114's blood glucose level was 389 mg/dL;
On 04/11/2025 at 8:00PM, Resident #114's blood glucose level was 398 mg/dL;
On 04/13/2025 at 8:00PM, Resident #114's blood glucose level was 385 mg/dL;
On 04/22/2025 at 8:00PM, Resident #114's blood glucose level was 361 mg/dL;
On 04/24/2025 at 8:00PM, Resident #114's blood glucose level was 369 mg/dL;
On 04/26/2025 at 8:00PM, Resident #114's blood glucose level was 394 mg/dL;
On 04/28/2025 at 8:00PM, Resident #114's blood glucose level was 365 mg/dL; and,
On 04/29/2025 at 8:00PM, Resident #114's blood glucose level was 389 mg/dL.
There was no documented evidence, and the facility did not present any documented evidence Resident #114's physician was notified of the above mentioned blood glucose levels as ordered.
In an interview on 05/01/2025 at 12:10PM, S2Director of Nursing (DON) indicated the nurses should have been notifying Resident #114's physician for any blood glucose level above 352.
In an interview on 05/01/2025 at 1:15PM, S2DON indicated the facility had no documented evidence Resident #114's physician was notified of the above elevated blood glucose levels as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow a physician's order to ensure daily wound care was provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow a physician's order to ensure daily wound care was provided for a resident with unhealed pressure ulcers for 1 (Resident #14) of 1 (Resident #14) sampled residents reviewed for pressure ulcers.
Findings:
Review of the May 2023 Louisiana Administrative Code, Title 46, Part XLVII revealed, in part: the registered nurse retained the accountability for the total nursing care of the individual and was responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she received, regardless of whether the care was provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. Further review revealed, in part, the plan for nursing care was implemented according to the following criteria: nursing actions were consistent with the plan for nursing care and nursing actions were documented by written records.
Review of the facility's Wound Care policy and procedure, dated 11/26/2014, revealed, in part, nursing interventions for the treatment of wounds included the cleansing and dressing of wounds as ordered.
Review of Resident #14's medical record revealed, in part, Resident #14 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (a disease that causes the heart to inefficiently pump blood), peripheral vascular disease, and unhealed pressure ulcers.
Review of Resident #14's Braden Scale assessment dated [DATE] revealed, in part, a total score of 15.0, which indicated Resident #14 was at a risk for skin breakdown and/or developing a pressure ulcer.
Review of Resident #14's March through April 2025 electronic Medication Administration Record (eMAR) revealed, in part, the following physician's orders were documented as not performed:
- Clean Resident #14's left heel with normal saline, pat dry, apply santyl (a medication used to remove damaged skin tissue from wounds) to the wound bed, apply a moisture barrier to the peri wound, and cover with a dressing once a day by an unnamed agency nurse on 03/21/2025 and 04/16/2025, S16LPN/TN on 04/17/2025 and 04/21/2025, and no eMAR entry on 04/05/2025;
- Paint distal aspect of left great toe with betadine and leave open to air once a day by an unnamed agency nurse on 03/21/2025, S16Licensed Practical Nurse (LPN)/Treatment Nurse (TN) on 04/17/2025 and 04/21/2025, and no eMAR entry on 04/05/2025;
- Cleanse Resident #14's left hip Stage 3 (a wound that has broken through the top two layers of skin and into the fatty tissue below) pressure ulcer wound with wound cleanser, pat dry, apply santyl, and cover with a clean dry dressing by an unnamed agency nurse on 04/16/2025, S16LPN/TN on 04/17/2025 and 04/21/2025; and,
- Clean Resident #14's Unstageable (a full-thickness tissue injury where the depth is obscured by eschar and/or slough) sacrum pressure ulcer wound with wound cleanser, apply santyl to wound bed and surrounding area, apply barrier of choice to the surrounding wound area, and cover with a dry dressing daily and as needed until healed once a day by S16LPN/TN on 04/23/2025.
Review of Resident #14's progress notes from March 2025 through April 2025 revealed, in part, no documented evidence Resident #14 was provided wound care as ordered on the above mentioned dates.
In an interview on 04/29/2025 at 3:40PM, Resident #14 indicated there were multiple days he did not receive wound care for his unhealed pressure ulcers when he left the facility for dialysis treatment.
In an interview on 05/01/2025 at 11:45AM, S18Registered Nurse/Treatment Nurse (RN/TN) indicated Resident #14 should have received daily wound care for his unhealed pressure injuries as ordered. S18RN/TN further indicated she was unaware of any orders to hold Resident #14's wound care on the above mentioned dates related to Resident #14 attending dialysis appointments
There was no documented evidence and the facility could not provide any documented evidence, Resident #14 refused or received wound care for his unhealed pressure injuries on the above mentioned dates.
In an interview on 05/01/2025 at 12:20PM, S2Director of Nursing (DON) indicated Resident #14 should have received daily wound care as ordered. S2DON further indicated Resident #14 should have received wound care before or after his scheduled dialysis appointments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 5 (Medication Cart a, Medication Cart b, Medication Cart c, Medicatio...
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Based on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 5 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e) of 5 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e) medication carts reviewed for the reconciliation documentation of controlled substances.
Findings:
Review of the facility's Medication Administration policy and procedure dated 10/04/2024 revealed, in part, at change of shift, the off going and oncoming nurses shall count the medications in the narcotic cabinet for any discrepancies utilizing the controlled drug package inventory form.
Review of the facility's undated Controlled Drug Count Record and Package Inventory form revealed, in part, a signature acknowledged the nurse had counted the controlled drugs and had found the quantity of each medication was in agreement with the quantity stated on the Controlled Dug Administration Record. Further review revealed the nurse should have signed and had another nurse witness.
Review of the facility's April 2025 Medication Cart a Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the oncoming nurse had reconciled Medication Cart a's controlled substances with the off going nurse on 04/06/2025 for the 11:00PM to 7:00AM shift.
There was no documented evidence and the facility did not present any documented evidence the facility's nurses reconciled the controlled substances on Medication Cart a as required for the above mentioned date and times.
Review of the facility's April 2025 Medication Cart b Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart b's controlled substances with the oncoming nurse on:
- 04/03/2025 for the 11:00PM to 7:00AM shift;
- 04/04/2025 for the 11:00PM to 7:00AM shift;
- 04/07/2025 for the 11:00PM to 7:00AM shift;
- 04/08/2025 for the 11:00PM to 7:00AM shift;
- 04/13/2025 for the 11:00PM to 7:00AM shift; and,
- 04/14/2025 for the 11:00PM to 7:00AM shift.
Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart b's controlled substances with the off going nurse on:
- 04/08/2025 for the 11:00PM to 7:00AM shift;
- 04/13/2025 for the 11:00PM to 7:00AM shift;
- 04/14/2025 for the 11:00PM to 7:00AM shift; and
- 04/28/2025 for the 7:00AM to 3:00PM shift.
There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart b for the above mentioned dates and/or times.
Review of the facility's April 2025 Medication Cart c Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart c's controlled substances with the oncoming nurse on:
- 04/22/2025 for the 11:00PM to 7:00AM shift; and,
- 04/29/2025 for the 7:00AM to 3:00PM shift.
Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart c's controlled substances with the off going nurse on:
- 04/22/2025 for the 3:00PM to 11:00PM shift; and,
- 04/23/2025 for the 11:00PM to 7:00AM shift.
There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart c for the above mentioned dates and/or times.
Review of the facility's April 2025 Medication Cart d Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart d's controlled substances with the oncoming nurse on:
- 04/05/2025 for the 11:00PM to 7:00AM shift; and,
- 04/28/2025 for the 11:00PM to 7:00AM shift.
Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart d's controlled substances with the off going nurse on:
- 04/23/2025 for the 3:00PM to 11:00PM shift; and,
- 04/29/2025 for the 7:00AM to 3:00PM shift.
Further review revealed the oncoming nurse and off going nurse did not document the total number of controlled medication packages reconciled on the following dates:
- 04/01/2025;
- 04/12/2025;
- 04/13/2025;
- 04/14/2025; and,
- 04/15/2025.
There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart d for the above mentioned dates and/or times.
Review of the facility's April 2025 Medication Cart e Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart e's controlled substances with the oncoming nurse on:
- 04/01/2025 for the 3:00PM to 11:00PM shift;
- 04/15/2025 for the 7:00AM to 3:00PM shift;
- 04/16/2025 for the 7:00AM to 3:00PM shift;
- 04/21/2025 for the 7:00AM to 3:00PM shift;
- 04/22/2025 for the 7:00AM to 3:00PM shift; and,
- 04/28/2025 for the 7:00AM to 3:00PM shift.
Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart e's controlled substances with the off going nurse on:
- 04/01/2025 for the 3:00PM to 11:00PM shift;
- 04/16/2025 for the 3:00PM to 11:00PM shift; and,
- 04/29/2025 for the 7:00AM to 3:00PM shift.
Further review revealed the oncoming nurse and off going nurse did not document the total number of controlled medication packages reconciled on 04/29/2025.
There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart e for the above mentioned dates and/or times.
In an interview on 04/29/2025 at 9:15AM, S12Licensed Practical Nurse (LPN) indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the oncoming nurse at the end of their shift. S12LPN further indicated the nurses should document that the controlled substance reconciliation was completed on the facility's Controlled Drug Count Record and Package Inventory form. S12LPN further indicated she did not sign the Medication Cart c Controlled Drug Count Record and Package Inventory with the off going nurse at the beginning of her above mentioned shift on 04/29/2025 and should have.
In an interview on 04/29/2025 at 10:10AM, S17LPN indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the oncoming nurse at the end of their shift. S17LPN further indicated the nurses should have documented that the controlled substance reconciliation was completed on the facility's Controlled Drug Count Record and Package Inventory form. S17LPN further indicated she did not sign the Medication Cart e Controlled Drug Count Record and Package Inventory with the off going nurse at the beginning of her above mentioned shift on 04/29/2025 and should have.
There was no documented evidence and the facility did not present any documented evidence to dispute the above mentioned deficient practice.
In an interview on 05/01/2025 at 12:20PM, S2Director of Nursing confirmed the above mentioned Controlled Drug Count Record and Package Inventory sheets were not completed with a nurse's signature at the beginning and/or at the end of the nurse's shift as required and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the required members of the Quality Assessment and Assurance committee met at least quarterly.
Findings:
Review of the facility's Qu...
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Based on interview and record review, the facility failed to ensure the required members of the Quality Assessment and Assurance committee met at least quarterly.
Findings:
Review of the facility's Quality Assurance Policy and Procedure revealed, in part, the facility's Quality Assurance committee would meet at least quarterly to identify issues and develop, implement, and/or oversee implementation of appropriate plans of correction for identified quality deficiencies. Further review revealed the Quality Assurance committee would consist of the Medical Director (MD), the Administrator, the Director of Nursing (DON) and 3 other staff members designated by the facility.
Review of the facility's Quarterly Quality Assurance (QQA) meeting minutes on 07/26/2024 revealed the sign-in sheet documented the staff that participated in the QQA meeting, validated by signatures, included the DON, the Administrator, Dietary Manager, and MD. Further review revealed no documented evidence, and the facility was unable to present any documented evidence, additional staff were present for the 07/26/2024 QQA meeting
Review of the facility's QQA meeting minutes on 10/30/2024 revealed the sign-in sheet documented the staff that participated in the QQA meeting, validated by signatures, included the included the DON, the Assistant Director of Nursing, 3 Minimum Data Set Nurses, 2 Social Workers, the Dietary Manager, and the Nurse Educator. Further review revealed there was no documented evidence, and the facility was unable to present any documented evidence the MD and the Administrator were present for the 10/30/2024 QQA meeting.
Review of the facility's QQA meeting minutes on 01/30/2025 revealed the sign-in sheet documented the staff that participated in the QA meeting, validated by signatures, included the DON, the Administrator, and the MD. Further review revealed no documented evidence, and the facility was unable to present any documented evidence additional staff were present for the QQA meeting on 01/30/2025.
There was no documented evidence, and the facility was unable to present any documented evidence the facility's Quality Assessment and Assurance committee was composed of all required members on 07/26/2024, 10/30/2024, and 01/30/2025.
In an interview on 05/01/2025 at 11:08AM, S2DON indicated she had no additional documented evidence to present to show the QQA meetings on 07/26/2024, 10/30/2024, and 01/30/2025 had the required members in attendance.
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to administer medications per the physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident's ...
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Based on record reviews and interviews, the facility failed to administer medications per the physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident's records reviewed for pharmaceutical services.
Findings:
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/2024 revealed, in part, Resident #1 received application of an ointment or medication other than to feet.
Review of Resident #1's October 2024 Physician Orders revealed, in part, Nystatin powder (an antifungal medication) was to be applied to Resident #1's right abdominal fold twice a day and as needed until resolved. Further review revealed the nystatin powder was originally ordered on 07/09/2024.
Review of Resident #1's September 2024 electronic Medication Administration Record (eMAR) revealed, in part, Nystatin powder was scheduled to be applied at 8:00 a.m. and 4:00 p.m. daily. Further review of the September 2024 eMAR revealed nystatin powder was not applied at 8:00 a.m. on 09/07/2024 and at 4:00 p.m. on 09/03/2024, 09/04/2024, 09/05/2024, 09/07/2024, 09/08/2024, 09/10/2024, 09/11/2024, 09/12/2024, 09/13/2024, 09/14/2024, 09/15/2024, 09/16/2024, 09/17/2024, 09/18/2024, 09/19/2024, 09/20/2024, 09/21/2024, 09/22/2024, 09/23/2024, 09/24/2024, 09/27/2024, 09/28/2024, 09/29/2024, and 09/30/2024.
In an interview on 10/15/2024 at 1:44 p.m., S3Treatment Nurse indicated Resident #1's Nystatin powder was not applied twice per day on the above documented dates because she thought the Nystatin powder was ordered as needed.
In an interview on 10/15/2024 at 2:00 p.m., S2DirectorOfNursing (DON) confirmed Resident #1's Nystatin powder was ordered to be applied twice per day and as needed.
In an interview on 10/15/24 at 3:20 p.m., S2DON reviewed Resident #1's eMAR and indicated Resident #1's Nystatin powder was not applied as per the physician's orders on the above documented dates in September 2024.
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
Based on record reviews and interviews, the facility failed to ensure a Licensed Practical Nurse displayed competency to clarify a physician's order related to a medication change for 1 (Resident #1) ...
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Based on record reviews and interviews, the facility failed to ensure a Licensed Practical Nurse displayed competency to clarify a physician's order related to a medication change for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident's records reviewed for pharmaceutical services.
Findings:
Review of Louisiana Revised Statue, Title 37, Section 961 revealed, in part, the licensed practical nurse must practice under the direction of a licensed physician, optometrist, or dentist acting individually or as a member of the medical staff, registered nurse or physician assistant.
Review of Resident #1's record revealed, in part, a diagnosis of Diabetes.
Review of Resident #1's current Care Plan revealed, in part, Resident #1 has a diagnosis of Diabetes with an intervention which included to administer medications as ordered by the physician.
Review of Resident #1's October 2024 Physician Orders with a start date of 10/11/2024 revealed an order to administer Tresiba (a long acting insulin used to control high blood sugar) 30 Units (U) every day at 7:00 p.m.
In an interview on 10/16/2024 at 9:11 a.m., S2Director Of Nursing (DON) indicated S4Licensed Practical Nurse (LPN) was Resident #1's assigned nurse on 10/15/2024 from 3:00 p.m. to 11:00 p.m. and she had reported a potential issue which required clarification for Resident #1's Tresiba order.
Review of Resident #1's October 2024 Discontinued Physician orders was completed on 10/16/204 at 9:20 a.m. and revealed, in part, Tresiba 30U to be injected two times a day was ordered on 10/15/2024 and it was discontinued on 10/15/2024.
Review of Resident #1's record revealed, in part, on 10/15/2024 at 10:51 a.m. S5LPN changed Resident #1's Tresiba order from 30U every day to 30U twice per day. Further review of Resident #1's record revealed no documented evidence, and the provider was unable to present any documented evidence, of a physician's order to change Resident #1's Tresiba to 30U twice a day.
There was no documented evidence and the facility did not present any documented evidence that S4LPN and/or S5LPN called Resident #1's physician to clarify the frequency of administration of Resident #1's above mentioned Tresiba order.
In an interview on 10/16/2024 at 1:01p.m., S5LPN indicated on 10/15/2024 she changed Resident #1's Tresiba order from once a day to twice a day. S5LPN indicated she did not have a physician order to change the Tresibia to twice a day.
Review of S5LPN's personnel record revealed, in part, a hire date of 09/02/2024.
Review of S5LPN's Nursing orientation and competency revealed, in part, the competency of medications was not completed.
In an interview on 10/16/2024 at 3:15 p.m., S6Assistant Director of Nursing indicated she completed S5LPN's orientation and she must have overlooked the competency of medications.
In an interview on 10/16/2024 at 1:53p.m., S2DON indicated on Monday 10/15/2024 S5LPN changed Resident #1's Tresiba order to twice a day without a physician's order and should not have been changed without an order.
In an interview on 10/16/2024 at 3:10 p.m., S2DON confirmed S5LPN's nursing orientation and competency revealed, in part, the competency of medications was not completed and should have been completed.
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
Based on record reviews and interviews, the facility failed to ensure medication administration records were complete and/or accurately documented for 2 (Resident #1 and Resident#2) of 3 (Resident #1,...
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Based on record reviews and interviews, the facility failed to ensure medication administration records were complete and/or accurately documented for 2 (Resident #1 and Resident#2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for pharmacy.
Findings:
Review of the Licensed Practical Nurse's job description dated 04/15/2015 revealed, in part, the following responsibilities:
1. Prepare and administer medications according to procedure; and,
2. Record nursing information on resident's care plan and clinical record, including medication records.
Resident #1
Review of Resident #1's October 2024 Physician's Orders revealed, in part, the following:
1.
Gabapentin tablet (a medication used to treat seizures and neuropathic pain) give 600 milligrams (mg) three times a day;
2.
Artificial tears (a medication used to treat dry eyes) ophthalmic solution instill one drop in the left eye four times a day, and
3.
Prednisolone-Moxifloxacin-Bromfenac eye drops (an eye drop used for inflammation, infection, and pain after surgery) instill one drop three times a day.
Review of Resident #1's October 2024 electronic Medication Administration Record (eMAR) revealed, in part, no documented evidence and the facility did not present any documented evidence that the following was documented as administered:
1.
Gabapentin 600 mg for scheduled dose on 10/05/2024 at 12:00 p.m.;
2.
Artificial tears ophthalmic solution for scheduled dose on 10/05/2024 at 12:00 p.m., and
3.
Prednisolone-Moxifloxacin-Bromfenac eye drops for scheduled dose on 10/05/2024 at 2:00 p.m.
In an interview on 10/16/2024 at 9:20 a.m., S2Director of Nursing (DON) confirmed the above mentioned eMAR omissions. S2DON further indicated all medications should have been documented as administered or the appropriate chart code should be documented if the medications were not administered.
Resident #2
Review of Resident #2's October 2024 Physician Orders revealed, in part, the following:
1.
Aspirin tablet (a medication used to prevent blood clots) 81 mg, give one tablet by mouth one time a day;
2.
Ferrous Sulfate tablet (a medication used to treat iron-deficiency anemia) 325 mg, give one tablet by mouth one time a day;
3.
Folic Acid tablet (a medication used to treat vitamin B deficiency) 1mg, give one tablet by mouth one time a day;
4.
Insulin Glargine solution (a medication used to treat high blood sugar) 100 unit/milliliter(ml), inject 14 units subcutaneously one time a day;
5.
Levothyroxine Sodium tablet (a medication used to treat thyroid) 50 microgram(mcg), give one tablet by mouth two times a day;
6.
Norvasc tablet (a medication used to treat high blood pressure) 10mg, give one tablet by mouth on time a day;
7.
Zoloft tablet (a medication used to treat depression, anxiety, and post-traumatic stress disorder) 100 mg, give one tablet by mouth one time a day;
8.
Fluoxetine Hydrochloride (HCl) tablet (a medication used to treat depression) 40mg, give one tablet by mouth two times a day;
9.
Senna tablet (a medication used to treat constipation) 8.6 mg, give one tablet by mouth two times a day; and
10.
Insulin Aspart tablet (a medication used to treat high blood sugar) 100 Unit/ml, inject 3 units subcutaneously three times a day.
Review of Resident #2's October 2024 Electronic Medication Administration Record revealed, in part, no documented evidence and the facility did not present any documented evidence that the following was documented as administered:
1.
Aspirin 81mg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.;
2.
Ferrous Sulfate 325mg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.;
3.
Folic Acid 1mg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.;
4.
Insulin Glargine solution 14 units for scheduled doses on 10/1/2024 at 6:00 a.m. and 10/12/2025 at 6:00 a.m.;
5.
Levothyroxine Sodium 50 mcg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.;
6.
Norvasc 10mg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.;
7.
Zoloft 100mg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.;
8.
Fluoxetine HCl 40mg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.;
9.
Senna 8.6 mg for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m. and,
10.
Insulin Aspart 3 units for scheduled doses on 10/5/2024 at 9:00 a.m. and 10/13/2025 at 9:00 a.m.
In an interview on 10/16/2024 at 10:12 a.m., S2DON confirmed the above eMAR omissions. S2DON indicated all medications should have been documented when administered or as applicable.
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident ...
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Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents observed.
Findings:
Review of the facility's Med Pass Guidelines policy and procedure dated 12/04/2017 revealed, in part, the nurse administering medications were not to leave residents with medications in a cup. Further review revealed the nurse should make sure to see the resident take their medications.
Review of Resident #1's Annual Minimum Data Set with an Assessment Reference Date of 07/03/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact.
Review of Resident #1's record revealed no documented evidence, and the facility did not present any documented evidence Resident #1 was assessed and/or care planned to self-administer medications.
Observation on 10/10/2024 at 9:47 a.m. revealed a medicine cup containing 9 pills was on Resident #1's bedside table.
In an interview on 10/10/2024 at 9:48 a.m., Resident #1 confirmed S2Licensed Practical Nurse (LPN) left the pills on Resident #1's bedside table for Resident #1 to self-administer later.
In an interview on 10/10/2024 at 9:58 a.m., S2LPN indicated she thought Resident #1 took his medications while she was in the room. S2LPN confirmed she should have ensured Resident #1 took his medications before leaving Resident #1's room. S2LPN further confirmed medications should not have been left on Resident #1's bedside table. S2LPN confirmed Resident #1 was not care planned to have medications at his bedside.
In an interview on 10/10/2024 at 10:02 a.m., S1Director of Nursing confirmed S2LPN should not have left medications at Resident #1's bedside.
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
Based on record reviews and interviews, the facility failed to ensure a dependent resident was provided a bath for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents in...
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Based on record reviews and interviews, the facility failed to ensure a dependent resident was provided a bath for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for activities of daily living (ADLs).
Findings:
Review of the facility's Bed Bath Policy and Procedure dated 08/01/2017 revealed, in part, bed baths were to be provided to residents as scheduled and/or as needed.
Review of Resident #1's Annual Minimum Data Set with an Assessment Reference Date of 09/25/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had limitations in range of motion in his bilateral upper and lower extremities and required partial to moderate staff assistance with bathing.
Review of Resident #1's Care Plan with a start date of 04/26/2023 revealed, in part, Resident #1 was care planned to require staff assistance with ADLs with an intervention for staff to assist Resident #1 with bathing.
In an interview on 10/07/2024 at 11:59 a.m., Resident #1 indicated that he required staff assistance with bathing, but Resident #1 had not been provided a bath in weeks. Resident #1 indicated he was scheduled to receive baths on Mondays, Wednesdays, and Fridays.
Review of Resident #1's August 2024 through October 2024 Activities of Daily Living documentation revealed, in part, Resident #1 was not provided a bath during the following time periods:
-From 08/05/2024 through 08/09/2024;
-From 08/17/2024 through 08/26/2024;
-From 08/29/2024 through 09/03/2024; and,
-From 10/03/2024 through 10/06/2024.
There was no documented evidence, and the facility was unable to present any documented evidence that Resident #1 was provided a bath during the above mentioned time periods.
In an interview on 10/10/2024 at 1:15 p.m., S1Director of Nursing confirmed she did not have any documented evidence Resident #1 was provided a bath during the above mentioned time periods. S1Director of Nursing confirmed Resident #1 should have been provided baths per Resident #1's bath schedule.
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
Based on record reviews and interviews, the facility failed to ensure a resident's bath type was accurately documented for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled resi...
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Based on record reviews and interviews, the facility failed to ensure a resident's bath type was accurately documented for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for activities of daily living.
Findings:
Review of Resident #1's Annual Minimum Data Set with an Assessment Reference Date of 09/25/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had limitations in range of motion in his bilateral upper and lower extremities and required partial to moderate staff assistance with bathing.
Review of Resident #1's Care Plan with a start date of 04/26/2023 revealed, in part, Resident #1 was care planned to require staff assistance with ADLs with an intervention for staff to assist Resident #1 with bathing.
Review of Resident #1's August 2024 Bath Log revealed, in part, documentation that Resident #1 was provided a shower on the following dates:
-08/04/2024;
-08/10/2024;
-08/12/2024;
-08/15/2024;
-08/16/2024;
-08/27/2024; and,
-08/28/2024.
In an interview on 10/09/2024 at 11:45 a.m., S3Certified Nursing Assistant (CNA) indicated Resident #1 only received bed baths, and she never witnessed him get a shower. She confirmed if a resident refused a bath, it should be documented.
In an interview on 10/09/2024 at 11:49 a.m., Resident #1 indicated he did not take showers. Resident #1 stated he only received bed baths.
In an interview on 10/09/2024 at 1:11 p.m., S4Shower Aide indicated she was the shower aide responsible for Resident #1's hall and worked Monday through Friday. S4Shower Aide confirmed Resident #1 did not receive showers. S4Shower Aide further confirmed Resident #1 only received bed baths.
In an interview on 10/10/2024 at 10:38 a.m., S5CNA confirmed Resident #1 only took bed baths. S5CNA further confirmed Resident #1's above mentioned bath documentation was incorrect because Resident #1 did not receive showers.
In an interview on 10/10/2024 at 1:15 p.m. S1Director of Nursing confirmed Resident #1's baths should have been documented accurately to reflect the type of bath Resident #1 received.
Apr 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure a resident's room and equipment was kept clean for 1 (Resident #124) of 4 (Resident #21, Resident #32, Resident #46, and Resident #1...
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Based on observations and interviews, the facility failed to ensure a resident's room and equipment was kept clean for 1 (Resident #124) of 4 (Resident #21, Resident #32, Resident #46, and Resident #124) residents reviewed for environment.
Findings:
Observation on 04/15/2024 at 12:00 p.m. revealed large areas of a dried tan substance on the floor near Resident #124's tube feeding pole and on the base of the tube feeding pole.
Observation on 04/16/2024 at 10:07 a.m. revealed large areas of a dried tan substance on the floor near Resident #124's tube feeding pole and on the base of the tube feeding pole.
Observation on 04/17/2024 at 11:49 a.m. revealed large areas of a dried tan substance on the floor near Resident #124's tube feeding pole and on the base of the tube feeding pole. Observation further revealed Resident #124's wheelchair had 2 law labels (a legally required label on new items describing the fabric and filling usually saying This tag may not be removed under penalty of law except by the consumer) that were covered in a dark brown substance.
In an interview on 04/17/2024 at 11:49 a.m., S3Quality Assurance Nurse confirmed there were areas of a dried tan substance on Resident #124's floor and the base of Resident 124's tube feeding pole. S3Quality Assurance Nurse confirmed Resident #124's wheelchair had a dark brown substance on the wheelchair law labels. S3Quality Assurance Nurse further indicated Resident #124's floor, tube feeding pole, and wheelchair were not sanitary and should have been kept clean.
In an interview on 04/17/2024 at 11:53 a.m., S2Director of Nursing confirmed Resident #124's floor, tube feeding pole, and wheelchair were not sanitary and should have been kept clean.
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to check a resident's peg tube placement prior to adm...
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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 check a resident's peg tube placement prior to administration of an enteral nutritional therapy feeding (nutritional supplementation supplied through a tube that enters the stomach) for 1 (Resident #146) of 2 ( Resident #94 and Resident #146) residents investigated for nutrition.
Findings:
Review of the facility's Enteral Nutritional Therapy (Tube Feeding) Policy and Procedure dated 01/14/2016 revealed, in part, check position of tube by placing the stethoscope over the stomach and instill a small amount of air into enteral feeding tube and listen for air to enter the stomach.
Review of Resident #146's electronic Medical Record (EMR) revealed, in part, Resident #146 was admitted to the facility on [DATE] with diagnosis of dysphagia 9difficulty in swallowing) and gastrostomy status.
Review of Resident #146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2024 revealed, in part, Resident #146 was dependent on staff for feeding. Further review revealed, Resident #146 had a feeding tube while she was a resident at the facility.
Review of Resident #146's Comprehensive Care Plan dated 02/08/2024 revealed, in part, an intervention to check placement of Resident #146's before initiating my feedings.
Observation on 04/18/2024 at 1:34 p.m., revealed S12Licensed Practical Nurse (LPN) failed to check placement prior to administering Resident #146's bolus enteral feeding (a feeding that is poured slowly by staff through a resident's gastrostomy tube).
In an interview on 04/18/2024 at 1:40 p.m., S12LPN stated she did not auscultate (listen for air movement with a stethoscope) prior to administering Resident #146's flush and feeding.
In an interview on 04/18/2024 at 1:47 p.m., S3Quality Assurance Nurse stated Resident #146's peg tube should have had auscultation performed prior to administration of enteral bolus feedings or enteral flushes.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure:
1.) Ensure a resident's fall mat was at th...
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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:
1.) Ensure a resident's fall mat was at the bedside for 2 (Resident #44 and Resident #98) of 3 (Resident #12, Resident #44, and Resident #98) sampled residents reviewed for accident hazards; and,
2.) Ensure a resident's dycem was in his wheelchair for 1 (Resident #44) of 3 (Resident #12, Resident #44, and Resident #98) sampled residents reviewed for accident hazards.
Findings:
Review of the facility's policy dated 10/22/2014 and titled, Fall Prevention Program Policy and Procedure revealed, in part, residents who are classified as a high risk for falls would have a careplan addressing their goals and approaches to prevent falls.
Resident #44
Review of Resident #44's electronic medical record (EMR) revealed, in part, Resident #44 was admitted to the facility on [DATE].
Review of Resident #44's Minimum Data Set with an Assessment Reference Date of 03/20/2024 revealed Resident #44's Brief Interview for Mental Status score was 8, which indicated Resident #44 had moderate cognitive impairment.
Review of Resident #44's Comprehensive Careplan revealed, in part, Resident #44 was at risk for falls. Further review revealed Resident #44 had unwitnessed falls on 12/18/2023 and 01/11/2024. Further review revealed Resident #44 had an intervention for a fall mat to be in place at his bedside on 12/18/2023. Further review revealed Resident #44 had an intervention for a dycem (a material used to prevent a resident from sliding) to be placed in Resident #44's wheelchair on 01/11/2024.
Observation on 04/16/2024 at 10:00 a.m. revealed Resident #44 was sitting in his wheelchair. Further observation revealed Resident #44's wheelchair did not contain a dycem.
Observation on 04/16/2024 at 2:30 p.m. revealed Resident #44 was lying in bed. Further observation revealed Resident #44 did not have a fall mat visible in his room.
Observation on 04/17/2024 at 11:06 a.m. revealed Resident #44 sitting in his wheelchair. Further observation revealed Resident #44's wheelchair did not contain a dycem.
Observation on 04/18/2024 at 9:15 a.m. revealed Resident #44 sitting in his wheelchair. Further observation revealed Resident #44's wheelchair did not contain a dycem.
In an interview on 04/18/2024 at 10:05 a.m., S9Certified Nurse Assistant (CNA) stated Resident #44 has had multiple falls and was a high risk for falls. S9CNA further stated Resident #44 did not require the placement of a fall mat or dycem.
In an interview on 04/18/2024 at 10:08 a.m., S3Quality Assurance Nurse stated Resident #44 should have had a fall mat in his room at all times and he did not.
In an interview on 04/18/2024 at 9:45 a.m., S2Director of Nursing(DON) confirmed Resident #44's wheelchair did not contain dycem and it should have. S2DON further stated Resident #44's fall mat was not in place it should have been.
Resident #98
Review of Resident #98's record revealed, in part, diagnoses of Parkinsonism (a disorder of the central nervous system that affects movement), unspecified lack of coordination, and generalized muscle weakness.
Review of Resident #98's April 2024 Physician's orders revealed, in part, an order with a start date of 01/31/2023 for a fall mat at the bedside.
Review of a Fall Risk assessment dated [DATE] revealed Resident #98 had a score of 12, which indicated a high risk for falls.
Observation on 04/16/2024 at 9:15 a.m. revealed Resident #98 was lying in bed with the bed in low position and no fall mat on floor at the bedside.
Observation on 04/16/2024 at 12:40 p.m. revealed Resident #98 lying in bed with no fall mat the bedside.
Observation on 04/17/2024 at 9:15 a.m. revealed Resident #98 lying in bed with no fall mat at the bedside.
In an interview on 04/17/2024 at 3:16 p.m., S5License Practical Nurse stated Resident #98 usually did not have a fall mat at the bedside.
In an interview o 04/18/2024 at 9:45 a.m., S10CNA stated yesterday was the first day she noted a fall mat at Resident #98's bedside.
In an interview on 04/18/2024 at 10:10 a.m., S2DON stated Resident #98 should have had a fall mat at his bedside at all times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview, the facility:
1. Failed to sanitize the thermometer when internal temperatures of foods were measured; and,
2. Failed to perform hand hygiene durin...
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Based on record review, observation, and interview, the facility:
1. Failed to sanitize the thermometer when internal temperatures of foods were measured; and,
2. Failed to perform hand hygiene during meal service.
Findings:
1.
Review of the 2022 Food Code United States Food and Drug Administration revealed, in part, temperature measuring device probes must be sanitized to prevent contamination of products when internal temperatures are measured.
Observation on 04/16/2024 at 11:27 a.m. revealed S7Culinary [NAME] did not sanitize the thermometer before she inserted the thermometer into the pureed cauliflower to obtain the temperature. S7Culinary [NAME] then used a dishtowel, located on the food preparation table, to wipe the thermometer. S7Culinary [NAME] inserted the thermometer into the pureed lasagna, obtained a temperature, and wiped the thermometer with a paper towel. S7Culinary [NAME] then inserted the thermometer into the regular consistency lasagna, obtained the temperature, and wiped the thermometer with a paper towel. S7Culinary [NAME] then inserted the thermometer into the broccoli, obtained the temperature, and wiped the thermometer with a paper towel. S7Culinary [NAME] then inserted the thermometer into the brown gravy, obtained a temperature, and wiped the thermometer with the same paper towel used with the broccoli. S7Culinary [NAME] then inserted the thermometer into the container of chicken noodle soup, obtained the temperature of the chicken noodle soup, and dropped the thermometer into the chicken noodle soup. S7Culinary [NAME] did not dispose of the chicken noodle soup.
In an interview on 04/16/2024 at 11:43 a.m., S6Culinary Manager stated S7Culinary [NAME] should have sanitized the thermometer before she obtained food temperatures and in between each food. S6Culinary Manager further stated the above documented actions were not acceptable.
2.
Review of the facility's Hand Hygiene Policy and Procedure dated 07/01/2020 revealed, in part, hand hygiene should be performed before and after a resident was assisted with meals.
Observation on 04/15/2024 at 12:17 p.m. revealed S8Certified Nursing Assistant (CNA) assisted residents with meal distribution. Further observation revealed the following:
S8CNA did not perform hand hygiene, opened the door of the food cart, and took a tray out of the food cart. S8CNA brought the food tray to room a, and opened the drink, unwrapped the straw, placed the straw in the drink, unwrapped the utensils, placed the fork on the plate, and placed the spoon into the dessert. S8CNA left room a, did not perform hand hygiene, and took a tray out of the food cart. S8CNA brought the tray to room b, removed the cover from the plate, removed the cover off of the drink and dessert, opened the straw, and opened the utensils. S8CNA left room b, did not perform hand hygiene, and took a food tray out of the food cart. S8CNA brought the food tray to a different resident in room b. S8CNA used her hand to assist the resident to a seated position, and placed her left hand on the resident back. S8CNA then positioned the resident's legs, adjusted the bedside table, opened the silverware, and placed a straw in the drink. S8CNA left room b and did not perform hand hygiene.
Observation on 04/15/2024 at 12:25 p.m. revealed S8CNA took a food tray out of the food cart and brought the tray to room e. S8CNA used the incontinence pad located under the resident to pull the resident up in the bed, used the remote control to adjust the bed, adjusted the height of the bedside table, opened the drink, and uncovered the food tray. S8CNA did not perform hand hygiene. S8CNA returned to the food cart and applied gloves, took a food tray out of the food cart, and brought the tray of food to room f. S8CNA set up the meal at the resident's bedside, left the room, and did not perform hand hygiene. S8CNA, with the same gloves, pulled the food cart down the hall. S8CNA took a food tray out of the food cart and brought the tray to room g
. S8CNA used the remote control to adjust the resident's bed, repositioned the resident, covered the resident with the bed sheet, and set up the resident's food tray. S8CNA left room g and did not perform hand hygiene.
In an interview on 04/17/2024 at 10:23 a.m., S8CNA stated she failed to perform hand hygiene when she assisted residents with dining on 04/15/2024.
In an interview on 04/18/2024 at 9:01 a.m., S2Director of Nursing (DON) stated hand hygiene should have been used in the above documented observations. S2DON stated the above documented observations were not an acceptable practice.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0638
(Tag F0638)
Minor procedural issue · This affected multiple residents
Based on record review and interview, the facility failed to complete quarterly assessments in a timely manner for 7 (Resident #45, Resident #56, Resident #74, Resident #88, Resident #132, Resident #1...
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Based on record review and interview, the facility failed to complete quarterly assessments in a timely manner for 7 (Resident #45, Resident #56, Resident #74, Resident #88, Resident #132, Resident #149, and Resident #164) of 18 (Resident #6, Resident #20, Resident #45, Resident #56, Resident #74, Resident #88, Resident #92, Resident #101, Resident #103, Resident #120, Resident #130, Resident #132, Resident #147, Resident #149, Resident #158, Resident #162, Resident #164, and Resident #170) residents reviewed for resident assessments.
Findings:
Resident #45
Review of Resident #45's Quarterly Assessment with an ARD (Assessment Reference Date) of 03/06/2024 revealed, in part, the assessment was completed on 04/12/2024, and the completion date was more than 14 days after the ARD;
Resident #56
Review of Resident #56's Quarterly Assessment with an ARD of 03/06/2024 revealed, in part, the assessment was completed on 04/15/2024, and the completion date was more than 14 days after the ARD;
Resident #74
Review of Resident #74's Quarterly Assessment with an ARD of 03/06/2024 revealed, in part, the assessment was completed on 04/03/2024, and the completion date was more than 14 days after the ARD;
Resident #88
Review of Resident #88's Quarterly Assessment with an ARD of 03/06/2024 revealed, in part, the assessment was completed on 04/12/2024, and the completion date was more than 14 days after the ARD;
Resident #132
Review of Resident #132's Quarterly Assessment with an ARD of 03/06/2024 revealed, in part, the assessment was completed on 04/12/2024, and the completion date was more than 14 days after the ARD;
Resident #149
Review of Resident #149's Quarterly Assessment with an ARD of 03/06/2024 revealed, in part, the assessment was completed on 04/03/2024, and the completion date was more than 14 days after the ARD; and,
Resident #164
Review of Resident #164's Quarterly Assessment with an ARD of 03/06/2024 revealed, in part, the assessment was completed on 04/03/2024, and the completion date was more than 14 days after the ARD.
Review of the facility's Final Validation Reports dated 04/15/2024 and 04/17/2024 revealed, in part, the above mentioned resident assessments were completed after the 14th day of the ARD.
In an interview on 04/17/2024 at 3:11 p.m., S4MDS Nurse stated the above mentioned assessments were completed late and should not have been.
In an interview on 04/18/2024 at 1:15 p.m., S2Director of Nursing confirmed the above mentioned assessments were completed after the 14th day of the ARD and were not completed timely as required.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
Based on record review and interview, the facility failed to submit resident assessments to Centers for Medicare and Medicaid Services (CMS) in a timely manner for 9 (Resident #6, Resident #20, Reside...
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Based on record review and interview, the facility failed to submit resident assessments to Centers for Medicare and Medicaid Services (CMS) in a timely manner for 9 (Resident #6, Resident #20, Resident #92, Resident #103, Resident #120, Resident #130, Resident #147, Resident #162, and Resident #170) of 18 (Resident #6, Resident #20, Resident #45, Resident #56, Resident #74, Resident #88, Resident #92, Resident #101, Resident #103, Resident #120, Resident #130, Resident #132, Resident #147, Resident #149, Resident #158, Resident #162, Resident #164, and Resident #170) residents reviewed for resident assessments.
Findings:
Resident #6
Review of Resident #6's Annual assessment with an ARD of 02/28/2024 revealed, in part, the assessment was completed on 02/29/2024.
Review of the facility's Final Validation Report dated 04/15/2024 revealed, in part, Resident #6's Annual assessment was submitted to CMS on 04/15/2024 and was submitted more than 14 days after the completion date.
Resident #20
Review of Resident #20's Quarterly assessment with an ARD of 02/28/2024 revealed, in part, the assessment was completed on 02/29/2024.
Review of the facility's Final Validation Report dated 04/15/2024 revealed, in part, Resident #6's Annual assessment with an ARD of 02/28/2024 was submitted to CMS on 04/15/2024 and was submitted more than 14 days after the completion date.
Resident #92
Review of Resident #92's Annual assessment with an ARD of 03/06/2024 revealed, in part, the assessment was completed on 03/06/2024.
Review of the facility's Final Validation Report dated 04/17/2024 revealed, in part, Resident #92's Annual assessment with an ARD of 03/06/2024 was submitted to CMS on 04/17/2024 and was submitted more than 14 days after the completion date.
Resident #103
Review of Resident #103's Quarterly assessment with an ARD of 02/28/2024 revealed, in part, the assessment was completed on 03/13/2024.
Review of the facility's Final Validation Report dated 04/15/2024 revealed, in part, Resident #103's Quarterly assessment with an ARD of 02/28/2024 was submitted to CMS on 04/15/2024 and was submitted more than 14 days after the completion date.
Resident #120
Review of Resident #120's Annual assessment with an ARD of 02/21/2024 revealed, in part, the assessment was completed on 02/29/2024.
Review of the facility's Final Validation Report dated 04/15/2024 revealed, in part, Resident #120's Annual assessment with an ARD date of 02/21/2024 was submitted to CMS on 04/15/2024 and was submitted more than 14 days after the completion date.
Resident #130
Review of Resident #130's Quarterly assessment with an ARD of 01/24/2024 revealed, in part, the assessment was accepted by CMS.
Review of the facility's Final Validation Report dated 02/21/2024 revealed, in part, Resident #130's Quarterly assessment with an ARD date of 01/24/2024 was rejected by CMS due to an invalid date on 02/21/2024 and therefore not submitted.
Resident #147
Review of Resident #147's Quarterly assessment with an ARD of 02/19/2024 revealed, in part, the assessment was completed on 02/29/2024.
Review of the facility's Final Validation Report dated 04/15/2024 revealed, in part, Resident #147's Quarterly assessment with an ARD of 02/19/2024 was submitted to CMS on 04/15/2024, and was more than 14 days after the completion date.
Resident #162
Review of Resident #162's Quarterly assessment with an ARD of 02/28/2024 revealed, in part, the assessment was completed on 02/29/2024.
Review of the facility's Final Validation Report dated 04/15/2024 revealed, in part, Resident #162's Quarterly assessment with an ARD of 02/28/2024 was submitted to CMS on 04/15/2024, and was more than 14 days after the completion date.
Resident #170
Review of Resident #170's Quarterly assessment with an ARD of 02/21/2024 revealed, in part, the assessment was completed on 03/06/2024.
Review of the facility's Final Validation Report dated 04/15/2024 revealed, in part, Resident #170's Quarterly assessment with an ARD of 02/21/2024 was submitted to CMS on 04/15/2024, and was more than 14 days after the completion date.
In an interview on 4/17/2024 at 3:07 p.m., S4MDS Nurse stated she was not aware Resident 130's Quarterly assessment with an ARD of 01/24/2024 was rejected on 02/21/2024 by CMS due to an error. S4MDS Nurse confirmed Resident #130's Quarterly assessment was not submitted to CMS and should have been.
In an interview on 04/17/2024 at 3:11 p.m., S4MDS Nurse stated the above mentioned assessments for Resident #6, Resident #20, Resident #92, Resident #103, Resident #120, Resident #147, Resident #162, and Resident #170 were submitted more than 14 days after the completion date and should not have been.
In an interview on 04/18/2024 at 1:15 p.m., S2Director of Nursing confirmed the above mentioned assessments were submitted more than 14 days after the completion date and not submitted timely as required.
Nov 2023
5 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
Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse by Resident #6 and Resident #R1.
This deficiant practice w...
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Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse by Resident #6 and Resident #R1.
This deficiant practice was identified for 2 (Resident #R2 and Resident #5) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #R1, and Resident #R2) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse-Prevention and Prohibition Policy and Procedure revealed, in part, each resident has to right to be free from abuse. Further review revealed, abuse is the willful infliction of injury and physical abuse included hitting and slapping.
Resident #6
Review of the facility's incident report dated 09/21/2023 revealed, in part, Resident #6 hit Resident #R2 on the left side of the face and on the right shoulder with a closed right hand.
Review of Resident #6's nurse's notes dated 09/21/2023 revealed, in part, at 5:30 p.m. Resident #6 stood up and punched another resident in the face twice.
In an interview on 11/16/2023 at 9:50 a.m. S1Administrator stated the review of the video surveillance confirmed Resident #6 hit Resident #R2 on the left side of Resident #R2's face and on the right shoulder because Resident #R2 attempted to touch Resident #6's food. S1Administrator stated the allegation of resident to resident physical abuse was substantiated.
Resident #5
Review of the facility's Resident Incident Report for Resident #5 dated 10/16/2023 revealed, in part, Resident #5 was wandering in and out of other resident's rooms and Resident #R1 roughly pushed Resident #5 out of her room and slapped Resident #5 in the head because Resident #5 touched her breast. Further review of Resident #5's incident report revealed video surveillance of the above mentioned incident showed Resident #R1 pushing Resident #5 out of her room and punching Resident #5.
Review of Resident #5's nurse's notes dated 10/16/2023 revealed, in part, Resident #5 was hit in the head by Resident #R1 for allegedly touching her breast.
Review of the facility's incident report documentation of the above dated 10/16/2023 revealed, in part, Resident #R1 stated she slapped Resident #5 because Resident #5 touched her breast.
In an interview on 11/14/2023 at 9:47 a.m. S1Adminstrator stated the video footage confirmed Resident #R1 slapped Resident #5 on the back of the head. S1Administrator agreed Resident #R1 slapping Resident #5 on the back of the head was considered resident to resident physical abuse.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to:
1. Ensure an allegation of resident to resident sexual abuse an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to:
1. Ensure an allegation of resident to resident sexual abuse and resident to resident physical abuse involving 3 (Resident #R1, Resident 5, and Resident 17) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #R1, and Resident #R2) sampled residents reviewed for abuse was reported to the state survey agency within 2 hours of the allegation and;
2. Ensure an allegation of staff to resident physical abuse for 1 (Resident #17) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #R1, and Resident #R2) sampled residents reviewed for abuse was reported to the state survey agency within 2 hours of the allegation.
Findings:
Review of the facility's policy for Abuse-Prevention and Prohibition Policy and Procedure revealed, in part, the Administrator shall immediately initiate a Statewide Incident Management System (SIMS) report to the Louisiana Department of Health and the facility's local law enforcement agency, but not more than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse of any type or results in serious bodily injury.
Resident #R1 and Resident #5:
Review of Resident #R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/27/2023 revealed, in part, Resident #R1 had a Brief Interview for Mental Status score of 15, which indicated Resident #R1 was cognitively intact.
Review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/20/2023 revealed, in part, Resident #5 had a Brief Interview for Mental Status score of 9, which indicated Resident #5 had moderate cognitive impairment.
Review of the facility's list of facility incident report for the last six months revealed no documented evidence and the facility presented no documented evidence that the facility had completed a facility incident report for the incident involving Resident #R1 and Resident #5 on 10/16/2023.
Review of the facility's documentation titled SIMS assessment dated [DATE] revealed, in part, an allegation sexual abuse was being reviewed due to Resident #R1 calling the local sheriff department to report Resident #5 had touched her breast. Review revealed physical abuse being reviewed due to Resident #R1 slapped Resident #5 after Resident #R1 touched Resident #5 breast. Further review of the documentation revealed a decision was made not to complete a SIMS report because S1Administrator did not believe Resident #5 intentionally touched Resident #R1 inappropriately and there was no injury when Resident #R1 physically hit Resident #5.
In an interview on 11/14/2023 at 9:47 a.m., S1Administrator stated a facility incident report had not been completed for the allegations of sexual abuse nor physical abuse involving Resident #R1 and Resident #5. S1Adminisrator further stated she did not believe Resident #5 intentionally touched Resident #R1's breast, and Resident #R1 hitting Resident #5 was minimal and did not cause injury.
In an interview on 11/14/2023 at 9:50 a.m., S1Administrator agreed a facility incident report should have been completed for the allegations of abuse involving Resident #R1 and Resident #5.
Resident #17
Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE].
Further review of Resident #17's medical record revealed diagnoses of, in part, Anxiety, Depression, Alcohol Abuse, and Suicidal Ideations.
Review of Resident #17's MDS with an Assessment Reference Date of 08/07/2023 revealed, in part, a Brief Interview for Mental Status score of 6. A score of 6 indicated severely impaired cognition. Further review of Resident #17's MDS revealed Section E (Behavior) indicated Resident #17 had verbal behavior symptoms directed towards others and rejection of care.
Review of Resident #17's Nurse's Notes dated 08/13/2023 at 9:08 p.m. revealed, in part, the nurse was called to Resident #17's room by a Certified Nursing Assistant because his left arm was bleeding. Further review revealed Resident #17 stated the smoker's aide blocked the door and choked him.
Review of Resident #17's Nurse's Notes dated 09/08/2023 at 5:03 a.m. revealed, in part, the nurse was called to the smoker's patio because Resident #17 had twisted a resident's arm and hit the smoker's aide.
In an interview on 11/15/2023 at 1:20 p.m., S2Director of Nursing (DON) stated she was aware of the above documented allegations of abuse on 08/13/2023 and 09/08/2023.
In an interview on 11/15/23 at 1:22 p.m., S3Regional Quality Improvement Nurse stated there were no facility incident reports for Resident #17 for the above documented allegations of abuse.
In an interview on 11/15/2023 at 1:29 p.m., S1Administrator confirmed a facility incident report had not been completed for the allegations of abuse on 08/13/2023 and 09/08/2023. S1Administrator stated she was aware of the above documented allegations and did not complete a facility incident report.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure allegations of resident to resident sexual abuse and allegations of resident to resident physical abuse was thoroughly investigate...
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Based on record reviews and interviews, the facility failed to ensure allegations of resident to resident sexual abuse and allegations of resident to resident physical abuse was thoroughly investigated for 2 (Resident #5 and Resident #R1) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #R1, and Resident #R2), and failed to initiate an appropriate corrective action plan for 1 (Resident #5) of the 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #R1, and Resident #R2) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure revealed, in part, the Administrator will complete a thorough investigation, including interviews of employee who were working in resident's room during the time in question and obtain signed statements from those employees. Further review of policy and procedure revealed the safety of other resident and employees of the facility is of primary concern.
Review of the facility's Resident Incident Report for Resident #5 dated 10/16/2023 at 10:00 a.m. revealed, in part, Resident #5 was accused of touching another resident's breast. In response, the other resident roughly pushed him out of her room and slapped Resident #5 on his head. Further review of the incident report revealed the incident was reported to S2Director of Nursing by a certified nursing assistant.
In an interview on 11/14/2023 at 9:47 a.m., S1Administrator stated she did not believe Resident #5's touch to Resident #R1's breast was intentional.
Review S1Administrator's documentation regarding the allegation of inappropriate sexual touching of Resident #R1by Resident #5 revealed, in part, I don't believe it was an intentional touch from Resident #5.
In an interview on 11/14/2023 at 10:00 a.m., S2Director of Nursing (DON) stated Resident #5 had a history of being sexually inappropriate with residents and staff. S2DON did not remember the certified nursing assistant who reported the incident and stated she did not have a signed written witness statement from the certified nursing assistant.
Review of S1Administrator's documented interview with Resident #R1 revealed, in part, on 10/16/2023 Resident #R1 called the local sheriff department to report Resident #5 touched her breast. Review revealed Resident #R1 reported she slapped Resident #5 in the face. Further review of the statement revealed, S6Licensed Practical Nurse (LPN) intervened at the time Resident #R1 slapped Resident #5.
In an interview on 11/15/2023 at 10:08 a.m., S6Licensed Practical Nurse stated on 10/16/2023 she heard Resident #R1 yelling get out my room and then she heard what sounded like a hit or a slap and she turned to see Resident #R1 pushing Resident #5 out of her room. S6LPN stated Resident #R1 stated she hit Resident #5 because he touched her breast. S6LPN further stated she was not asked to provide a signed written witness statement and did not provide administration with a signed witness statement of the incident.
Review of Resident #5's Assessment for the Special Care Unit revealed, in part, Resident #5 was moved to the special care unit on 10/16/2023 from the general public because Resident #5 had a history of wandering in other resident's rooms and touching other residents and staff members inappropriately.
In an interview on 11/15/2023 at 10:10 a.m. S3Regional Quality Improvement Nurse confirmed Resident #5 was transferred to the dementia care unit due to Resident #5's behaviors of wandering and being sexually inappropriate with residents. S3Regional QI Nurse agreed Resident #5 was transferred to an area with vulnerable residents who are unable to report or defend themselves due to their cognitive impairments.
In an interview on 11/16/2023 at 10:00 a.m. S1Administrator stated there were no signed written witness statement from the certified nursing assistant who reported the incident and there was no signed written statement from S6LPN.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure medications were maintained in a secure manner.
Findings:
Observation on 11/13/2023 at 12:49 p.m. revealed S4Licensed Practical Nurs...
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Based on observations and interviews, the facility failed to ensure medications were maintained in a secure manner.
Findings:
Observation on 11/13/2023 at 12:49 p.m. revealed S4Licensed Practical Nurse (LPN) opened the over the counter (OTC) medication storage closet and S4LPN opened the OTC medication storage closet without the use of a key. Further observation revealed obtained a medication, closed the OTC medication storage closet door, did not lock the door, and returned to her medication cart. The surveyor remained within eyesight of the OTC medication storage closet until 12:59 p.m., at which time, S3Regional Quality Improvement Nurse approached the surveyor.
In an interview on 11/13/2023 at 12:59 p.m., S3Regional Quality Improvement Nurse stated the OTC medication storage closet should be locked at all times, and he confirmed the door was unlocked when S3Regional Quality Improvement Nurse accompanied the surveyor to the OTC closet and found the door to be unlocked. S3Regional Quality Improvement Nurse confirmed there were 57 different OTC medications stored in the unlocked OTC medication storage closet.
In an interview on 11/13/2023 at 1:02 p.m., S2Director of Nursing stated the OTC medication storage closet should have been locked.
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 F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure Licensed Practical Nurses (LPNs) did not work without their designated on-site supervisor per their Consent Agreement/Orders from ...
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Based on record reviews and interviews, the facility failed to ensure Licensed Practical Nurses (LPNs) did not work without their designated on-site supervisor per their Consent Agreement/Orders from the Louisiana State Board of Practical Nurse Examiners for 2 (S4LPN and S5LPN) of 2 (S4LPN and S5LPN) Licensed Practical Nurses reviewed for compliance with Louisiana State Board of Practical Nurse Examiners probation requirements.
Findings:
S4LPN
Review of S4LPN's Louisiana State Board of Practical Nurse Examiners Employer's agreement with a start date of 10/17/2023 revealed, in part, S4LPN would work a 7-3 shift at the facility and S2DON would be S4LPN's designated on-site supervisor. Further review revealed the on-site supervisor must be physically present at the facility at all times while the probated licensed practical nurse was present and working.
Review of S4LPN and S2DON's time sheets for November 2023 revealed, in part, S4LPN worked in the facility 6 evening shifts when S2DON was not present.
S5LPN
Review of S5LPN's Louisiana State Board of Practical Nurse Examiners Consent Agreement/Order dated 10/27/2022 revealed, in part, the license of S5License Practical Nurse (LPN), was placed on probation from 11/02/2022 until 11/01/2023. Further review of the Consent Agreement/Order revealed S5LPN must be supervised on a regular and consistent basis by S2DON, S5LPN's designated on-site supervisor.
Review of S5LPN's and S2Director of Nursing (DON)'s time sheets for the month of October 2023 revealed, in part, S5LPN worked 23 shifts in which S2DON did not supervise S5LPN as per the Consent Agreement/Order.
In an interview on 11/13/2023 at 2:29 p.m., S2DON stated she was completing the supervisor reports for S4LPN and S5LPN. S2DON further state that she was S4LPN and S5LPN's designated on-site supervisor, but was under the impression that they could work under the supervision of any administrative nurse while they were on probation.
In a telephone interview on 11/14/2023 at 9:59 a.m., the Compliance Investigator with Louisiana State Board of Practical Nurses stated when a Licensed Practical Nurse(LPN) was on probation the LPN may only work in the agreed upon facility when the agreed upon designated nurse supervisor was present in the facility. She further stated the supervisory duties could not be assigned to any other nurse. The Compliance Investigator further stated the designated supervisory nurse would have a special computer account to complete quarterly reports for the LPN on probation. She further stated S2DON completed all of S5LPN's quarterly reports to the Compliance Department for the Louisiana State Board of Practical Nurses while S5LPN was on probation and S2DON was the designated on site supervisory nurse for S4LPN.
In an interview on 11/15/2023 at 10:30 a.m., S2DON stated S4LPN and S5LPN worked shifts at the facility without her (S2DON) being physically present in the facility.
In an interview on 11/15/2023 at 10:40 a.m., S4LPN stated S2DON did not supervise her for all her shifts.
Sept 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer a resident's medication as ordered. This deficient pract...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer a resident's medication as ordered. This deficient practice was identified for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for medication administration.
Findings:
Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of, in part, History of Stroke, Hypertension, and Diabetes Mellitus Type 2.
Review of Resident #2's July 2023's Physician's Orders revealed, in part, an order for Ozempic (diabetic medication) 1 milligrams (mg) Sub Q (Subcutaneous) injection every Tuesday with a start date of 07/11/2023.
Review of Resident #2's August 2023's Physician's Orders revealed, in part, an order for Ozempic 2 mg Sub Q injection every Tuesday.
Review of Resident #2's September 2023's Physician's Orders revealed, in part, an order for Ozempic 2 mg Sub Q injection every Tuesday.
Review of Resident #2's July 2023 electronic-Medication Administration Record (e-MAR) revealed, in part, the Ozempic medication was not administered on 07/25/2023 as ordered. Further review revealed there was no documented evidence explaining why the Ozempic medication was not administered on 07/25/2023.
Review of Resident #2's August 2023 e-MAR revealed, in part, the Ozempic medication was not administered on 08/22/2023 as ordered. Further review revealed there was no documented evidence explaining why the Ozempic medication was not administered on 08/22/2023.
Review of Resident #2's September 2023 e-MAR revealed, in part, the Ozempic medication was not administered on 09/12/2023 as ordered. Further review of e-MAR's nurse's notes dated 09/13/2023 revealed, in part, Ozempic 2mg/dose scheduled for 09/12/2023 at 8:00 a.m. was not administered.
The facility was unable to provide any evidence that the above mentioned medication was administered as ordered on the above mentioned dates.
In an interview on 09/20/2023 at 2:10 p.m., S1Director of Nursing (DON), upon review of Resident #2's July, August, and September 2023's e-MAR, confirmed that Resident #2's Ozempic medication was not administered on 07/25/2023, 08/22/2023 and 09/12/2023. S1DON stated Resident #2's Ozempic medication should have been given.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to have accurate and complete documentation for oral care and bath ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to have accurate and complete documentation for oral care and bath care for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for activities of daily living.
Findings:
Resident #1:
Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed, in part, assessments of Brief Interview for Mental Status (BIMS) was a 3, which was severely impaired cognition. Review of Functional Status revealed personal hygiene and bathing required one person physical assist.
Review of Resident #1's Personal Hygiene Roster revealed, in part, from 07/09/2023 to 07/20/2023 there was no documentation of oral care being provided twice a day.
Review of the Bath Day Roster revealed, in part, from 08/20/2023 to 08/28/2023 and from 09/14/2023 to 09/18/2023 revealed no documentation of a bath.
In an interview on 09/20/2023 at 10:40 a.m., S1Director of Nursing (DON) confirmed for Resident #1 there was no documentation the resident had at bath three times a week. She also stated per their documentation the same dates keep repeating on the rooster because staff cannot update the roster to show an addendum for the previous date the bath was actually given.
In an interview on 09/20/2023 at 1:15 p.m., S1DON stated the oral care was not documented twice a day for Resident #1.
Resident #5:
Review of Resident #5's MDS dated [DATE] revealed, in part, assessments of BIMS was a 3 which was severely impaired cognition. Review of Functional Status revealed, in part, for personal hygiene and bathing Resident #1 required one person physical assistance.
Review of Resident #5 Bath Day Roster revealed in part, from 8/31/2023 to 09/06/2023 revealed no documentation of a bath.
In an interview on 09/20/2023 at 9:20 a.m., S1DON confirmed Resident#5s documentation failed to reveal a bath was given 3 times a week.
Aug 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
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure that a resident received an assistive device to...
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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 that a resident received an assistive device to maintain vision abilities for 1 (Resident #2) of 5 ( Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents.
FINDINGS:
Review of Resident #2's diagnosis revealed, in part, a history of cataracts (a cloudy area in the lens of the eye that leads to decreased vision) and Diabetes.
Review of Resident #2's MDS (Minimum Data Sheet) with ARD (Assessment Reference Data) dated 06/28/2023 revealed, in part, Section B (Hearing Speech, Vision )- corrective lenses; and Section C (Cognition) - BIMS (Brief Interview for Mental Status) Score of 15 which indicated Resident #2 was cognitively intact.
Review of progress notes dated 02/09/2023 revealed, in part, Resident #2 had surgery to her left eye.
Review of progress note dated 04/06/2023 revealed, in part, Resident #2 had surgery to her right eye.
Review of the physician's post-operative cataract surgery visit note dated 05/19/2023 revealed, in part, Resident #2 was to order new glasses at the physician's office on 05/19/2023 and follow- up with the physician in six months.
Review of a prescription dated 05/19/2023 revealed, in part, Resident #2 was ordered prescription eye glasses.
Review of Resident #2's social assessment dated [DATE] revealed, in part, Resident #2 needed a special pair of eyeglasses. Further review revealed Resident #2 was losing vision in her right eye.
In an interview on 08/22/2023 at 9:04 a.m., Resident #2 stated she had complained several times to facility staff that she had not received her prescription glasses since May of 2023. Resident #2 stated she had difficulty seeing clearly without eye glasses.
In an observation on 08/22/2023 at 9:06 a.m., Resident #2 was not wearing eye glasses.
In an interview on 08/23/2023 at 9:30 a.m., S2Director of Nursing Services (S2DNS) acknowledged Resident #2 should have had her prescription eye glasses that were ordered on 05/19/2023. S2DNS further stated S3Social Services Director (S3SSD) should have ordered Resident #2's eye glasses when the facility received the prescription 05/19/2023.
In an interview on 08/23/2023 at 10:39 a.m., S3SSD stated she was responsible for ordering Resident #2's eye glasses by sending the prescription to a provider or by scheduling her an appointment to be fitted for eye glasses.S3Social Services Director (S3SSD) stated she had no knowledge of Resident #2's eyeglass prescription dated 05/19/2023. S3SSD further stated she should have had knowledge of the eye glass prescription for Resident #2.
Jul 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to ensure residents who required assistance with activities of daily living (ADL) from staff with grooming and personal hygie...
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Based on observations, interviews, and record reviews, the facility failed to ensure residents who required assistance with activities of daily living (ADL) from staff with grooming and personal hygiene for 3 (Resident #2, Resident #3 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents reviewed.
Findings:
Resident #2
Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicated Resident #2 had moderate cognitive impairment. Further review revealed Resident #2 required physical help from staff during bathing and with personal hygiene.
Review of Resident #2's assigned task list revealed bath days were Monday, Wednesday and Friday.
Observation on 07/24/2023 at 10:20 a.m. revealed Resident #2 was in his room and S4Certified Nursing Assistant (CNA) was about to provide care for Resident #2. S4CNA stated Resident #2 required assistance with oral care and he was scheduled for a shower every Monday, Wednesday and Friday. S4CNA stated no one in her assigned section would have a shower today because they did not have a bath aide. In an interview on 07/24/2023 at 10:25 a.m., S4CNA stated there was a toothbrush on top of Resident #2's paper towel dispenser; however, it was not labeled and it was not in a container so she told Resident #2 to put toothpaste on his finger and pass it in his mouth.
In an interview on 07/24/2023 at 1:45 p.m., S3CNA Supervisor stated Resident #2 should have been provided assistance with his shower. S3CNA Supervisor stated Resident #2 should have had a toothbrush and should have been assisted with oral care.
Review of Resident #2's completed care bath task sheet for 06/01/2023 thru 07/26/23 revealed the only date a bath was given was on 07/23/2023.
In an interview on 07/26/2023 at 11:25 a.m., S2MDS Nurse stated it was the expectation that the CNA provide assistance to the resident as identified on the care plan.
S1 DON further stated the aides were responsible to bathe the residents in their section on the appropriate days and provide oral care with a toothbrush.
Resident #3
Review of Resident #3's MDS with an ARD of 06/14/2023 revealed, in part, a BIMS with a score of 15 which indicated Resident #3 was cognitively intact. Further review revealed Resident #3 required physical help from staff during bathing and with personal hygiene.
Review of Resident #3's assigned task list revealed his bath days were Monday, Wednesday and Friday.
Review of Resident #3's Completed Care Bath Task sheet revealed, no documentation and the facility did not present any documented evidence of baths being provided between; 05/13/2023 and 05/18/2023, 05/19/2023 and 05/24/2023, 06/12/2023 and 06/27/2023, and 06/27/2023 and 07/05/2023.
In an interview on 07/26/2023 at 12:00 p.m., S2MDS Nurse stated Resident #3 received baths only on the days listed on the bath report summary from the completed care documentation.
In an interview on 07/26/2023 at 1:20 p.m., S6Corporate Nurse acknowledged Resident #3's Completed Care Bath Task revealed, no baths were given between; 05/13/2023 and 05/18/2023, 05/19/2023 and 05/24/2023, 06/12/2023 and 06/27/2023, and 06/27/2023 and 07/05/2023.
Resident #4
Review of Resident #4's MDS with ARD of 05/10/2023 revealed, in part, a BIMS score of 11 which indicated Resident #4 had moderate cognitive impairment. Further review revealed Resident #4 required total assistance with bathing and toileting and was incontinent of bowel and bladder.
Review of Resident #4's care plan revealed an assigned task list which included bath days were Monday, Wednesday and Friday.
In an interview on 07/25/2023 at 12:30 p.m., S5CNA stated peri-care was documented in the electronic medical record.
In an interview on 07/26/2023 at 8:55 a.m., S1DON confirmed Resident #4's bath schedule was Monday, Wednesday and Friday.
Review of Resident #4's completed care bath task sheet dated 06/01/2023 thru 07/17/2023 revealed Resident #4 received a shower on 06/02/2023, 06/28/2023, 06/30/2023 and 07/03/2023.
Review of Resident #4's completed care hygiene task sheet dated 06/01/2023 thru 07/17/2023 revealed
Resident #4 received peri-care on 06/03/2023, and 07/08/2023.
In an interview on 07/26/2023 1:10 p.m., S1DON stated when the CNA staff provide peri-care after an incontinent episode, the CNA should document the assistance in the electronic health record. S1DON confirmed Resident #4's completed care hygiene task sheet dated 06/01/2023 thru 07/17/2023 revealed peri care was completed on 06/03/2023 and 07/08/2023.
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
Based on interview and record review, the facility failed to ensure medications were available for resident use as ordered by the Physician for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident...
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Based on interview and record review, the facility failed to ensure medications were 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 July 2023 Physician Orders revealed Lidocaine 5% patch (a medication used to treat itching and pain) apply onto skin every day.
Review of Resident #2's July 2023 electronic Medication Administration Record (eMAR) revealed, in part, on 07/10/2023, 07/20/2023, 07/21/2023, 07/22/2023 and 07/25/2023 at 8:00 a.m Lidocaine 5% patch was documented as N. Review of the eMAR's legend revealed when a N indicated the medication was not administered as ordered.
On 07/25/2023 at 12:50 p.m., S1Director of Nursing (DON) reviewed Resident #2's July 2023 eMAR and confirmed Resident #2's Lidocaine 5% patch was documented as not administered on 07/10/2023, 07/20/2023, 07/21/2023, 07/22/2023 and 07/25/2023. S1DON stated Resident #2's Lidocaine 5% patch was not administered because it was not available in the facility because it required a prior authorization from the physician.
May 2023
10 deficiencies
2 IJ (1 affecting multiple)
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected 1 resident
The facility failed to be administered in a manner that uses resources to effectively and efficiently meet the needs of the residents by failing to:
1. Ensure residents (Resident #143 and Resident #13...
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The facility failed to be administered in a manner that uses resources to effectively and efficiently meet the needs of the residents by failing to:
1. Ensure residents (Resident #143 and Resident #132), with a known history of unsafe, smoking were supervised while smoking; and,
2. Ensure residents who were identified as unsafe smokers, did not have access to smoking materials for 4 (Resident #41, Resident #109, Resident #132, Resident #143) of 4 unsafe smokers reviewed for safe smoking. The facility documented 13 residents that were unsafe smokers.
The deficient practice resulted in an Immediate Jeopardy situation for Resident #143 on 05/21/2023 at 1:02pm when Resident #143, an unsafe smoker that required supervision, was sitting in her wheelchair in the smoking patio near the entrance of Dayroom Z smoking a cigarette without supervision of staff and without a smoker's apron in place. Resident #143 was observed smoking a cigarette with visible ashes noted falling on Resident #143's shirt and wheelchair. The immediate Jeopardy situation continued for the following: On 05/22/2023 at 2:48 p.m. when Resident #41, an unsafe smoker, was observed in his room lying across his bed with a red pack of cigarettes with 2 cigarettes in the pack, exposed out the bottom of his shorts. On 05/23/2023 at 5:54 a.m. Resident #132, an unsafe smoker that required supervision, was sitting outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision. On 05/23/2023 at 9:48 a.m. when Resident #109, an unsafe smoker, was observed rolling down Hall Y towards the smoking area with an unlit cigarette in his mouth.
S1Administrator was notified of the Immediate Jeopardy on 05/23/2023 at 11:01 a.m.
The Immediate Jeopardy was removed on 05/23/2023 at 4:40 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included:
1.
Corrective actions were taken for the residents (Resident #41, Resident #109, Resident #132 and Resident #143) affected by the deficient practice by:
-
Regional Director in-serviced the Administrator and Administrative staff on 05/23/2023 at 2:00 p.m. on ensuring the safety of unsafe smokers,
-
Facility audit performed on 05/23/2023 at 10:45 revealed that unsafe smokers did not have any smoking materials in their possession.
2.
All residents who reside in the facility had the potential to be affected by the deficient practice. The facility had a census of 173.
3.
Measures were put into place to ensure the deficient practice would not recur were:
-
Regional Director in-serviced the Administrator on 05/23/2023 at 2:00 p.m. on ensuring the safety of unsafe smokers.
-
Facility audit performed on 05/23/2023 at 10:45 revealed that unsafe smokers did not have any smoking materials in their possession.
4.
The facility planned to monitor its performance to ensure solutions were achieved and sustained by:
-
Regional Director or designee would perform Quality Assurance (QA) administration audits 2 times per week until 06/23/2023 to ensure the facility was being administered in a manner that use its resources to effectively and efficiently meet the needs and safety of unsafe smokers.
-
Regional Quality Improvement Nurse or designee would perform QA administration nursing audits 2 times per week until 06/23/2023 to ensure the facility was being administered in a manner that use its resources to effectively and efficiently meet the needs and safety of unsafe smokers.
5.
The likelihood of serious harm to Resident #41, Resident #109, Resident #132 and Resident #143 no longer existed after 2:00 p.m. on 05/23/2023.
The deficient practice has the likelihood to cause serious harm to the remaining 9 residents identified as unsafe smokers by the facility.
Findings:
Cross Reference F689
In an interview on 05/23/2023 at 10:00 a.m., S2Director of Nursing (DON) stated Resident #143 was caught smoking in her room the weekend prior to 05/01/2023 and Resident #143 was deemed an unsafe smoker after that incident.
In an interview on 05/23/2023 at 10:05 a.m., S1Administrator stated the designated smoking area was the patio centrally located in the center of the building. S1Administrator stated residents who require assistance or are unsafe smokers have specific interventions specified on their careplan and smoking assessment that outlined the reason they are unsafe and the interventions the facility has put into place. S1Administrator stated Resident #40, Resident #109, Resident #132, and Resident #143 are all unsafe smokers. S1Adminstrator stated Resident #143 is an unsafe smoker because she was caught smoking in her room. S1Administrator stated she was not concerned Resident #143 would catch herself on fire. S1Adminsitrator stated unsafe smokers should not have their smoking material on their person in the facility at any time.
In an interview on 05/23/2023 at 10:25 a.m., S7Coorporate Nurse confirmed Resident #143 had half of a brown cigarette on her bedside table. S7Cooporate Nurse further stated Resident #143 should not be in possession of smoking material.
In an interview on 05/23/2023 at 1:30 p.m., S30Regional Director stated he had in-serviced S1Adminsitrator on ensuring the safety of unsafe smokers. S30Regional Director further stated, S30Regional Director or designee would perform administrative audits 2 times per week until 06/23/2023 to ensure the facility is being administered in a manner that used its resources to effectively and efficiently meet the needs and safety of unsafe smokers.
In an interview on 05/24/2023 at 10:30 a.m., S29Clinical Director of Operations stated the facility needed to ensure they had a better system in place for all of the smokers in the facility.
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to:
1. Ensure residents (Resident #143 and Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to:
1. Ensure residents (Resident #143 and Resident #132), with a known history of unsafe, smoking were supervised while smoking; and,
2. Ensure residents who were identified as unsafe smokers, did not have access to smoking materials for 4 (Resident #41, Resident #109, Resident #132, Resident #143) of 4 unsafe smokers reviewed for safe smoking. The facility documented 13 residents that were unsafe smokers.
The deficient practice resulted in an Immediate Jeopardy situation for Resident #143 on 05/21/2023 at 1:02pm when Resident #143, an unsafe smoker that required supervision, was sitting in her wheelchair in the smoking patio near the entrance of Dayroom Z smoking a cigarette without supervision of staff and without a smoker's apron in place. Resident #143 was observed smoking a cigarette with visible ashes noted falling on Resident #143's shirt and wheelchair. The immediate Jeopardy situation continued for the following: On 05/22/2023 at 2:48 p.m. when Resident #41, an unsafe smoker, was observed in his room lying across his bed with a red pack of cigarettes with 2 cigarettes in the pack, exposed out the bottom of his shorts. On 05/23/2023 at 5:54 a.m. Resident #132, an unsafe smoker that required supervision, was sitting outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision. On 05/23/2023 at 9:48 a.m. when Resident #109, an unsafe smoker, was observed rolling down Hall Y towards the smoking area with an unlit cigarette in his mouth.
S1Administrator was notified of the Immediate Jeopardy on 05/23/2023 at 10:19 a.m.
The Immediate Jeopardy was removed on 05/23/2023 at 4:40 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included:
1.
Corrective actions were taken for residents (#143, #132, #41, and #109) for the deficient practice by:
-
The Director of Nursing (DON) in-serviced all staff who were currently in the facility on 05/23/2023 at 1:00 p.m. to ensure unsafe smokers were supervised and ensure their smoking materials/or cigarettes were not in their possession. An unsafe smokers list was placed at the nurse's station. Staff were given copies of the unsafe smokers list. Staff currently not at the facility would be in-serviced at the beginning of their next shift. All staff would be in-serviced by 05/25/2023.
-
Corporate nurse went to Resident #143's room on 05/23/2023 at 10:00 a.m. and removed smoking materials from resident's possession and educated on ensuring smoking materials were kept on the nurses cart.
-
DON, Assistant Director of Nursing(ADON) and Administrator removed smoking materials from Resident #132, #41, #109, and #143 on 05/23/2023 at 10:45 a.m. Residents were educated to ensure smoking materials were kept on the nurses cart.
2.
All residents who resided in the facility had the potential to be affected by the deficient practice. The facility had a census of 173.
3.
Measures put into place to ensure the deficient practice would not recur were:
-
DON in-serviced staff on 05/23/2023 at 1:00 p.m. to ensure unsafe smokers were supervised and ensured their smoking materials/or cigarettes were not in their possession. Staff in-serviced that an unsafe smokers list was placed at the nurse's station. Staff were also given a copy of the unsafe smokers list. Staff currently not at the facility would be in-serviced at the beginning of their next shift. All staff would be in-serviced by 05/25/2023.
-
A facility wide audit was performed by the DON, ADON, Administrator, and Corporate Nurse on 05/23/2023 at 10:45 a.m. to ensure all unsafe smokers were not in possession of smoking materials/cigarettes.
-
Starting on 05/23/2023 at 11:00 a.m. the facility would have a smoking aide assigned to the smoker's patio to supervise unsafe smokers from 7:00 a.m. - 10:00 p.m. During the times of 10:00 pm - 7:00 a.m. the charge nurse would make visual observations of the smoker's patio to ensure safety. If an unsafe smoker would like to smoke between the hours of 10:00 p.m. - 7:00 a.m., the charge nurse would perform supervision.
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Starting on 05/23/2023 at 4:00 p.m. the DON or designee would provide direct supervision observations 2 times a week until 06/25/2023 to ensure the smoking aid or designated staff were supervised residents appropriately.
-
The facility performed a resident council meeting on 05/23/2023 at 2:00 p.m. to educate smoking resident on not sharing smoking materials with other residents.
-
On 05/23/2023 at 11:00 a.m. the facility placed a nursing intervention order on all unsafe smokers electronic record to be signed every shift to ensure staff were aware of which resides were considered unsafe smokers.
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On 05/23/2023 at 12:30 p.m. the facility placed an unsafe smokers alert on the unsafe resident's task care plan in the resident's electronic chart to be signed off by certified nursing assistants (CNAs) every shift.
4.
The facility planned to monitor its performance to ensure solutions were achieved and sustained by:
-
DON or designee would perform visual observation facility audits 2 times per week until 06/23/2023 to ensure unsafe smokers were appropriately supervised and were not in possession of smoking materials.
5.
The likelihood of serious harm to resident #132, #41, #109, and #143 no longer existed after 2:00 p.m. on 05/23/2023.
The deficient practice has the likelihood to cause serious harm to the remaining 9 residents identified as unsafe smokers by the facility.
Findings:
Review of the facility's Smoking Policy and Procedure revealed, in part, safe smoking assessment and/or Interdisciplinary (ID) Team will determine if resident is safe to smoke. Residents deemed unsafe will be discussed with ID Team to determine protocol to be implemented on individual basis (ex. smoking apron needed, cigarettes stored at nurses station, lighter removed from resident from resident possession, direct supervision needed, etc.). Safe smoking assessments will be completed on residents who smoke upon admission, re-smoking assessments will be completed on residents who smoke upon admission, readmission, quarterly, annually, significant changes, and as needed. Further review revealed no documented evidence for the protocol of when direct supervision was required for unsafe smokers.
Resident #143
Review of Resident #143's face sheet revealed, in part, Resident #143 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease and Nicotine Dependence
Review of Resident #143's social services note dated 04/11/2023 revealed, in part, Resident #143's Brief Interview for Mental status Score was 15 which indicated Resident #143 was cognitively intact.
Review of Resident #143's Comprehensive Care Plan revealed, in part, Resident #143 may be at risk for potential for injury related to her smoking habit and on 05/01/2023 Resident #143 was deemed an unsafe smoker. Further review revealed Resident #143 should have a smoker's apron when she smoked, be instructed to smoke in designated smoke areas, be instructed on safe measures to dispense smoking material, may need her cigarettes and lighter administered to her by staff when Resident #143 needed to smoke. Further review revealed, in part, Resident #143 may need supervision when she smoked.
Review of Resident #143's nurses' notes revealed, in part, a nurse's note with a date of 05/01/2023 written by S2DirectorOfNursing which stated Resident #143 was reported to have smoked in her room over the weekend. Further review revealed, in part, all smoking paraphernalia was removed from Resident #143's room and was placed in the nurse's cart.
Review of Resident #143's assessment for safe smoking date of completion: 05/31/2023 revealed, in part, Resident #143 was an unsafe smoker. Review of this assessment revealed Resident #143 had a history of smoking and had been considered an unsafe smoker since an episode of smoking in her room. Review of this assessment revealed Resident #143's smoking material was removed from her room and must be kept on the nurse's cart. Review of this assessment revealed Resident #143 must ask a nurse for her cigarettes and be supervised in the smoking area.
Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #143 was an unsafe smoker. Review revealed Resident #143 required her smoking items be kept on the cart, supervision while smoking, and assistance provided as needed while smoking.
Observation on 05/21/2023 at 1:02 p.m. revealed, Resident #143, an unsafe smoker that required supervision, was sitting in her wheelchair in the smoking patio near the entrance of Dayroom Z. Observation revealed Resident #143 took a cigarette from Resident #13. Resident #13 then lit Resident #143's cigarette and the two residents began to smoke together. Observation revealed Resident #143 dropped ashes on her shirt. Observation further revealed Resident #143 discarded her cigarette in the sewage drain. At this time Resident #143 did not have a smoking apron on and no staff were present to supervise Resident #143.
In an interview on 05/21/2023 at 1:28 p.m., Resident #143's son stated Resident #143 does smoke.
In an interview on 05/21/2023 at 1:30 p.m., S14Certified Nursing Assistant (CNA) stated Resident #143 goes outside and smokes frequently on the smoking patio near Dayroom Z. S14CNA stated Resident #143 does not require supervision when smoking and she is allowed to keep her own cigarettes.
Observation on 05/22/2023 at 12:31 p.m. revealed, Resident #143 in her room in her wheelchair with cigarette ashes on her green velvet pants and shirt. Observation revealed a half of a brown cigarette on Resident #143's bedside table.
Observation on 05/22/2023 at 1:45 p.m. revealed Resident #143 was sitting at a table in Dayroom Z, playing cards with a gold and white pack of Marlboro cigarettes noted on the table.
In an interview on 05/22/2023 at 1:48 p.m., Resident #143 stated the cigarettes on the table belong to her. Resident #143 stated she normally smokes right outside of the Dayroom Z doorway with Resident #13. Resident #143 further stated she does not wear an apron and she does not need staff to supervise her when she smokes.
In an interview on 05/22/2023 at 1:58 p.m., Resident #13, a cognitively intact resident, stated him and Resident #143 smoke every day together in the smoking pavilion near Day Room Z door. Resident #13 stated Resident #143 usually has her own cigarettes and she does not have to be watched by staff or wear an apron. Resident #13 stated when they smoke they are usually by their self.
Observation on 05/22/2023 at 4:25 p.m. circular piles of gray ash noted in Resident #143's wheelchair. Observation further revealed gray ash noted on Resident #143's floor near her bedside.
In an interview on 05/22/2023 at 4:32 p.m., Resident #143 stated she has her Marlboro cigarettes in her drawer in her room. Resident #143 stated she hid the cigarettes in her drawer. Resident #143 stated when she gets ready to go outside, she is going to go with Resident #13 and get a light from him. Resident #143 stated she normally smokes with Resident #13 and she gets a light from him or any resident that is on the smoking patio. Resident #143 further stated if she doesn't have cigarettes she will get them from Resident #13. Resident #143 further stated she does not have to be supervised by staff when smoking.
Observation on 05/23/2023 at 5:19 a.m. revealed, a half of a brown cigarette on Resident #143's bedside table.
In an interview on 05/23/2023 at 5:21 a.m., S16Certified Nursing Assistant (CNA) stated Resident #143 keeps her smoking material on her person and she smokes all the time. S16CNA stated Resident #143 usually goes with Resident #13 or other residents to smoke at night, but she can smoke unsupervised if she wants. S16CNA stated Resident #143 is not an unsafe smoker to her knowledge. S16CNA stated Resident #143 was awake around 2:00 a.m. and went outside to smoke with Resident #13. S16CNA stated she had worked at the facility about 2 weeks and the facility had not informed her of any residents on her hall who were unsafe smokers or who needed to be supervised.
In an interview on 05/23/2023 at 5:30 a.m., S23Licensed Practical Nurse (LPN) stated Resident #40, Resident #109, Resident #132, Resident #143 are all unsafe smokers, but none of them smoke at night.
Observation on 05/23/2023 at 6:37 a.m. revealed half of a brown cigarette on Resident #143's bedside table.
In an interview on 05/23/2023 at 8:09 a.m., S21MDSCoordinator stated Resident #143 should have had a smoking assessment done on 05/01/2023 when she was observed smoking in her room and she did not. S21MDSCoordinator stated unsafe smokers are communicated with staff and the IDT team in the morning meeting. S21MDSCoordinator stated Resident #143 was an unsafe smoker after smoking in her room and should have direct supervision of staff when she smoked. S21MDS Coordinator stated Resident #143 should not be allowed to have smoking materials at any time. S21MDS Coordinator stated the nurse on the hall or the front desk should keep her smoking material.
Observation on 05/23/2023 at 8:30 a.m. revealed Resident #143 sitting at the table located in the middle of the smoking patio out of sight of S17Smoking Aide smoking a cigarette. Further observation revealed Resident #143 put the cigarette to her mouth, dropped ash onto her green felt shirt, wiped it off of her shirt, and then placed the lit cigarette into the table and twisted it.
In an interview on 05/23/2023 at 8:35 a.m., Resident #143 stated she smoked last night between 1:00 a.m. and 2:00 a.m. with Resident #13, Resident #143 stated she did not have staff supervision while she was smoked.
In an interview on 05/23/2023 at 10:00 a.m. S2Director of Nursing (DON) stated Resident #143 was caught smoking in her room over the weekend and Resident #143 was deemed an unsafe smoker after that incident.
Observation on 05/23/2023 at 10:23 a.m. revealed half of a brown cigarette on her bedside table.
In an interview on 05/23/2023 at 10:25 a.m. S7Coorporate Nurse confirmed Resident #143 had half of a brown cigarette on her bedside table. S7Cooporate Nurse further stated Resident #143 should not be in possession of smoking material.
Resident #132
Review of Resident #132's face sheet revealed, in part, Resident #132 was admitted to the facility on [DATE] with diagnoses that included: Acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease, and Tobacco Use.
Review of Resident #132's Minimal Data Set with an Assessment Reference Date of 05/10/2023 revealed, in part, Resident #132's Brief Interview for Mental status Score was 12 which indicated Resident #132 was cognitively intact.
Review of Resident #132's Comprehensive Care Plan, with a start date of 11/16/2021, revealed, in part, Resident #132 may be at risk for potential for injury related to at times I am an unsafe smoker. Review revealed on 12/29/2022 Resident #132 had burns noted on his fingers and needed a smoker's apron. Review revealed Resident #132 should be instructed to smoke in designated smoking areas, be instructed on safe measures to dispense smoking material, and may need his cigarettes and lighter administered to him by staff when Resident #132 needed to smoke. Further review revealed, in part, Resident #132 may need supervision when he smoked.
Review of Resident #132's assessment for safe smoking with a completion date of 03/13/2023 revealed, in part, Resident #132 was an unsafe smoker. Review of this assessment revealed Resident #132 was not able to understand smoking materials are for use only in designated areas, was not able to understand that sharing materials with other residents is considered an unsafe smoking behavior, was not observed not sharing smoking materials with other residents, and was not able to understand that all smoking material was to be stored and distributed by nursing staff.
Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #132 was an unsafe smoker. Review revealed Resident #132 required his smoking items be kept on the cart, supervision while smoking, and a smoking apron be worn while smoking.
In an interview on 05/23/2023 at 5:30 a.m., S23Licensed Practical Nurse (LPN) stated Resident #40, Resident #109, Resident #132, Resident #143 are all unsafe smokers, but none of them smoke at night that she is aware of except Resident #132. S23LPN further stated Resident #132 did not have cigarettes at this time.
Observation on 05/23/2023 at 5:45 a.m. revealed Resident #132 was observed walking down Hall X with a green lighter and a pack of cigarettes in his hand.
Observation on 05/23/2023 at 5:54 a.m. revealed Resident #132 was outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision and without a smoker's apron.
In an interview on 05/23/2023 at 6:02 a.m., Resident #132 stated he keeps his cigarettes and lighter on his person at all times. Resident #132 further stated he does not have to have staff supervision when he is smoking.
In an interview on 05/23/2023 at 6:03 a.m., Resident #56, a cognitively intact resident, stated she is a safe smoker who frequently smokes every few hours. Resident #56 further stated Resident #132 smokes often at night with her. Resident #56 further stated the facility does not have a smoking aide after 7:00 p.m. Resident #56 stated the smoking aide usually worked 7:00 a.m. - 7:00p.m. and at night who ever smokes was not supervised by staff.
Observation on 05/23/2023 at 6:40 a.m. revealed Resident #132 sitting outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision and without a smoker's apron. Observation revealed Resident #132 was in possession of a pack of cigarettes and a green lighter at this time. Further observation revealed Resident #132 used the green lighter to light a random resident's cigarette.
In an interview on 05/23/2023 at 7:08 a.m., S17Smoking Aide stated she was a part time employee and worked 3 days a week. S17Smoking Aide stated her understanding of her job position was to ensure residents do not fight on the smoking patio and provide them a smoker's apron if they need it. S17Smoking Aide stated she was not sure who required a smoker's apron, but as far as she was aware there was only one female resident. S17Smoking Aide stated she does not administer the residents their cigarettes or monitor when they have cigarettes.
Review of the facility's staffing schedules for 05/21/2023-05/23/2023 revealed the following staff were assigned to Smoking Aide: 05/21/2023-S28Smoking Aide; 05/22/2023-S28smoking Aide and S17Smoking Aide; 05/23/2023-S26Smoking Aide and S27Smoking Aide
Review of S17Smoking Aide's time sheet revealed on 05/22/2023 S17Smoking Aide worked from 8:32 a.m. - 3:12 p.m.
Review of S26Smoking Aide's time sheet revealed on 05/23/2023 S26Smoking Aide arrived at 7:03 a.m.
Review of S27Smoking Aide's time sheet revealed on 05/23/2023 S27Smoking Aide arrived at 7:06 a.m.
Review of S28Smoking Aide's time sheet revealed on 05/21/2023 S28Smoking Aide worked from 9:38 a.m.-6:55 p.m. and on 05/22/2023 S28Smoking Aide worked from 7:27 a.m.- 5:50 p.m.
Resident #41
Review of Resident #41's face sheet revealed, in part, Resident #41 was admitted to the facility on [DATE] with diagnoses that included: Extrapyramidal and Movement Disorder, Alcohol Abuse, and Legal Blindness of the Left Eye.
Review of Resident #41's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2023 revealed, in part, a Brief Interview for Mental Status score of 8 which indicated moderately cognitive impaired. Further review revealed Resident #41 used tobacco use.
Review of Resident #41's Comprehensive Care Plan with a start date of 05/03/2023 revealed, in part, Resident #41 may be at risk for potential for injury related to his smoking habit and Resident #41 was an unsafe smoker. Further review revealed, Resident #41 should have a smoking apron when he smoked, be instructed to smoke in designated smoke areas, be instructed on safe measures to dispense smoking material, may need his cigarettes and lighter administered to him by staff when Resident #41 needed to smoke. Further review revealed, in part, Resident #41 may need supervision when he smoked.
Review of Resident #41's assessment for safe smoking dated 05/01/2023 revealed, in part, Resident #41 was an unsafe smoker. Review of this assessment revealed Resident #41 had a history of smoking and was observed sharing smoking materials with other residents. Further review of this assessment revealed Resident #41 remained an unsafe smoker and all smoking paraphernalia was to be kept in the nurse's care.
Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #41 was an unsafe smoker. Review revealed Resident #41 required his smoking items be kept on the cart, supervision while smoking, a smoking apron be worn while smoking, and assistance as needed.
Observation on 05/22/2023 at 2:48 p.m. revealed, Resident #41 was lying across his bed on his left side with a red pack of cigarettes exposed out the bottom of his shorts on his right leg with 2 cigarettes in the pack.
In an interview on 05/22/2023 at 2:48 p.m., Resident #41 stated the cigarettes observed in the previous observation belonged to him.
Observation on 05/23/2023 at 10:21 a.m. revealed Resident #41 sitting in his wheelchair at the smoking area door on Hall Y with a red pack of cigarettes with 2 cigarettes tucked under his left leg.
In an interview on 05/23/2023 at 10:32 a.m., Resident #41 stated he keeps his cigarettes in his possession.
4.) Resident #109
Review of Resident #109 face sheet revealed an admit date of 04/01/2021 with diagnoses, in part, that included Tobacco Use.
Review of Resident #109 Minimal Data Set with an Assessment Reference Date of 03/22/2023 revealed, in part Resident #109 had a Brief Interview for Mental Status Score of 11 which indicated Resident #109 had moderate cognitive impairment.
Review of Resident #109's Comprehensive Care Plan, with a start date of 03/27/2023, revealed, in part, Resident #109 may be at risk for potential for injury related to being an unsafe smoker. Further review revealed, Resident #109 should have a smoker's apron when he smoked, be instructed to smoke in designated smoking areas, be instructed on safe measures to dispense smoking material, and may need his cigarettes and lighter administered to him by staff when Resident #109 needed to smoke. Further review revealed, in part, Resident #109 may need supervision when he smoked.
Review of Resident #109 Assessment for Safe Smoking with a completion date of 03/21/2023 revealed, in part, Resident #109 was not able to light and smoke a cigarette while demonstrating safe technique by putting out the lighter or matches and disposing of ash. Further review revealed, in part, Resident #109 was not able to communicate understanding that smoking materials were for use only in designated smoking areas and was not able to communicate his understanding that sharing smoking materials (cigarettes, matches, lighter, etc.) with other residents was considered an unsafe smoking behavior. Further review Resident #109's cigarettes must be kept on the nurse's cart.
Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #109 was an unsafe smoker. Review revealed Resident #109 required his smoking items be kept on the cart, supervision while smoking, and a smoking apron be worn while smoking.
Observation on 05/21/2023 at 10:11 a.m., revealed Resident #109 on Hall X getting a cigarette from Resident #88.
Observation on 05/23/2023 at 9:48 a.m., revealed Resident #109 rolled down Hall Y towards the smoking area with an unlit cigarette in his mouth.
In an interview on 05/23/2023 at 10:05 a.m., S1Administrator stated the designated smoking area was the patio centrally located in the center of the building. S1Administrator stated residents who require assistance or are unsafe smokers have specific interventions specified on their careplan and smoking assessment that outlines the reason they are unsafe and the interventions the facility has put into place. S1Administrator stated Resident #40, Resident #109, Resident #132, and Resident #143 are all unsafe smokers. S1Adminstrator stated Resident #143 is an unsafe smoker because she was caught smoking in her room. S1Administrator stated she was not concerned Resident #143 would catch herself on fire. S1Adminsitrator stated unsafe smokers should not have their smoking material on their person in the facility at any time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure a resident's room was clean for 1 (Resident #94) of 3 (Resident #88, Resident #94, and Resident #138) sampled residents reviewed for...
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Based on observations and interviews, the facility failed to ensure a resident's room was clean for 1 (Resident #94) of 3 (Resident #88, Resident #94, and Resident #138) sampled residents reviewed for environment.
Findings:
Review of Resident #94's Minimum Data Set with an Assessment Reference Date of 03/29/2023 revealed, in part, a Brief Interview for Mental Status score of 11, which indicated Resident #94 had moderate cognitive impairment.
Observation on 05/22/2023 at 12:49 p.m. revealed a dried brown and red substance on Resident 94's wall next to the head of Resident #94's bed.
In an interview 05/22/2023 at 12:50 p.m., Resident #94 stated the above mentioned dried brown and red substance was her vomit from when she was sick.
Observation on 05/22/2023 at 3:09 p.m. revealed a dried brown and red substance on Resident #94's wall next to the head of Resident #94's bed.
Observation on 05/22/2023 at 6:44 a.m. revealed a dried brown and red substance on Resident #94's wall next to the head of Resident #94's bed.
Observation on 05/23/2023 at 10:08 a.m. revealed a dried red and brown substance on Resident #94's wall next to the head of Resident #94's bed.
In an interview on 05/23/2023 at 10:21 a.m., S19 Housekeeper stated that each room should be cleaned daily.
Observation on 05/23/2023 at 1:43 p.m. revealed a dried brown and red substance on Resident #94's wall next to the head of Resident #94's bed.
Observation on 05/24/2023 at 9:27 a.m. revealed a dried brown and red substance on Resident #94's wall next to the head of Resident #94's bed.
In an interview on 05/24/2023 at 9:28 a.m., S5Licensed Practical Nurse (LPN) stated the dried brown and red substance on Resident #94's wall looked like vomit. S5LPN further stated Resident #94's wall needed to be cleaned.
In an interview on 05/24/2023 at 9:40 a.m., S2Assistant Administrator confirmed the dried brown and red substance on Resident #94's wall looked like dried vomit. S2Assisant Administrator stated the dried vomit should have been cleaned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure proper positioning of a resident receiving a tube feeding for 1 (Resident #138) of 1 resident investigated for servi...
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Based on observations, interviews, and record review, the facility failed to ensure proper positioning of a resident receiving a tube feeding for 1 (Resident #138) of 1 resident investigated for services related to tube feedings.
Findings:
Review of facility's policy for Enteral Nutritional Therapy revealed, in part, place resident in semi-Fowler's positon.
Observation on 05/22/2023 at 1:53 p.m. revealed, S12Certified Nursing Assistant (CNA) performing incontinence care while Resident #138 head of bed (HOB) was positioned flat and Resident #138 was lying on his side. Further observation revealed rotary pump mechanism still moving on the tube feeding pump, and the tube feeding Isosource 1.5 infusing to Resident #138. Further observation revealed S12CNA, finish incontinence care and position #138's HOB at less than 30 degrees.
In an interview on 05/22/2023 at 1:58 p.m., S12CNA stated that she thought she had paused Resident #138's tube feeding pump when she had positioned Resident #138's head of bed flat to perform incontinence care. S12CNA further stated that Resident #138's HOB should be positioned at 45 degrees or higher when Resident #138 was being administered the tube feeding.
In an interview with on 05/23/2023 at 9:17 a.m., S9Licensed Practical Nurse (LPN) stated if the rotary pump mechanism on the front of tube feeding pump was turning, the tube feeding pump was not off or paused.
In an interview on 05/24/2023 at 10:30 a.m., S3DON stated that she had spoken to S12CNA and that Resident #138's HOB was positioned flat while the tube feeding was still infusing and should not have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on record reviews, observations and interviews, the facility failed to ensure a resident's oxygen was administered as ordered for 1 (Resident #112) of 3 (Resident #51, Resident #112, and Residen...
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Based on record reviews, observations and interviews, the facility failed to ensure a resident's oxygen was administered as ordered for 1 (Resident #112) of 3 (Resident #51, Resident #112, and Resident #145) sampled residents investigated for respiratory care.
Findings:
Review of the facility's Oxygen Administration Policy and Procedure revealed, in part, the administration of oxygen will be performed as ordered by the physician.
Review of Resident #112's record revealed, in part, diagnoses of acute on chronic congestive heart failure, acute on chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD).
Review of Resident #112's Minimum Data Set with an Assessment Reference Date of 04/26/2023 revealed, in part, Resident #112 was documented with shortness of breath on exertion and when lying flat. Further review revealed Resident #112 required oxygen therapy.
Review of Resident #112's May 2023 Physician's Orders revealed, in part, an order for continuous oxygen at 2 liters per minute (L/min) via nasal cannula.
Review of Resident #112's care plan revealed, in part, Resident #112 had asthma and COPD and required continuous oxygen.
Observation on 05/21/2023 at 12:30 p.m. revealed Resident #112 had no oxygen in use.
Observation on 05/22/2023 at 12:44 p.m. revealed Resident #112 had oxygen set at 1 L/min via nasal cannula in use.
Observation on 05/22/2023 at 3:10 p.m. revealed Resident #112 had oxygen set at 1 L/min via nasal cannula in use.
Observation on 05/23/2023 at 6:45 a.m. revealed Resident #112 had oxygen set at 1 L/min via nasal cannula in use.
Observation on 05/23/2023 at 10:11 a.m. revealed Resident #112 had oxygen set at 1 L/min via nasal cannula in use.
Observation on 05/23/2023 at 1:46 p.m. revealed Resident #112 had oxygen set at 1 L/min via nasal cannula in use.
Observation on 05/24/2023 at 9:42 a.m. revealed Resident #112 had oxygen set at 1 L/min via nasal cannula in use.
In an interview on 05/24/2023 at 9:45 a.m., S22Licensed Practical Nurse (LPN) stated Resident #112 had an order for continuous oxygen at 2 L/min via nasal cannula.
In an interview on 05/24/2023 at 9:49 a.m., S22LPN confirmed Resident #112's oxygen was not set at 2 L/min via nasal cannula as ordered.
In an interview on 05/24/2023 at 10:00 a.m., S1Administrator stated a nurse should assess a resident's oxygen setting every shift to ensure the oxygen was set at the correct liter per minute, as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interviews, the facility failed to ensure a medication room was locked when unattended for 1 (Medication Room a) of 3 Medication rooms (Medication Room a, Medi...
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Based on record review, observation, and interviews, the facility failed to ensure a medication room was locked when unattended for 1 (Medication Room a) of 3 Medication rooms (Medication Room a, Medication Room b, and Medication Room c) reviewed for storage of medications.
Findings:
Review of the facility's Medication Administration policy revealed, in part, medications must be secured at all times, and medications should not be left unattended on the counters or at the workstations.
Observation on 05/23/2023 at 5:17 a.m., revealed Medication Room a was left open and unattended.
Observation on 05/23/2023 at 5:58 a.m., revealed S20Certified Nursing Assistant (CNA) entered the open and unattended Medication Room a.
Observation on 05/23/2023 at 6:38 a.m., revealed S18Housekeeper entered the open and unattended Medication Room a. Further observation revealed, S18 Housekeeper then exited Medication Room a and closed the door.
When surveyor tested the door of Medication Room a on 05/23/2023 at 6:43 a.m., Medication Room a was found to be unlocked and unattended.
Observation on 05/23/2023 at 7:05 a.m., revealed S10Licensed Practical Nurse (LPN) entered the unlocked and unattended Medication Room a. Further observation revealed, S10LPN exited Medication Room a and left Medication Room a open and unattended.
Observation on 05/23/2023 at 7:09 a.m., revealed S10LPN returned and entered the open and unattended Medication Room a.
Observation on 05/23/2023 at 7:10 a.m., revealed S10LPN exited Medication Room a and left Medication Room a open and unattended.
Observation on 05/23/2023 at 7:13 a.m., revealed S10LPN returned and entered the open and unattended Medication Room a.
Observation on 05/23/2023 at 7:24 a.m., revealed S10LPN exited Medication Room a and left Medication Room a open and unattended.
Observation on 05/23/2023 at 7:31 a.m., revealed S10LPN returned and entered the open and unattended Medication Room a.
Observation on 05/23/2023 at 7:32 a.m., revealed S10LPN exited Medication Room a and left Medication Room a open and unattended.
Observation on 05/23/2023 at 7:34 a.m., revealed S4Assistant Director of Nursing (ADON) walked by and closed the door to Medication Room a.
When surveyor tested the door of Medication Room a on 05/23/2023 at 7:34 a.m., Medication Room a was found to be unlocked and unattended.
In an interview on 05/23/2023 at 7:36 a.m., S11LPN stated she should not have left Medication Room a open, unlocked, and unattended.
In an interview on 05/23/2023 at 7:36 a.m., S10LPN stated she did not have a key to Medication Room a but was able to enter Medication Room a because it was unlocked.
In an interview on 05/23/2023 at 7:38 a.m., S4ADON confirmed Medication Room a was left unlocked and unattended and Medication Room a should not have been left open, unlocked, and unattended.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to ensure a resident dependent on staff for activities of daily living (ADL) received assistance to maintain grooming and per...
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Based on observations, interviews, and record reviews, the facility failed to ensure a resident dependent on staff for activities of daily living (ADL) received assistance to maintain grooming and personal hygiene for 3 residents (Resident #50, Resident #64, and Resident #128) reviewed for ADL care in a total sample of 8 (Resident #6, Resident #15, Resident #50, Resident #56, Resident #64, Resident #80, Resident #94, and Resident #128).
Findings:
Review of Resident #50's Minimum Data Set with an Assessment Reference Date of 03/29/2023 revealed, in part, a Brief Interview for Mental Status with a score of 15 which indicated Resident #50 was cognitively intact. Further review revealed Resident #50 required physical help from staff during bathing activity.
Review of Resident #50's Care Plan with a start date of 03/29/2023 revealed, in part, Resident #50 required assistance with bathing.
Observation on 05/23/2023 at 1:34 p.m. revealed Resident #50 was in the Shower Room d and there was no staff present in the shower room.
In an interview on 05/23/2023 at 1:45 p.m., S8Certified Nursing Assistant Supervisor (CNAS) confirmed Resident #50 was not provided assistance with his shower. S8CNAS stated Resident #50 should have been provided assistance with his shower.
In an interview on 05/23/2023 at 1:55 p.m., S2Assistant Administrator stated Resident #50 should have been provided assistance with his shower.
Resident #64
Review of Resident #64 Minimum Data Set with an Assessment Review Date of 04/19/2023 revealed, in part, Resident #64 had a Brief Interview for Mental Status of 3, which indicated Resident #64 was severely cognitively impairment. Further review revealed, in part, Resident #64's required extensive assistance for dressing and personal hygiene.
Review of Resident #64 completed care from 05/01/2023 to 05/22/2023 revealed, in part, no indication Resident #64's nails were trimmed.
Review of Resident #64 Care Plan revealed, in part, Resident #64 required assistance from staff to assess/trim finger nails monthly.
Observation on 05/21/2023 at 11:18 a.m. revealed, Resident #64's fingernails were past the tip of the finger on all fingers on the left hand and on all fingers except the thumb on the right hand. Observation further revealed, Resident #64's fingernails were jagged with a brown substance noted under the fingernails.
Observation on 05/22/2023 at 10:30 a.m. revealed Resident #64 had fingernails that were past the tip of the finger on all fingers on the left hand and on all fingers except the thumb on the right hand. Observation further revealed, Resident #64's fingernails were jagged with a brown substance noted under them.
In an interview on 05/22/2023 at 10:30 a.m., Resident #64 stated his fingernails had not been trimmed and he would like them trimmed.
Observation on 05/22/2023 at 2:40 p.m. revealed Resident #64 was lying in bed asleep and his fingernails were past the tip of the finger on all fingers on the left hand and on all fingers except the thumb on the right hand.
Observation on 05/23/2023 at 11:35 a.m. revealed Resident #64 lying in bed, his fingernails had not been trimmed. Fingernails were past the tip of the finger on all fingers on the left hand and on all fingers except the thumb on the right hand. Resident #64 stated he would like his fingernails trimmed.
Interview on 05/23/2023 at 2:07 p.m., Resident #64 stated no one came to trim his fingernails and he would like them trimmed.
Interview on 05/23/2023 at 2:10 p.m., S6Infection Preventionist (IP) confirmed Resident #64's nails were past the tip of his fingers and needed to be trimmed. Resident #64 told S6IP he wanted his nails trimmed.
Observation on 05/24/2023 at 8:53 a.m. revealed Resident #64's fingernails had not been trimmed. Fingernails were past the tip of the finger on all fingers on the left hand and on all fingers except the thumb on the right hand.
In an interview on 05/24/2023 at 8:59 a.m., S7Corporate Nurse confirmed Resident #64's nails need to be trimmed.
Resident #128
Review of Resident #128's Minimum Data Set with an Assessment Reference Date of 04/05/2023 revealed, in part, a Brief Interview for Mental Status with a score of 15 which indicated Resident #128 was cognitively intact. Further review revealed Resident #128 required extensive assistance with bathing and physical help from staff.
Review of Resident #128's Care Plan with a start date of 04/06/2023 revealed, in part, Resident #128 required assistance with bathing.
Observation on 05/24/2023 at 10:57 a.m. revealed Resident #128 in the Shower Room f giving himself a shower without staff present.
In an interview on 05/24/2023 at 1:41 p.m. S31Shower Aide stated she forgot Resident #128 was in Shower Room f and she went to go get another resident.
In an interview on 05/24/2023 at 2:15 p.m., S2Assistant Administrator stated Resident #128 should not have been left in the shower room unattended. S2Assistant Administrator stated Resident #128 should have been provided assistance with his shower.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to maintain communication with a dialysis center for 1 (Resident #163) of 1 (Resident #163) sampled resident investigated for dialysis servic...
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Based on record review and interviews, the facility failed to maintain communication with a dialysis center for 1 (Resident #163) of 1 (Resident #163) sampled resident investigated for dialysis services.
Findings:
Review of Resident #163's record revealed, in part, an admit date of 09/15/2022 with diagnoses of End Stage Renal Disease, Chronic Kidney Disease, and Type 2 Diabetes Mellitus.
Review of Resident #163's Quarterly Minimum Data Set with an Assessment Reference Date of 01/04/2023 revealed, in part a Brief Interview for Mental Status 15, which indicated #163 was cognitively intact. Further review revealed Resident #163 received dialysis (a process of removing excess water, solutes, and toxins, from the blood in people whose kidneys can no longer perform these functions naturally).
Review of Resident #163's May 2023 Physician's orders revealed, in part, dialysis every Tuesday, Thursday, and Saturday.
Review of Resident #163's dialysis communication binder revealed, in part, no documentation of communication between the facility and dialysis unit from 01/14/2023 and 05/13/2023.
In an interview on 05/22/2023 at 1:45 p.m. S5Licensed Practical Nurse (LPN) stated a dialysis communication form should be filled out before Resident #163 leaves for dialysis and should be reviewed for communication from the dialysis center when Resident #163 returns to the Facility. He further stated Resident #163 should have had completed communication forms from 01/14/2023 to 05/13/2023.
In an interview on 05/23/2023 at 3:30 p.m., S4Assistant Director of Nursing (ADON) stated Resident #163 should have had completed dialysis communication forms from 01/14/2023 through 05/13/2023. S4ADON further stated there should have been communication between the facility and the dialysis center regarding Resident #163 for each dialysis appointment.
In an interview on 05/24/2023 at 10:05 a.m., S3Director of Nursing (DON) stated there was no documentation and she could not present documentation of communication between the facility and the dialysis center for Resident #163 between 01/14/2023 and 05/13/2023. S3DON further stated there should have been communication between the facility and the dialysis center regarding Resident #163 for each visit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure a resident's insulin (a medication to lower blood glucose) was accurately documented as administered as ordered for 1 (Resident #1...
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Based on record reviews and interviews, the facility failed to ensure a resident's insulin (a medication to lower blood glucose) was accurately documented as administered as ordered for 1 (Resident #18) of 2 (Resident #18 and Resident #90) sampled residents investigated for insulin administration.
Findings:
Review of Resident #18's Minimum Data Set with an Assessment Reference Date of 03/01/2023 revealed, in part, Resident #18 had a diagnosis of diabetes and received insulin injections.
Review of Resident #18's Diabetes Care Plan revealed, in part, interventions for staff to monitor blood glucose and administer insulin as ordered.
Review of Resident #18's laboratory results from 12/05/2022 revealed, in part, a Hemoglobin A1C (a test used to measure blood glucose over a 3 month period) result of 9.7%, which was outside the normal range of 4.5-5.7%.
Review of Resident #18's March 2023 Physician's Orders signed by Resident #18's physician on 03/07/2023 revealed, in part, an order with a start date of 08/25/2020 for Accuchecks (blood glucose measurement) before meals and at bedtime with Humalog (fast acting insulin to decrease blood glucose) 100units/1mL Flexpen administered as follows:
-for blood glucose 61-200 milligrams per deciliter (mg/dL), administer 0 units;
-for blood glucose 201-250mg/dL, administer 3 units;
-for blood glucose 251-300mg/dL, administer 6 units;
-for blood glucose 301-350mg/dL, administer 8 units;
-for blood glucose 351-400mg/dL, administer 10 units;
-for blood glucose 401-499mg/dL, administer 10 units; and,
-for blood glucose greater than 500mg/dL, administer 12 units and call the physician.
Review of Resident #18's March 2023 Electronic Medication Administration Record (eMAR) revealed the following documentation:
-On 03/18/2023 at 4:00 p.m., Resident #18's blood glucose was 255mg/dL and 3 units of Humalog insulin were administered;
-On 03/20/2023 at 8:00 p.m., Resident #18's blood glucose was 416mg/dL and 12 units of Humalog insulin were administered;
-On 03/27/2023 at 4:00 p.m., Resident #18's blood glucose was 413mg/dL and 12 units of Humalog insulin were administered; and,
-On 03/29/2023 at 4:00 p.m., Resident #18's blood glucose was 342mg/dL and 1 unit of Humalog insulin was administered.
Review of Resident #18's April 2023 Physician's Orders signed by Resident #18's physician on 04/11/2023 revealed, in part, an order with a start date of 08/25/2020 for Accuchecks before meals and at bedtime with Humalog 100units/1mL Flexpen administered as follows:
-for blood glucose 61-200 milligrams per deciliter (mg/dL), administer 0 units;
-for blood glucose 201-250mg/dL, administer 3 units;
-for blood glucose 251-300mg/dL, administer 6 units;
-for blood glucose 301-350mg/dL, administer 8 units;
-for blood glucose 351-400mg/dL, administer 10 units;
-for blood glucose 401-499mg/dL, administer 10 units; and,
-for blood glucose greater than 500mg/dL, administer 12 units and call the physician.
Review of Resident #18's April 2023 eMAR revealed the following documentation:
-On 04/04/2023 at 4:00 p.m., Resident #18's blood glucose was 344mg/dL and 10 units of Humalog insulin were administered;
-On 04/06/2023 at 11:00 a.m., Resident #18's blood glucose was 202mg/dL and 211 units of Humalog insulin were administered;
-On 04/13/2023 at 4:00 p.m., Resident #18's blood glucose was 309mg/dL and 184 units of Humalog insulin were administered;
-On 04/14/2023 at 8:00 p.m., Resident #18's blood glucose was 312mg/dL and 234 units of Humalog insulin were administered;
-On 04/17/2023 at 8:00 p.m., Resident #18's blood glucose was 258mg/dL and 3 units of Humalog insulin were administered;
-On 04/29/2023 at 11:00 a.m., Resident #18's blood glucose was 401mg/dL and 12 units of Humalog insulin were administered;
-On 04/30/2023 at 11:00 a.m., Resident #18's blood glucose was 403mg/dL and 12 units of Humalog insulin were administered; and,
-On 04/30/2023 at 4:00 p.m., Resident #18's blood glucose was 412mg/dL and 12 units of Humalog insulin were administered.
Review of Resident #18's May 2023 Physician's Orders signed on 05/02/2023 revealed, in part, an order with a start date of 08/25/2020 for Accuchecks before meals and at bedtime with Humalog 100units/1mL Flexpen administered as follows:
-for blood glucose 61-200 milligrams per deciliter (mg/dL), administer 0 units;
-for blood glucose 201-250mg/dL, administer 3 units;
-for blood glucose 251-300mg/dL, administer 6 units;
-for blood glucose 301-350mg/dL, administer 8 units;
-for blood glucose 351-400mg/dL, administer 10 units;
-for blood glucose 401-499mg/dL, administer 10 units; and,
-for blood glucose greater than 500mg/dL, administer 12 units and call the physician.
Review of Resident #18's May 2023 eMAR revealed the following documentation:
-On 05/04/2023 at 6:00 a.m., Resident #18's blood glucose was 471mg/dL and 12 units of Humalog insulin were administered;
-On 05/05/2023 at 6:00 a.m., Resident #18's blood glucose was 494mg/dL and 12 units of Humalog insulin were administered;
-On 05/05/2023 at 11:00 a.m., Resident #18's blood glucose was 454mg/dL and 12 units of Humalog insulin were administered;
-On 05/07/2023 at 8:00 p.m., Resident #18's blood glucose was 499mg/dL and 12 units of Humalog insulin were administered;
-On 05/11/2023 at 8:00 p.m., Resident #18's blood glucose was 228mg/dL and 6 units of Humalog insulin were administered; and,
-On 05/20/2023 at 8:00 p.m., Resident #18's blood glucose was 489mg/dL and 12 units of Humalog insulin were administered.
In an interview on 05/24/2023 at 3:54 p.m., S3Director of Nursing (DON) stated the above mentioned insulin administration documentation was incorrect. S3DON further stated the eMAR's Humalog insulin special requirement text was incorrect, causing an error in the documentation of the insulin administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record reviews, observations, and interviews, the facility failed to ensure certified nursing assistants (CNA) completed hand hygiene after providing incontinence care for 4 (Resident #15, Re...
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Based on record reviews, observations, and interviews, the facility failed to ensure certified nursing assistants (CNA) completed hand hygiene after providing incontinence care for 4 (Resident #15, Resident #37, Resident #88, and Resident #160) of 5 (Resident #15, Resident #37, Resident #80, Resident #88, and Resident #160) sampled residents observed for incontinence care.
Findings:
Review of the facility's Hand Hygiene Policy and Procedure revealed, in part, hand hygiene shall be performed:
1. Before and after assisting a resident with personal care;
2. Before and after assisting a resident with toileting;
3. After contact with a resident's mucous membranes and bodily fluids or excretions;
4. After handing soiled or used linens, dressings, bedpans, catheters, and urinals;
5. After removing gloves; and,
6. If hands will be moving from a contaminated body site to a clean body site during patient care.
Resident #37
Observation on 05/23/2023 at 5:18 a.m. revealed S16CNA entered Resident #37's room, removed gloves from her pocket, put on gloves, and removed Resident #37's brief soiled with stool. Observation then revealed S16CNA cleaned the stool from Resident #37's groin and buttocks, then touched Resident #37's water pitcher and straws on Resident #37's bedside table without removing her soiled gloves or washing her hands.
In an interview on 05/23/2023 at 5:32 a.m., S16CNA stated she should have changed her gloves and washed her hands before she touched Resident #37's items on his bedside table after she performed incontinence care.
Resident #88
Observation on 05/23/2023 at 5:33 a.m. revealed S24CNA, entered Resident #88's room, washed her hands, donned gloves, and removed Resident #88's diaper soiled with urine. S24CNA then wiped Resident #88's soiled buttocks and groin and applied a clean brief. S24CNA did not remove her soiled gloves or wash her hands. S24CNA then assisted Resident #88 with putting on pants and shoes, transferred Resident #88 into his wheelchair and removed Resident #88's shirt. S24CNA then opened Resident #88's closet, sifted through Resident #88's clothing, removed a clean shirt and assisted Resident #88 with putting on the shirt. S24CNA then removed her gloves, left Resident #88's room, opened the Hall X linen closet and removed a towel. S24CNA then returned to Resident #88's room, donned another pair of gloves and wiped Resident #88's face with the towel.
In an interview on 05/23/2023 at 5:53 a.m., S24CNA, confirmed she did not remove her gloves or wash her hands after she performed Resident #88's incontinence care and prior to touching Resident #88's personal items and providing routine morning care to Resident #88.
Resident #15
Observation on 05/23/2023 at 6:11 a.m. revealed S25CNA entered Resident #15's room, performed hand hygiene, and donned gloves prior to performing Resident #15's incontinence care. S25CNA then cleaned stool from Resident #15's groin and buttocks. Observation further revealed S25CNA placed Resident #15 a new brief and then changed Resident #15's linens without removing her soiled gloves or washing her hands.
Resident #160
Observation on 05/24/2023 at 10:46 a.m. revealed S15CNA entered Resident #160's room to provide incontinence care. S15CNA completed hand hygiene, put on gloves, removed Resident #160's brief soiled with urine and feces, and cleaned Resident #160's groin and buttocks. Observation further revealed S15CNA removed her soiled gloves, did not complete hand hygiene, and donned a pair of gloves pulled from her pocket. S15CNA then placed a new brief on Resident #160.
In an interview on 05/24/2023 at 10:48 a.m. S15CNA confirmed she did not perform hand hygiene after she removed her soiled gloves following Resident #160's incontinence care.
In an interview on 05/24/2023 at 2:00 p.m., S3Director of Nursing (DON) stated staff should change gloves and complete hand hygiene after they performed incontinence care and prior to touching surfaces or applying new linens.
In an interview on 05/24/2023 at 3:30 p.m., S6Infection Preventionist stated gloves should be removed and hand hygiene should be completed after she performed incontinence care on a resident.
Feb 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a thorough investigation was conducted for an alleged abuse incident reported for 1 (Resident #1) of 5 (Resident #1, Resident #2, Re...
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Based on record review and interview, the facility failed to ensure a thorough investigation was conducted for an alleged abuse incident reported for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for abuse.
Findings:
Review of the facility's Policies and Procedures titled Abuse Prevention and Prohibition revealed, in part, the following:
1. Types of Abuse:
a.) Verbal Abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents;
Examples: Name calling, cursing, or yelling at a resident in anger; and threats of harm;
and,
2. Abuse Prohibition Practice: Each resident has the right to be free from mistreatment. The facility takes steps to identify residents whose personal histories render them at risk for abusing other residents;
a.) Identification: The facility Administrator proactively identifies events that may constitute abuse and determines the direction of the investigation;
b.) Investigation: Administrator completes a thorough investigation, including interviews of employees during the time in question and obtaining signed statements from these employees. The investigator interviews the resident. The investigator maintains a private and confidential file in the administrator's office;
c.) Protection: Resident to resident altercations: When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's mental status and notify the physician for a determination regarding treatment.
Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 11/23/2022 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 13 which indicated Resident #1's cognition was intact.
Review of Resident #1's Departmental Notes by S5SocialServiceDirector dated 12/09/2022 revealed, in part, Resident #1 was outside in smoking section in another resident's face cursing and screaming, Resident #1 stood up and picked up his wheelchair, and tried to hit/harm another resident. Further review of the departmental note dated 12/09/2022 revealed, in part, a CNA (Certified Nurse Assistant) witnessed the incident and called for help from the nursing staff and social services department. Further review of the departmental note dated 12/09/2022 revealed, in part, Resident #1 was witnessed entering the building and stated that he would annihilate the other resident. Further review of the departmental note dated 12/09/2022 revealed, in part, social service notified administration and S4DON (Director of Nursing), spoke to Resident #1 regarding his behavior and encouraged him to notify an employee of his issue, and social service will continue to monitor.
Review of facility's Incident Log revealed, in part, Resident #1 had no documented incident report on 12/09/2022.
In an interview on 02/15/2023 at 10:40 a.m., S1Administrator stated an incident report and an investigation was not completed on the incident that took place on 12/09/2022 involving Resident #1 and another resident. S1Administrator stated she did not know the identity of the other resident involved or the identity of the CNA who witnessed the incident on 12/09/2022. S1Administrator stated she did not have any documentation that an investigation was completed for the incident on 12/09/2022 involving Resident #1 and another resident.
In an interview on 02/15/2023 at 12:53 p.m., S5SocialServiceDirector could not confirm the identity of the CNA who notified her of the incident involving Resident #1 on 12/09/2022. S5SocialServiceDirector could not confirm the identity of the other resident involved in the incident with Resident #1 on 12/09/2022.
In an interview on 02/15/2023 at 1:42 p.m., S4DON stated she reviewed all residents' documented departmental notes on 12/09/2022 and could not confirm the identity of the other resident involved in the incident on 12/09/2022 with Resident #1. S4DON confirmed it was the responsibility of the administrator to initiate an investigation of incidents involving concerns of abuse. S4DON acknowledged the facility should have completed an investigation of the incident on 12/09/2022 that involved Resident #1 and another unknown resident.
In an interview on 02/15/2023 at 4:05 p.m., S1Administrator stated she did not agree an investigation was warranted for the incident on 12/09/2022 involving Resident #1 and another resident because there was no physical contact between residents.
In an interview on 02/16/2023 11:20 a.m., S2AssistantAdministrator stated he did not know the identity of the CNA or the other resident involved in the incident involving Resident #1 on 12/09/2022. S2AssistantAdministrator stated he did not agree an incident report or an investigation of the incident on 12/09/2022 should have been completed.
Jan 2023
2 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on record reviews, interviews, and observations, the facility failed to:
1.Ensure oxygen cylinders were stored and secured in a manner that prevented the potential for serious harm or injury for...
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Based on record reviews, interviews, and observations, the facility failed to:
1.Ensure oxygen cylinders were stored and secured in a manner that prevented the potential for serious harm or injury for 4 residents (Resident #9, Resident #10, Resident #11, and Resident #12) out of the 34 residents that required oxygen as identified on the oxygen Physician Orders List and;
2. Ensure residents who were identified as unsafe smokers did not have access to smoking materials for 3 (Resident #6, Resident #7, and Resident #8) out of 9 unsafe smokers identified on the Unsafe Smoker List.
The deficient practice resulted in an Immediate Jeopardy (IJ) situation on 01/23/2023 at 2:15 p.m. when Resident #9 knocked over one large oxygen cylinder in his room, and the large oxygen cylinder's valve opened and oxygen was inadvertently released with a hissing sound. On 01/23/2023 at 2:15 p.m., surveyor was standing with S6Treatment Nurse (TN) outside of Resident #9's room. A crash was heard followed by a hissing sound. S6TN and the surveyor ran into Resident #9's room to find Resident #9 had tangled up his oxygen tubing into his electric scooter wheel, and reversed backward into three large and one small free standing oxygen cylinder next to his bed. Further observation revealed, two large oxygen cylinders and one small oxygen cylinder were knocked over, and one large oxygen cylinder's valve was opened and oxygen was inadvertently released. Resident #9's oxygen tubing was disconnected from oxygen concentrator that he was supposed to be on, and Resident #9's room was cluttered with multiple oxygen cylinders unsecured, oxygen concentrators, multiple cords, and tubing lying on the floor causing the likelihood for the potential for severe harm or injury.
The deficient practice resulted in an Immediate Jeopardy (IJ) situation on 01/23/2023 at 3:00 p.m., when Resident #8 was observed smoking a cigarette in his bed and stated you caught me smoking and extinguished his cigarette into a small bowl on his bedside table. Resident #8 stated that he asked to go outside and smoke, but that staff would never bring him outside, so he smoked in his room. Resident #8 stated that he was not able to get out of bed by himself and transfer to a wheelchair. Resident #8 had a red pack of cigarettes, a purple lighter, and one extinguished cigarette butt at his bedside.
This deficient practice had the likelihood to potentially cause serious harm or injury to all 178 residents residing in the facility as identified on the Facility Census List.
The facility submitted a plan of removal that consisted of the following:
1.Corrective actions were taken for Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 by the alleged deficient practice by:
Registered Nurse (RN) Director of Nursing (DON) in-serviced nursing staff on 01/24/2023 on ensuring oxygen cylinders are secured in cylinder racks/cylinder stands and properly stored in designated areas, ensuring unsafe smokers are supervised and ensuring smoking materials and/or cigarettes are not in possession of any unsafe smokers and kept on the nurse's carts. The nursing staff will ensure unsafe smokers are not in possession of smoking material by observation every shift.
Agency staff and new hires will be in-serviced on oxygen cylinders and unsafe smokers prior to working any shift. Regular staff will be in-serviced prior to the next shift.
Facility wide audits performed by S2Directior of Nursing (DON), S7Assistant Director of Nursing (ADON), S1Administrator, and S3Corporate Nurse on 01/24/2023 to ensure all oxygen cylinders were stored and secured properly and to ensure unsafe smokers were not in possession of smoking materials/cigarettes.
The facility will contact family members of unsafe smokers via phone call on 01/25/2023 to inform them that when delivering smoking materials they should give the materials to the resident's assigned nurse and not the resident.
2. All residents who reside in the facility have the potential to be affected by the alleged deficient practice. The facility had a census of 178.
3. Measures put in place to ensure the alleged deficient practice will not recur are:
RN DON in-serviced nursing staff on 01/24/2023 on ensuring oxygen cylinders are secured in cylinder racks/cylinder stands and properly stored in designated areas, ensuring unsafe smokers are supervised and ensuring smoking materials and/or cigarettes are not in possession of any unsafe smokers and are kept on the nurse's carts. The nursing staff will ensure unsafe smokers are not in possession of smoking materials by observation every shift.
Agency staff any new hires will be in-services on oxygen cylinders and unsafe smokers prior to working any shift.
Facility wide audit performed by S2Directior of Nursing (DON), S7Assistant Director of Nursing (ADON), S1Administrator, and S3Corporate Nurse on 01/24/2023 to ensure all oxygen cylinders were stored and secured properly and to ensure unsafe smokers were not in possession of smoking material/cigarettes.
The facility will contact family members of unsafe smokers via phone call on 01/15/2023 to inform them that when delivering smoking materials they should give the materials to the resident's assigned nurse and not the resident.
The facility performed smoking assessments on all residents that smoke on 01/24/2023.
Smoking binders identifying unsafe smokers were updated on 01/24/2023 and placed at each nurse's station.
Cognitive unsafe smokers were counseled per S1DON and S7ADON on 01/24/2023 on smoking policy and ensuring smoking materials are given to their nurse.
4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by:
RN DON or designee to perform facility audits 2 times per week to ensure oxygen cylinders are properly secured, unsafe smokers are appropriately supervised and to ensure unsafe smokers are not in possession of smoking materials/cigarettes. Audits began on 01/24/2023. Audits will continue until 02/25/2023.
5. Corrective actions will be completed by: 01/25/2023.
The Immediate Jeopardy was removed on 01/25/2023 at 2:32 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal.
Findings:
1.
Review of the facility's Oxygen Administration Policy and Procedure revealed, in part, oxygen cylinders should be secured on a stand with a safety strap or chain and appropriate oxygen sign should be placed per facility procedure.
Resident #9
Review of Resident #9's electronic medical recorded (EMR) revealed Resident #9 was admitted to facility on 10/26/2022 with diagnoses which included, in part, pain, shortness of breath, anxiety, wheezing, and person history of malignant neoplasm of prostate.
Review of Resident #9's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 11/08/2022 revealed, in part, Resident #9 had a BIMS (brief interview mental status) score of 13 which indicated mild cognitive impairment, and Resident #9 required extensive two person physical assistance with bed mobility, transfer, and requires supervision with locomotion on hall with motorized scooter.
Review of Resident #9's care plan revealed, in part, a goal of Resident #9 will exhibit no shortness of breath with interventions that include administer oxygen as ordered. Further review revealed, in part, no interventions or goals related to safe/unsafe smoking.
Review of Resident #9's physician orders for January 2023 revealed, in part, an order for oxygen at 2-8 liters via nasal cannula continuous (may remove for ADL's).
Review of Resident #9's Assessment for Safe Smoking dated 10/27/2022 revealed, in part, Resident #9 was a safe smoker.
Observation on 01/23/2023 at 10:56 a.m., revealed one (1) oxygen cylinder unsecured and lying on the floor in Resident #9's room.
On 01/23/2023 at 2:15 p.m., surveyor was standing with S6Treatment Nurse (TN) outside of Resident #9's room. A crash was heard followed by a hissing sound. S6TN and the surveyor ran into Resident #9's room to find Resident #9 had tangled up his oxygen tubing into his electric scooter wheel, and reversed backward into three large and one small free standing oxygen cylinder unsecured next to his bed. Further observation revealed, two large oxygen cylinders and one small oxygen cylinder were knocked over, and one large oxygen cylinder's valve was opened and oxygen was inadvertently released. Resident #9's room was cluttered with multiple oxygen cylinders, oxygen concentrators, multiple cords, and tubing lying on floor.
Observation on 01/23/2023 at 2:16 p.m. of Resident #9's room revealed 3 large oxygen cylinders free standing, unsecured between the night stand and bed, 1 large oxygen cylinder lying on the floor under the sink, unsecured, 1 small oxygen cylinder standing unsecured by the bed. Further observation revealed Resident #9 in his motorized scooter without nasal cannula on his nose. Resident #9 oxygen tubing was unconnected from oxygen concentrator when tangled in motorized scooter wheels.
On 01/23/2023 at 2:30 p.m., the survey team performed a facility wide audit of resident rooms and nurse's stations ensuring the safe storage of oxygen cylinders.
Resident #10
Review of Resident #10's electronic medical recorded (EMR) revealed Resident #10 was admitted to facility on 01/15/2021 and readmitted to facility on 01/17/2022 with diagnoses which included, in part, Hereditary Spastic Paraplegia and Aspiration Pneumonia.
Review of Resident #10's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 11/08/2022 revealed, in part, Resident #10 required extensive to total assistance for all ADLs, with limited assistance for eating only.
Review of Resident #10's Assessment for Safe Smoking dated 08/01/2022 revealed, in part, Resident #10 was a safe smoker.
Observation on 01/23/2023 at 2:35 p.m., revealed one free standing oxygen cylinder unsecured in Resident #10's room.
Resident #12
Review of Resident #12's electronic medical recorded (EMR) revealed Resident #12 was admitted to facility on 11/24/2021 with diagnoses which included, in part, Spinal Stenosis and Chronic Obstructive Pulmonary disease (COPD).
Review of Resident #12's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 01/04/2022 revealed, in part, Resident #12 had a BIMS (brief interview mental status) score of 13 which indicated mild cognitive impairment, and Resident #12 required extensive assistance with transfers, dressing, personal hygiene, and toilet use.
Observation on 01/23/2023 at 2:50 p.m., revealed one free standing oxygen cylinder unsecured in Resident #12's room.
Resident #11
Review of Resident #11's electronic medical recorded (EMR) revealed Resident #11 was admitted to facility on 03/24/2021 with diagnoses which included, in part, COPD, Tobacco use, and Obstructive Sleep Apnea.
Review of Resident #11's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 10/12/2022 revealed, in part, Resident #11 had a BIMS (brief interview mental status) score of 14 which indicated he was cognitively intact, and Resident #11 required limited assistance for all activities of daily living (ADLs).
Observation on 01/23/2023 at 2:52 p.m., revealed one free standing oxygen cylinder unsecured in Resident #11's room.
Observation on 01/23/2023 at 3:10 p.m. of Nurse' Station b revealed 6 large oxygen cylinders and 4 small oxygen cylinders on the floor not secured. Further observation revealed, 2 small oxygen cylinders on the counter not secured on the medication room counter.
In an interview on 01/23/2023 at 3:11 p.m., S1Director of Nursing (DON) stated all oxygen cylinders should be properly stored when in residents rooms or in the medication rooms. S1DON further stated there should not be any oxygen cylinders free standing and not in a holder or stand.
On 01/23/2023 at 3:30 pm, S3Corporate Nurse (CN) and S1Administrator were notified that oxygen cylinders were free standing and unsecured in multiple resident's rooms and nurse's station. S3CN and S1Administrator stated that staff would perform a facility wide audit to ensure no oxygen cylinders were free standing and unsecured.
Observation on 01/24/2023 at 9:30 a.m., revealed one free standing oxygen cylinder unsecure in Resident #10's room.
Observation on 01/24/2023 at 10:11 a.m., revealed one free standing oxygen cylinder unsecure in Resident #12's room.
Observation on 01/24/2023 at 2:15 p.m. revealed the Nurse's Station b revealed 2 small oxygen cylinders and 1 large oxygen cylinder free standing and unsecured in Nurse's Station b. One small oxygen cylinder also placed on top of another small oxygen cylinder in the holder.
In an interview on 01/24/2023 at 2:16 p.m., S11 Licensed Practical Nurse (LPN) stated that the two large and two small oxygen tanks in South Nursing Station are not secured and should be secured.
Observation on 01/24/2023 at 2:20 p.m. of Nurse's Station a revealed one small oxygen tank improperly stored on its side on top of multiple other large oxygen tanks on the rack.
In an interview on 01/24/2023 at 2:20 p.m., S12Licensed Practical Nurse (LPN) stated that 1 small oxygen tank was stored improperly in Nurse's Station a should be properly secured.
Observation on 01/24/2023 at 2:45 p.m. did not reveal any oxygen safety signs on the doors of the oxygen storage area of the Nurse's Station a and the Nurse's Station b.
In an interview on 01/24/2023 at 2:50 p.m., S3Corporate Nurse (CN) stated facility does not have oxygen safety signs in the designated areas where oxygen tanks are stored.
2.
Review of facilities' smoking policy and procedure revealed, in part, a Safe Smoking Assessment and/or the Interdisciplinary Team will determine if a resident is safe to smoke. Further review revealed, in part, Safe Smoking Assessments will be completed on all resident who smoke upon admission, readmission, quarterly, annually, significant change, and as needed.
Resident #8:
Review of Resident #8's electronic medical recorded (EMR) revealed Resident #8 was admitted to facility on 06/03/2022 with diagnoses which included, in part, sequelae of cerebral infarction, schizophrenia primary insomnia, tobacco use, cerebral infarction, and hemiplegia affecting left non dominant side.
Review of Resident #8's Quarterly MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 12/02/2022 revealed, in part, Resident #8 had a BIMS (brief interview mental status) score of 10 which indicated he was mildly cognitively impaired, and Resident #8 required extensive two person physical assistance with bed mobility, transfer, and one person limited physical assistance for locomotion.
Review of Resident #8's care plan revealed, in part, goal of Resident #8 will have minimal to no injuries r/t smoking with interventions that include Resident #8 will be reminded to smoke in designated smoke areas, Resident #8 will be instructed on safe measures to dispense smoking material, Resident #8 may need his cigarettes and lighter administered to me when he needs to smoke, and Resident #8 may need supervision when he smokes.
Review of the facility's Resident Unsafe Smoker List dated 12/29/2022 revealed, in part, Resident #8 was listed as needing smoking items kept on nurse's cart.
Review of Resident #8's Assessment for Safe Smoking dated 09/05/2022 revealed, in part, Resident #8 had a memory problem, was observed sharing smoking materials with other residents, and was noted for smoking in his room. Further review revealed, in part, a summary that Resident #8 is an unsafe smoker.
Review of Resident #8's nurse's note revealed, in part, note dated 06/14/2022 that noted that resident stated that he is a smoker, but has not smoked since he came into the facility because he doesn't have any cigarettes.
Review of Resident #8's nurse's note revealed, in part, note dated 07/06/2022 revealed, in part, resident had half smoking cigarette sitting on end table by his bed.
Review of Resident #8's nurse's note revealed, in part, a note dated 08/09/2022 that noted that Resident #8 was caught smoking by nurse in Resident #8's room.
Observation on 01/23/2023 at 3:00 p.m., revealed Resident #8, who was identified as an unsafe smoker per the smoking assessment completed on 09/05/2022, was smoking a cigarette in his bed. Resident #8 stated you caught me smoking and extinguished cigarette in small bowl on his bedside table. Resident #8 stated that he requested to go out and smoke, but staff do not bring him outside, so he smokes in his room. Resident #8 stated that he is not able to get out of bed by himself and transfer to a wheelchair. Resident #8 had a red pack of cigarettes, a purple lighter, and one extinguished cigarette butt at his bedside.
In an interview on 01/23/2023 at 3:15 p.m., S2Director of Nursing (DON) stated that Safe Smoking assessments are to be performed quarterly when MDS is completed. S2DON further stated that anyone who is an unsafe smoker should have smoking materials kept on nursing carts.
On 01/23/2023 at 3:30 p.m., S3Corporate Nurse (CN) and S1Administrator were notified that Resident #8 was found smoking in his room. S3CN and S1Administrator stated staff would perform a facility wide audit to ensure smoking paraphernalia is stored appropriately.
Resident #6
Review of Resident #6's Quarterly MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 11/09/2022 revealed, in part, Resident #6 had a BIMS (brief interview mental status) score of 14 which indicated she was cognitively intact.
Review of Resident #6's care plan with a target date of 03/31/2023 revealed, in part, Resident #6 was a smoker, and was caught smoking in room on 10/05/2022, 11/09/2022, and 11/15/2022. Further review revealed, in part, interventions that included Resident #6 cigarettes to be administered to her and that Resident #6 was to be directed to the authorized smoking areas.
Review of Resident #6's assessment for safe smoking dated 11/07/2022 revealed, in part, unsafe smoker since episode of smoking in room and resident aware cigarettes are in the nurse's cart.
Observation on 01/24/2023 at 10:50 a.m., revealed Resident #6 had an open pack of cigarettes and a purple lighter in her shirt pocket.
In an interview on 01/24/2023 at 10:50 a.m., Resident #6 stated she was allowed to keep her cigarettes and lighter because she smoked by herself at night.
Observation on 01/24/2023 at 11:10 a.m. with S1Administrator, S2DON, S3Corporate Nurse, S13Regional Director, revealed Resident #6 was in the possession of a lighter and cigarettes.
In an interview on 01/24/2023 at 12:30 p.m., S1Administrator, S2DON, S3Corporate Nurse, S13Regional Director, all agreed and acknowledged residents who were assessed as unsafe smokers should not have had possession of a lighter and cigarettes without staff supervision.
Resident #7
Review of Resident #7's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/28/2022 revealed, in part, Resident #7 had a BIMS (brief interview mental status) score of 14 which indicated she was cognitively intact, and Resident #7 required extensive assistance with transfers; and total dependence with dressing, personal hygiene, and toilet use.
Review of Resident #7's smoking assessment completed on 11/07/2022 identified Resident #7 as an unsafe smoker.
Observation on 01/24/2023 at 10:00 a.m., revealed Resident #7 had an open pack of cigarettes on his bed containing 5-6 cigarettes.
In an interview on 01/24/2023 at 10:00 a.m., Resident #7 stated he had possession of cigarettes but did not have a lighter.
Observation on 1/24/2023 at 10:28 a.m., revealed Resident #7 had an open pack of cigarettes on his bed containing 5-6 cigarettes.
In an interview on 01/24/2023 at 11:15 a.m., S1Administrator stated Resident #7 did have a pack of cigarettes in his room, and she had removed a pack of cigarettes from Resident #7's room on 01/24/2023.
In an interview on 01/24/2023 at 12:30 p.m., S2DON stated any residents identified as an unsafe smoker should not be in possession of any smoking materials. She further stated the ADONs checks every day the unsafe smoker's rooms for smoking materials but does not document their rounds unless there is an issue.
Observation on 01/24/2023 at 1:00 p.m., revealed Unsafe Smokers List housed at the three nursing stations in the facility were last printed on 11/10/2022 and were not up to date.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on interviews the facility failed to administer its resources effectively and efficiently by failing to:
1. Ensure oxygen cylinders were stored and secured in a manner that prevented the potenti...
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Based on interviews the facility failed to administer its resources effectively and efficiently by failing to:
1. Ensure oxygen cylinders were stored and secured in a manner that prevented the potential for serious harm or injury for 4 residents (Resident #9, Resident #10, Resident #11, and Resident #12) out of the 34 residents that required oxygen as identified on the oxygen Physician Orders List and;
2. Ensure residents who were identified as unsafe smokers did not have access to smoking materials for 3 (Resident #6, Resident #7, and Resident #8) out of 9 unsafe smokers identified on the Unsafe Smoker List.
This deficient practice resulted in an Immediate Jeopardy (IJ) on 01/23/2023 when the facility's administration failed to utilize resources to ensure the resident's environment was free of hazards for all residents residing in the facility due to the unsafe storage of unsecured oxygen cylinders, and due to the facilities' administrator failing to ensure the safety of unsafe smokers. On 01/23/2023 at 2:15 p.m, Resident #9 knocked over one large oxygen cylinder in his room, and the large oxygen cylinder's valve opened and oxygen was inadvertently released with a hissing sound. On 01/23/2023 at 2:15 p.m., surveyor was standing with S6Treatment Nurse (TN) outside of Resident #9's room. A crash was heard followed by a hissing sound. S6TN and the surveyor ran into Resident #9's room to find Resident #9 had tangled up his oxygen tubing into his electric scooter wheel, and reversed backward into three large and one small free standing oxygen cylinder next to his bed. Further observation revealed, two large oxygen cylinders and one small oxygen cylinder were knocked over, and one large oxygen cylinder's valve was opened and oxygen was inadvertently released. Resident #9's oxygen tubing was disconnected from oxygen concentrator that he was supposed to be on, and Resident #9's room was cluttered with multiple oxygen cylinders unsecured, oxygen concentrators, multiple cords, and tubing lying on the floor causing the likelihood for the potential for severe harm or injury.
On 01/23/2023 at 3:00 p.m., Resident #8 was observed smoking a cigarette in his bed and stated you caught me smoking and extinguished his cigarette in a small bowl on his bedside table. Resident stated that he asked to go outside and smoke, but that staff would never bring him outside, so he smoked in his room. Resident #8 stated that he was not able to get out of bed by himself and transfer to a wheelchair. Resident #8 had a red pack of cigarettes, a purple lighter, and one extinguished cigarette butt at his bedside.
This deficient practice had the likelihood to potentially cause serious harm or injury to all 178 residents residing in the facility as identified on the Facility Census List.
The Immediate Jeopardy was removed on 01/25/2023 at 2:32 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, which included:
1.Corrective actions were taken for the residents (Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #120 by the alleged deficient practice by:
Regional Director in-services Administrator on 01/24/2023 on ensuring the safety of unsafe smokers and ensuring oxygen cylinders are secured and properly stored.
Facility audit performed on 01/24/2023 and it is noted that there are no unsecured oxygen cylinders improperly stored. Audit also revealed that unsafe smokers had no smoking material in their possession.
2. All residents who reside in the facility have the potential to be affected by the alleged deficient practice. The facility has a census of 178.
3. Measures put in place to ensure the alleged deficient practice will not reoccur are:
Regional Director in-serviced Administrator on 01/24/2023 on ensuring the safety of unsafe smokers and ensuring oxygen cylinders are secured and properly stored.
Facility audit performed on 01/24/2023 which noted that there are no unsecured oxygen cylinders improperly stored.
4. The facility planned to monitor its performance to ensure solutions are achieved and sustained by:
Regional Director or designee will perform quality assurance administration audits 2 times per week to ensure the safety of unsafe smokers and to ensure oxygen cylinders are secure and stored properly.
Audits began on 01/25/2023. Rounds will continue until 02/25/2023.
5. Corrective actions will be completed by:
The facility plans to have the alleged deficient practice completed by 01/25/2023.
Findings:
Cross reference F689.
On 01/23/2023 at 3:30 pm, S3Corporate Nurse (CN) and S1Administrator were notified that oxygen cylinders were free standing and unsecured in multiple resident's rooms and nurse's station. S3CN and S1Administrator confirmed that oxygen cylinders were not secured and stored properly. S3CN and S1Administrator further stated that staff would perform a facility wide audit to ensure no oxygen cylinders were free standing and unsecured.
On 01/23/2023 at 3:30 p.m., S3Corporate Nurse (CN) and S1Administrator were notified that Resident #8 was found smoking in his room. S3CN and S1Administrator confirmed that Resident #8 was an unsafe smoker and should not have access to smoking paraphernalia or be smoking in his room. S3CN and S1Administrator further stated staff would perform a facility wide audit to ensure smoking paraphernalia was stored appropriately.
Observation on 01/24/2023 at 11:10 a.m. with S1Administrator, S2DON, S3Corporate Nurse, S13Regional Director, revealed Resident #6, who was an unsafe smoker, in the possession of a lighter and cigarettes
In an interview on 01/24/2023 at 11:15 a.m., S1Administrator stated Resident #7, who was an unsafe smoker, did have a pack of cigarettes in his room, and she just had removed a pack of cigarettes from Resident #7's room on 01/24/2023.
In an interview on 01/24/2023 at 2:50 p.m., S3Corporate Nurse (CN) stated the facility does not have oxygen safety signs in the designated areas where oxygen cylinders are stored.
In an interview on 01/25/2023 at 1:30 p.m., S13Regional Director stated he had in-serviced facility's administrator on ensuring the safety of unsafe smokers and ensuring oxygen cylinders are secured and properly stored. S13Regional Director further stated, S13Regional Director or designee would perform administrative audits 2 times per week to ensure the safety of unsafe smokers and to ensure oxygen cylinders are secure and stored properly. S13Regional Director stated that audits began on 01/25/2023 and would continue until 02/25/2023.
Dec 2022
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
Based on observation, interview and record review the facility failed to ensure a resident dependent on staff for nail care received assistance to ensure their fingernails and/or toenails were kept cl...
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Based on observation, interview and record review the facility failed to ensure a resident dependent on staff for nail care received assistance to ensure their fingernails and/or toenails were kept clean and/or trimmed.
This deficient practice was identified for 1 (Resident #1) of 5 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for nail care.
Findings:
Review of Resident #1's care plan revealed he was care planned to assess/trim fingernails and toenails monthly.
Review of Resident #1's record, in part, revealed an order dated 07/28/2022 to refer to podiatry related to right foot fungus & toenails. Further review of Resident #1's record, in part, revealed he was last seen by a podiatrist on 04/20/2021.
Review of Resident #1's Minimum Data Set with an Assessment Reference date of 11/02/2022, in part, revealed he was totally dependent on 1 person for personal hygiene. Further review of Resident #1's Minimum Data Set revealed he had severe cognitive impairment.
Observation on 12/12/2022 at 11:06 a.m. revealed Resident #1 to have long fingernails extending past the fingertips of both hands with a dark unknown substance underneath.
Observation on 12/12/2022 at 1:50 p.m. revealed Resident #1's toenails were long, thick and yellow and both feet to be dry. Further observation revealed Resident #1's toenails on the right and left great toe to curl downward.
Observation on 12/13/2022 at 2:40 p.m. revealed Resident #1 had a dark unknown substance underneath his fingernails on his right hand.
In an interview on 12/12/2022 at 1:50 p.m., S2Wound Care Nurse stated Resident #1's fingernails need to be cleaned, toenails need to be cut and he needs to see a podiatrist.
In an interview on 12/13/2022 at 11:55 a.m., S1Director of Nursing confirmed Resident #1's fingernails needed to be cleaned and trimmed. S1Director of Nursing further confirmed Resident #1's toenails should have been trimmed and he should have been seen by a podiatrist.
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: 4 life-threatening violation(s), $70,651 in fines, Payment denial on record. Review inspection reports carefully.
- • 52 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $70,651 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 4 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Jefferson Healthcare Center's CMS Rating?
CMS assigns Jefferson Healthcare Center 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 Jefferson Healthcare Center Staffed?
CMS rates Jefferson Healthcare Center's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Jefferson Healthcare Center?
State health inspectors documented 52 deficiencies at Jefferson Healthcare Center during 2022 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 46 with potential for harm, and 2 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 Jefferson Healthcare Center?
Jefferson Healthcare Center 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 222 certified beds and approximately 168 residents (about 76% occupancy), it is a large facility located in Jefferson, Louisiana.
How Does Jefferson Healthcare Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Jefferson Healthcare Center's overall rating (1 stars) is below the state average of 2.4, staff turnover (60%) 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 Jefferson Healthcare Center?
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 Jefferson Healthcare Center Safe?
Based on CMS inspection data, Jefferson Healthcare Center has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Jefferson Healthcare Center Stick Around?
Staff turnover at Jefferson Healthcare Center is high. At 60%, the facility is 14 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 60%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. 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 Jefferson Healthcare Center Ever Fined?
Jefferson Healthcare Center has been fined $70,651 across 2 penalty actions. This is above the Louisiana average of $33,785. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Jefferson Healthcare Center on Any Federal Watch List?
Jefferson Healthcare Center 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.