Jena Nursing and Rehabilitation Center, LLC
For profit - Limited Liability company
108 Beds
NORBERT BENNETT & DONALD DENZ
Data: November 2025
Trust Grade
10/100
#215 of 264 in LA
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Jena Nursing and Rehabilitation Center, LLC has a Trust Grade of F, indicating significant concerns and poor performance overall. They rank #215 out of 264 facilities in Louisiana, placing them in the bottom half, and #2 out of 2 in LaSalle County, meaning there is only one other local option available that performs better. The facility is showing an improving trend as issues decreased from 17 in 2024 to 15 in 2025, but they still have a high staffing turnover rate of 62%, which is concerning compared to the state average of 47%. Specific incidents include a serious case of abuse where one resident was physically harmed by another, and failures in care planning and skin audits that could lead to potential harm for residents. Although there are some strengths, such as average RN coverage, the overall picture is troubling, and families should weigh these factors carefully when considering this facility.
- Trust Score
- F
- In Louisiana
- #215/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $38,851 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
10/100
Bottom 19%
Review needed
17 → 15 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 15 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: 62%
16pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $38,851
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: NORBERT BENNETT & DONALD DENZ
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (62%)
14 points above Louisiana average of 48%
The Ugly 43 deficiencies on record
1 actual harm
Jun 2025
11 deficiencies
CONCERN
(D)
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 interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse for 1 (#51) of 4 (#31, #50, #51, and #172) sampled residents investigated for...
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Based on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse for 1 (#51) of 4 (#31, #50, #51, and #172) sampled residents investigated for abuse. The facility failed to protect Resident #51 from physical abuse by Resident #272.
This failed practice resulted in an actual harm for Resident #51 on 05/20/2025 at 4:09 p.m. when Resident #272 hit Resident #51 multiple times on the head, causing lacerations to Resident #51's left cheek, right cheek, forehead, and chin.
Findings:
Review of the facility's undated policy entitled Abuse Prevention revealed, in part .the facility is committed to protection residents from abuse. Physical abuse includes hitting.
Review of Resident #51's medical record revealed an admission date of 05/06/2024 with diagnoses including, in part .Depression, Anxiety, Mood Disorder, and Other Seizures.
Review of Resident #51's Annual MDS with an ARD of 05/06/2025 revealed, in part .a BIMS Score of 11, indicating moderately impaired cognition. Resident #51 did not have a history of physical behaviors directed towards others.
Review of Resident #272's medical record revealed an admission date of 08/08/2023 with diagnoses including, in part .Schizoaffective Disorder and Major Depressive Disorder with Psychotic Symptoms.
Review of Resident #272's Annual MDS with an ARD of 04/15/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #272 did not have a history of physical behaviors directed towards others.
Review of the facility's investigation report dated 05/20/2025 revealed, in part .on 05/20/2025 at 4:09 p.m. Resident #272 hit Resident #51 multiple times on the head with his fist. As a result of the incident, Resident #51 had lacerations to his left cheek, right cheek, forehead, and chin. Resident #51 was evaluated at the emergency room, where he had a negative CT scan of the head. Resident #272 was placed on 1:1 care until he was transferred to the hospital and subsequently admitted to a behavioral hospital with a PEC.
Interview with S25 CNA on 06/03/2025 at 10:05 a.m. revealed Resident #51 was not physically aggressive with others.
Interview with Resident #51 on 06/04/2025 at 2:00 p.m. revealed on 05/20/2025 at 4:09 p.m. Resident #272 asked him for a cigarette. Resident #51 refused to give Resident #272 a cigarette. Resident #272 hit Resident #51 multiple times on the head, causing multiple lacerations to his face.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
Based on record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, for 1 (#34) of 6 (#16, #21, #28, #34...
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Based on record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, for 1 (#34) of 6 (#16, #21, #28, #34, #49, and #122) residents sampled for Unnecessary Medications.
Findings:
Review of Resident #34's medical record revealed an admission date of 11/06/2020 with diagnoses including, in part .Schizophrenia.
Review of Resident #34's Annual MDS with an ARD of 05/20/2025 revealed, in part .a BIMS Score of 15, indicating intact cognition. Resident #34 used antipsychotic medication, a gradual dose reduction had not been attempted, and the physician had not documented a gradual dose reduction was contraindicated.
Review of Resident #34's current orders revealed, in part .Risperdal 1mg tablet by mouth two times a day related to Schizophrenia, ordered on 09/13/2024.
Review of Resident #34's Consultant Pharmacist Communication to Physician dated 04/17/2025 revealed the provider had not documented a response to the pharmacist's recommendation of gradual dose reduction for Risperdal 1mg.
Review of Resident #34's medical record revealed there was no documentation of a gradual dose reduction, or documentation of a clinical contraindication for a gradual dose reduction for Risperdal 1mg.
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 interview the facility failed to ensure an injury of unknown origin and allegation of abuse was repor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an injury of unknown origin and allegation of abuse was reported immediately to management staff for 2 (#50 and #172) of 30 sampled residents.
Findings:
Review of the facility's 01/2025 policy titled, Abuse Prevention, read in part The facility is committed to protecting the resident from abuse by anyone .Identification: 1. Identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 2. The Executive Director and Director of nursing services must be promptly notified of suspected abuse or incidents of abuse.
Resident # 172
Review of Resident #172 medical record revealed an admit date of 02/11/2025 with diagnoses that included: COPD, Congestive Heart Failure, Atherosclerotic Heart Disease, Depression, and Essential HTN.
Review of Resident #172's Quarterly MDS with an ARD of 02/18/2025 revealed a BIMS score of 03, which indicated severe cognition impairment.
Review of a SIMS report completed by the facility on 05/15/2025 revealed on 05/13/2025 Resident #172 was sent out to a local hospital due to respiratory issues. On 05/15/2025, S21 Marketer visited Resident #172 at the local hospital and was made aware, by hospital staff, of an undisclosed small bruise to the corner of his right eye and large bruise to his right lower abdomen/hip area. During the facility investigation, S9 LPN notified management staff that she observed the bruises (accompanied with Resident #172's responsible party) while in his room on 5/11/2025, but had not notified any facility staff of the bruising.
Interview on 06/04/2025 at 9:15 a.m. with S1 Admin revealed Resident #172 was sent out to the hospital on [DATE]. S1 Admin stated S21 Marketer notified her that during a hospital visit with Resident #172, S21 Marketer was notified of undisclosed bruising to the corner of his right eye and to his right lower abdomen/hip area. S1 Admin revealed that she was not made aware of any bruising on Resident #172 prior to being notified by S21 Marketer on 05/15/2025. S1 Admin stated that during the facility investigation of Resident #172's bruises, S9 LPN stated that she observed the bruising on 05/11/2025 and did not notify management staff. S1 Admin stated that S9 LPN should have notified management staff immediately after observing Resident #172's bruising on 05/11/2025, but did not.
Interview on 06/04/2025 at 9:28 a.m. with S9 LPN revealed she observed a bruise to Resident #172's left corner of his right eye and observed a bruise to his right hip area on 05/11/2025. S9 LPN confirmed that on 05/11/2025 she should have notified S1 Admin or management staff immediately when she first observed Resident #172's bruising, but did not because she thought it had already been addressed.
Resident #50
Review of Resident #50's medical record revealed an admit date of 10/15/2024 with diagnoses that included in part: Dementia, Anxiety, Cerebrovascular Disease, and Major Depressive Disorder.
Review of Resident #50's Quarterly MDS with an ARD of 07/23/2025 revealed a BIMS score of 12, which indicated moderate cognitive impairment.
Telephone interview on 06/03/2025 at 1:34 p.m. with S3 LPN revealed S22 CNA reported to her that Resident #50 had mentioned that to her (S22 LPN) that two women were trying to hold her down and break her legs and arms. S3 LPN stated she went to Resident #50's bedroom to assess her of the reported allegation. S3 LPN stated she had a lot going on that night and knew to report any allegations of abuse to S1 Admin right away. S3 LPN confirmed she sent S1 Admin a text message of the alleged abuse around 3:40 a.m. on 05/22/2025. S3 LPN stated she should have reported the allegation of abuse immediately but had not.
Interview on 06/03/2025 at 1:40 p.m., with S1 Admin stated she was notified via text message by S3 LPN on 05/22/2025 around 3:40 a.m., of Resident #50 stating that two women were trying to break her legs and arms. S1 Admin stated after speaking with Resident #50, Resident #50 stated this incident happened at another facility and couldn't give a description of what the women looked like. S1 Admin confirmed that S3 LPN should've notified her immediately of the alleged abuse but had not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 3 (#34, #51, and #60) of 5 (#16, ...
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Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 3 (#34, #51, and #60) of 5 (#16, #34, #44, #51, and #60) residents sampled for review of resident vaccinations.
Findings:
Resident #34
Review of Resident #34's most recent MDS revealed, in part .COVID-19 vaccination was not up-to-date.
Review of Resident #34's Resident Immunization Record revealed COVID-19 vaccinations were administered to Resident #34 on 09/22/2021, 10/22/2021, 04/29/2022, 01/31/2024, and 06/12/2024.
Resident #51
Review of Resident #51's most recent MDS revealed, in part .COVID-19 vaccination was not up to date.
Review of Resident #51's Resident Immunization Record revealed COVID-19 vaccinations were administered to Resident #51 on 04/08/2021, 06/12/2024, and 11/13/2024.
Resident #60
Review of Resident #60's most recent MDS revealed, in part .COVID-19 vaccination was not up to date.
Review of Resident #60's Resident Immunization Record revealed COVID-19 vaccinations were administered to Resident #60 on 05/03/2021 and 12/28/2021.
Interview with S23 IP on 06/04/2025 at 1:49 p.m. revealed residents were considered up to date with COVID-19 vaccination when they had received two doses of vaccine, 6 months apart. S23 IP confirmed the most recent MDS assessments for Resident #34, Resident #51, and Resident #60 should have indicated COVID-19 vaccinations were up to date, but did not.
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 observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maint...
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Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene.
The facility failed to:
1.
Perform AM care including face/hair washing and shaving for Resident # 38; and
2.
Provide daily bed baths for 2 (Resident #26 and Resident #34) residents.
The total Sample Size is 29 residents.
Findings:
Review of the facility's 10/2009 policy titled A.M. Care read in part . A.M. Care will be given to residents daily. Procedure: 5. Residents to wash, rinse and dry face and hands if able. 11. Provide/assist with shaving (male and female) as needed.
Resident #38
Review of Resident #38's Care plan with a review date of 06/11/2025 revealed impaired mobility due to Muscular Dystrophy. Resident #38 requires 2 person assist with bathing, dressing, and grooming.
Review of Resident #38's Quarterly MDS with ARD of 03/11/2025 revealed the BIMS was not conducted because Resident #38 is rarely/never understood. Resident #38 is dependent on staff for all ADL's. Resident #38 exhibited no behaviors.
Observation on 06/02/2025 at 10:10 a.m. revealed Resident #38 lying in bed with a great amount of white and brown flakes to her forehead and neck hairline and hair was unkempt. Resident #38's face had dried sputum and white and brown flakes near mouth area, and long facial hair to chin.
Interview on 06/02/2025 at 10:30 a.m. with S6 LPN confirmed that Resident #38's hair and face was unkempt/dirty and confirmed that her facial hair on her chin was long and needed to be shaved, but had not been.
Interview on 06/03/2025 at 4:05 p.m. with S11 CNA revealed that Resident #38 does not refuse care. S11 CNA stated that she bathed and shaved her this morning and was about to go and wash her hair.
Resident #34
Review of Resident #34's medical record revealed an admission date of 11/06/2020 with diagnoses including, in part .Schizophrenia and Morbid Obesity.
Review of Resident #34's Annual MDS with an ARD of 05/20/2025 revealed, in part .a BIMS Score of 15, indicating intact cognition. Resident #34's was dependent for toileting hygiene, bathing, and personal hygiene.
Review of Resident #34's Care Plan Report revealed, in part .staff was to assist with activities of daily living (ADL) care daily and provide daily bed baths.
Review of Resident #34's Bed Bath Daily on Night Shift task record for the last two weeks revealed Resident #34's did not have a bed bath on 06/02/2025, 05/31/2025, 05/30/2025, 05/29/2025, 05/28/2025, 05/27/2025, or 05/26/2025.
Observation of Resident #34 on 06/02/2025, 06/03/2025, and 06/04/2025 revealed a foul odor to the room.
Interview with Resident #34 on 06/03/2025 at 9:23 a.m. revealed Resident #34 did not have a bed bath on 06/02/2025. Resident #34 could not remember when he was last bathed.
Interview with S10 Tx Nurse on 06/03/2025 at 9:54 a.m. confirmed there was a foul odor in Resident #34's room.
Interview with S25 CNA on 06/03/2025 at 10:05 a.m. confirmed Resident #34 did not receive a bed bath on 06/02/2025.
Interview with S2 DON on 06/04/2025 at 1:10 p.m. revealed Resident #34 was supposed to have a bed bath daily. S2 DON confirmed Resident #34 did not have a bed bath on 06/02/2025, 05/31/2025, 05/30/2025, 05/29/2025, 05/28/2025, 05/27/2025, or 05/26/2025, but should have.
Resident # 26
A review of facility undated policy titled, Bed Bath, revealed in part .Policy: Bedfast residents will receive a bed bath daily .
A review of Resident # 26's medical record revealed an admission date of 05/17/2023 with diagnoses that included Spinal Stenosis of lumbar region without neurogenic claudication, Alzheimer's with late onset, Epilepsy unspecified with Status Epilepticus, Morbid (severe) Obesity due to excess calories, Obstructive Sleep Apnea, Osteoarthritis, Neuromuscular Dysfunction of bladder, Cognitive Communication Deficit, Atrial Fibrillation, and Candidiasis of skin and nail.
Review of Resident # 26's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/18/2025 revealed a BIMS score of 13, which indicated intact cognition. Resident # 26 was dependent for personal hygiene and toileting hygiene. Resident #26 required substantial/maximal assistance for bathing.
Review of Resident# 26's care plan revealed Resident # 26 required staff assistance with all activities of daily living (ADLs) with interventions that included in part . staff assist x1 with bed mobility, toileting, dressing, and grooming.
On 06/02/2025 at 09:25 a.m. observation of Resident # 26's room revealed a foul odor to entire room.
On 06/02/2025 at 09:25 a.m. interview with Resident # 26 revealed Resident # 26's last bed bath was on 05/29/2025. Resident # 26 stated she only received bed baths when she would request a bed bath from staff. Resident # 26 stated she requested a bed bath that morning of 06/02/2025 and facility staff told Resident # 26 they would come back.
On 06/02/2025 at 12:15 p.m. review of Resident # 26's electronic health record facility task named BED BATH DAILY ON DAY SHIFT with review dates 05/15/2025 to 06/02/2025, revealed Resident # 26 did not receive a bed bath on 05/16/2025, 05/17/2025, 05/18/2025, 05/21/2025, 05/22/2025, 05/26/2025, 05/27/2025, 05/30/2025, 05/31/2025, and 06/01/2025.
On 06/03/2025 at 10:30 a.m. interview with S14 LPN revealed S14 LPN was the staff nurse for Resident #26. S14 LPN revealed CNA's are made aware of residents' baths schedules and preferences by reviewing bath schedule posted on wall in nurses station daily and reviewing residents' paper kardex daily.
On 06/03/2025 at 10:30 a.m. observation of bath schedule located in Hall 1 nurses station revealed in part . Resident #26 - Bed bath daily on day shift (AM).
On 06/03/2025 review of Resident #26's facility paper kardex revealed in part . BATHING: Bed bath daily on day shift.
On 06/03/2025 at 12:45 p.m. interview with S12 CNA revealed she was the primary and only CNA for Hall 1 that day. S12 CNA confirmed Resident # 26 was scheduled to receive a bed bath daily.
On 06/03/2025 at 01:00 p.m. review of Resident # 26's electronic health record facility task named Bed bath daily on day shift revealed bed bath task was completed on 06/03/2025 at 11:00 a.m.
On 06/03/2025 at 1:01 p.m. observation/interview with Resident # 26 revealed minimal but notable odor to room. Resident # 26 stated she did not receive the bed bath she requested on 06/02/2025 or earlier that day of 06/03/2025. Resident #26 reviewed personal calendar that was located on her bedside table. Resident #26 stated her last bath documented on her personal calendar was Thursday, 05/29/2025. Resident #26 stated her last bath before 05/29/2025 was approximately 10 days prior to 05/29/2025. Resident #26 stated her bed linens were changed on 06/02/2025 due to linens saturated in urine, but she did not receive a bed bath.
On 06/03/2025 at 01:23 p.m. interview conducted with S12 CNA. S12 CNA confirmed she did document that Resident #26 received a bed bath that morning of 06/03/2025 at 11:00 a.m. although she had not provided a bed bath to Resident #26 on 06/03/2025.
On 06/03/2025 at 01:48 p.m. interview conducted with S2 DON. S2 DON confirmed Resident #26 was scheduled to receive a bed bath daily. Resident #26's task documentation Bed bath daily on day shift (05/15/2025- 06/03/2025) was reviewed with S2 DON. S2 DON confirmed documentation for the time period reviewed revealed Resident #26 did not receive a bed bath on 05/16/2025, 05/17/2025, 05/18/2025, 05/21/2025, 05/22/2025,05/26/2025, 05/27/2025, 05/30/2025, 05/31/2025, 06/1/2025 and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide necessary services to maintain optimal skin integrity for 1 (Resident # 26) of 29 sampled residents.
Findings:
Reside...
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Based on observation, interview, and record review the facility failed to provide necessary services to maintain optimal skin integrity for 1 (Resident # 26) of 29 sampled residents.
Findings:
Resident # 26
A review of facility policy titled, Turning and Positioning Program with revision date of 07/2018, revealed in part .
Policy: All residents will be turned and positioned as per the plan of care in an organized system .
A review of Resident #26's medical record revealed an admission date of 05/17/2023 with diagnoses that included Spinal Stenosis of lumbar region without neurogenic claudication, Alzheimer's with late onset, Epilepsy unspecified with Status Epilepticus, Morbid (severe) Obesity due to excess calories, Obstructive Sleep Apnea, Osteoarthritis, Neuromuscular Dysfunction of bladder, Cognitive Communication Deficit, Atrial Fibrillation, Candidiasis of skin and nail, and other lack of coordination.
A review of Resident # 26's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/18/2025 revealed a BIMS score of 13, which indicated intact cognition. Resident #26 required moderate assistance to roll left to right, always incontinent to bowel and bladder, and at risk for pressure ulcers/injuries.
Review of Resident of #26's care plan revealed Resident #26 required staff assistance with all activities of daily living (ADLs) with interventions that included in part . staff assist x1 with bed mobility, toileting, dressing, and grooming. Resident #26 was at risk for impaired skin integrity related to decreased mobility and activities of daily living (ADL) function, bowel and bladder incontinence, diagnosis of Alzheimer's dementia, neuropathy, and neurogenic bladder. Interventions included in part .Turn and reposition every 2 hours and as needed.
On 06/03/2025 at 09:30 a.m. observation of Resident #26 revealed Resident #26 resting in bed with eyes closed. Resident #26 was positioned on her back with head of bed elevated.
On 06/03/2025 at 10:25 a.m. observation of Resident #26 revealed Resident #26 resting in bed with eyes closed. Resident # 26 was positioned on her back with head of bed elevated. Resident #26 lying in bed in same position from observation at 06/03/2025 09:30 a.m.
On 06/03/2025 at 12:21 p.m. observation of Resident #26 revealed Resident #26 resting in bed with eyes closed. Resident #26 was positioned on her back with head of bed elevated. Resident # 26 lying in bed in same position from observations at 06/03/2025 09:30 a.m. and 10:25 a.m.
On 06/03/2025 at 12:45 p.m. interview with S12 CNA revealed S12 CNA worked Hall 1 routinely on the 7 a.m. to 7 p.m. shift and was familiar with the care Resident #26 required. S12 CNA stated Resident #26 was bed bound, could feed herself, but required assistance for all other ADLs. S12 CNA confirmed Resident #26 could not reposition herself independently. S12 CNA confirmed she had not repositioned Resident #26 that day.
On 06/03/2026 at 01:00 p.m. interview conducted with Resident #26. Resident #26 stated she was not turned and repositioned by staff routinely. Resident #26 confirmed she was unable to turn and reposition in the bed independently.
On 06/03/2025 at 01:48 p.m. interview conducted with S2 DON. S2 DON stated all residents that were care planned to be turned and repositioned every two hours and as needed, would have task turn and repositioned every two hours and as needed reflected on each resident's paper kardex and be listed as a task in facility electronic charting system to be acknowledged by the CNA's each shift.
Review of Resident #26 care plan reviewed with S2 DON. S2 confirmed Resident #26 was care planned to be turned and repositioned every two hours and as needed. S2 DON confirmed Resident #26 did not have a turn and reposition task listed in facility electronic charting system and should have.
Resident #26's paper kardex was reviewed with S2 DON. S2 DON confirmed paper kardex did not reflect Resident #26 was required to be turned every two hours and as needed and should have.
On 06/04/2025 at 1:00 p.m. interview conducted with S13 CNA. S13 revealed she was the only CNA assigned to Hall 1 that day and familiar with the care Resident #26 required. S13 CNA confirmed Resident #26 required to be turned and repositioned by staff. S13 CNA confirmed she had not turned or repositioned Resident #26 at any time during her ongoing shift on 06/04/2025. S13 CNA confirmed she was supposed to turn and reposition Resident #26 every 2 hours and had not done so that day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as orde...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered by the physician for 1 (#25) of 3 (#25, #53, and #122) residents reviewed for tube feeding.
Findings:
Review of the Facility's 01/2025 policy titled Tube Feeding read in part Residents with a Gastrostomy or Jejunostomy tube will be provided nutrition and hydration via the feeding tube. Procedure: Administer feeding as ordered via continuous pump feeding per physicians orders.
Review of Resident #25's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included: Acute Respiratory Failure, Hyperlipidemia, Hypothyroidism, and Insomnia.
Review of Resident #25's admission MDS with an ARD of 05/14/2025 revealed a BIMS of 13, which indicated intact cognition.
Review of Resident #25's Care Plan with a review date of 08/13/2025 read in part: Resident requires tube feeding related to nothing by mouth status. The resident is dependent on tube feeding and water flushes. See MD orders for current feeding orders.
Review of Resident #25's current Physician Orders revealed the following, in part:
05/07/2025 -Glucerna 1.5 @ 60ml/hr via pump
05/07/2025- H20 Flush @ 250ml/Q4h via pump
Review of Resident #25's MAR/Progress notes dated June 2025 revealed no documentation tube feeding was held or refused on 06/01/2025 or 06/02/2025.
An observation and interview on 06/02/2025 at 9:52 a.m. revealed Resident #25's peg feeding was not infusing and was turned off. Resident #25 stated he does not know how long the feeding had been turned off. Observation of the feeding hanging: Glucerna 1.5 cal with start date written 06/01/2025 at 17:12. Rate 60ml/hr. 600ml left in bottle. H20 Water flush bag dated 5/31/2025 23:00 with a rate of 250ml/q4 hour. 700ml was left in bag.
Interview on 06/02/2025 at 9:52 a.m. with S7 LPN at the time of observation revealed she was unaware that the feeding pump was off and does not how long it had been off and was not notified of any issues with Resident #25's feedings at 7:00 a.m. shift change.
Interview on 06/03/2025 at 11:58 a.m. with S8 LPN revealed she worked on the night shift of 06/01/2025-06/02/2025 from 7p.m. to 7a.m. S8 LPN stated she could not find any H20 flush bags in the storage the building so she had to refilled Resident #25'swater bag that was currently hanging. S8 LPN stated at the beginning of the shift Resident #25 told her that his stomach was hurting so she turned it off the tube feeding to let his stomach rest sometime around 7:30 p.m. S8 LPN stated that she turned the tube feeding back on around 10:30 p.m. S8 LPN stated Resident #25 slept the rest of the night and the feeding ran and she cannot recall hearing his tube feeding alarm during the night.
Interview on 06/03/20205 at 10:20 a.m. with S2 DON revealed she was notified there was some issues with tube feeding on 06/02/205 but does not know why Resident #25 was off of the tube feeding that morning and how long it had been off, but should not have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to complete an annual performance review and provide regular in-service education based on the outcome of the annual performance reviews for 2...
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Based on record review and interview, the facility failed to complete an annual performance review and provide regular in-service education based on the outcome of the annual performance reviews for 2 (S16 CNA and S17 CNA) of 3 (S13 CNA, S16 CNA, S17 CNA) certified nursing assistants reviewed for sufficient and competent nurse who required it.
Findings:
Review of S16 CNA's personnel records revealed a date of hire of 11/01/2023. Further review revealed no evidence of an annual performance being completed within the past 12 months. Record review revealed the last annual performance was completed on 06/19/2023.
Review of S17 CNA's personnel records revealed a date of hire of 05/24/2024. Further review revealed no evidence of an annual performance review being completed in the past 12 months.
In an interview on 06/04/2025 at 2:01 p.m., S1 Administrator acknowledged annual performance reviews had been requested multiple times for the sampled CNAs, but had not been provided.
In an interview on 06/04/2025 at 2:15 p.m., S15 HR (Human Resources) stated she provided the requested annual performance reviews. An observation of S16 CNA's annual performance review with S15 HR at that time revealed it was signed and dated 06/19/2023. S15 HR stated it must have been dated wrong. S15 HR acknowledged S16 CNA and S17 CNA's personnel records had no evidence of an annual performance evaluation being completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prev...
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Based on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure:
1. Facility staff wore a gown while administering medications to a resident on EBP, Resident #122, through a Gastrostomy (PEG tube);
2. Standard Precautions were utilized during wound care,
3. Unused resident care items were not stored on the floor
4. Resident's used basins were not stored in a shower
5. Resident's used urinal was not stored in a shower, and
6. A Curtain in the shower area was not visibly soiled.
Findings:
Resident #122
On 6/04/2025 at 10:30 a.m. the facility provided a copy of their Enhanced Barrier Precautions Policy with a History date of 4/24. Review of the policy revealed, Enhanced Barrier Precautions only require use of gown/ gloves when performing high contact resident activities: a. g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy, or ventilator h.
Resident #122
Review of Resident #122's medical record revealed an admit date of 05/22/2025 with diagnoses including Quadriplegia, Seizures, Generalized Anxiety Disorder, and Attention to Gastrostomy (PEG tube.)
On 06/03/2025 at 12:45 p.m. the midday medication pass for Resident #122 was observed. S14 LPN began to administer Resident #122's medications through PEG tube. Syringe was no longer in the resident's room and S14 LPN did not have any syringes on medication cart. S14 LPN stepped into the hallway to ask another staff member to get a syringe. S14 LPN put on gloves to handle the resident's PEG tube, but did not wear a gown. S14 LPN checked residual, administered two crushed medications, Baclofen and Gabapentin, and flushed PEG tube per orders, without wearing a gown.
Review of Resident #122's Orders:
Baclofen Oral Tablet 5 MG; Give 1 tablet via PEG-Tube three times a day related to quadriplegia; Active; Start date: 05/22/2025
Gabapentin Oral Tablet 600 MG; Give 1 tablet via PEG-Tube three times a day related to Neuralgia and Neuritis; Active; Start date: 05/22/2025
Flush peg tube with 30mls of water before and after administration of medication; every day and night shift; Start date: 05/22/2025
On 06/03/2025 at 2:45 p.m. an interview with S14 LPN was conducted. S14 LPN was asked to explain the EBP policy and how it relates to medication administration through a PEG tube. S14 LPN explained that the EBP policy states to wear gown and gloves for using the resident's PEG tube. S14 LPN also confirmed that she had forgotten to put a gown on prior to handling Resident #122's PEG tube for medication administration but should have.
On 06/04/2025 at 10:05 a.m. an interview with S2 DON was conducted. S2 DON confirmed that S14 LPN should have worn a gown with her gloves to administer medications through Resident #122's PEG tube per EBP policy.
Review of the facility's policy entitled Standard Precautions revised in 09/2019, revealed, in part .Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious agents among patients and healthcare personnel. Standard Precautions include, in part, hand hygiene. During delivery of healthcare, staff is to avoid unnecessary touching of surfaces to prevent transmission of pathogens from contaminated hands. Wash hands before direct contact with patients.
Review of the facility's policy entitled Shower Room Cleaning dated 06/2018 revealed no guidance regarding cleaning or changing of shower curtains.
2.
Observation of S10 Tx Nurse on 06/03/2025 at 8:05 a.m. revealed she was preparing to perform wound care. No observation of hand hygiene prior to preparation. S10 Tx Nurse used her ungloved hand to place clean gauze into a cup and then sprayed the contaminated gauze with wound cleanser. Observed S10 Tx Nurse use her ungloved hand to place more clean gauze into the same cup. No observation of hand hygiene throughout wound care preparation procedures. Observed S10 Tx Nurse continue to provide wound care for a resident with the contaminated cup of gauze she prepared.
Interview with S10 Tx Nurse on 06/03/2025 at 8:26 a.m. confirmed she did not perform hand hygiene before touching the gauze or performing wound care, but should have. S10 Tx Nurse confirmed she used the gauze to clean the resident's wound, but should not have.
3.
Observation of Room A on Hall X on 06/03/2025 at 8:35 a.m. revealed opened packages of adult briefs, unpackaged adult briefs, plastic wash basins, a purple foam wedge, and cloth under-pads stored directly on the floor.
4. and 5.
Observation of Room B on Hall X on 06/03/2025 at 8:43 a.m. revealed 2 plastic wash basins and a soiled urinal stored directly on the shower floor.
Interview with S1 Admin on 06/03/2025 at 8:49 a.m. revealed unused resident care items should not be stored directly on the floor. S1 Admin confirmed there were opened packages of adult briefs, unpackaged adult briefs, plastic wash basins, a purple foam wedge, and cloth under-pads stored directly on the floor of Room A on Hall X, but should not have been. S1 Admin confirmed used resident care items were stored directly on the shower floor in Room B, but should not have been.
6.
Observation of Shower C on Hall Y 06/03/2025 at 8:57 a.m. revealed a brown substance on the shower curtain at waist level and dark discoloration observed along the bottom of the shower curtain.
Interview with S24 HK Sup on 06/03/2025 at 8:58 a.m. revealed she did not know how often the shower curtain should be cleaned and the shower curtain needed cleaning.
Sup- is that the right identifier?
Interview with S1 Admin on 06/03/2025 at 8:59 a.m. confirmed the shower curtain was visibly soiled and needed cleaning, but was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observations, record review, and interviews the facility failed to develop and implement a person-centered care plan for each resident to maintain the resident's highest practicable physical,...
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Based on observations, record review, and interviews the facility failed to develop and implement a person-centered care plan for each resident to maintain the resident's highest practicable physical, mental, and psychosical well-being. The facility failed to:
1. Ensure staff placed, connected, and ensured proper functioning of Resident #122's bed alarm, as ordered;
2. Develop a comprehensive person-centered care plan for Resident #19; and Resident #30
There were 29 sampled residents.
Findings:
Resident #122
Review of Resident #122's medical record revealed an admit date of 05/22/2025 with diagnoses including Quadriplegia, Seizures, Generalized Anxiety Disorder, and Attention to Gastrostomy (PEG tube.)
Observation and interview with Resident #122 on 06/02/2025 at 09:40 a.m. found resident's bed against the wall with the fall mat on the open side. Bed observed in low position. Detached bed alarm control box was noted hanging on bed frame. There were no wires observed connected to the bed alarm box. Geri chair noted at bedside reclined with bed alarm mat in seat of chair. Resident #122 did have a call light but stated she didn't know where it was and just calls out for assistance. Resident #122 stated she had previously fallen, but could not recall when.
In an observation on 06/03/2025 at 08:30 a.m. Resident #122 was asleep in bed. Fall matt is on the open side of the bed with the other side of the bed against the wall. Bed alarm box was still hanging on bed frame with no wires connected. Bed alarm mat remains in Geri chair, not in resident's bed.
In an observation on 06/03/2025 at 9:47a.m., Resident #122's bed alarm remained disconnected. Facility staff were observed removing bed alarm mat from Geri chair and leaving alarm box connected to bed frame with no wires connected to bed alarm control box.
On 06/04/2025 at 08:45 a.m., Resident #122's bed alarm was observed with S13 CNA. S13 CNA confirmed bed alarm pad was not on the bed. S13 CNA could not find bed alarm mat and went to supplies to get another mat and alarm for resident's bed.
Review of Current Physician Orders for Resident #122 revealed the following order:
06/02/2025 at 7:00 p.m.: Bed alarm to bed. Monitor for proper placement and batteries every shift, every day and night shift for fall risk.
In an interview on 06/04/2025 at 10:05 a.m., S2 DON confirmed that Resident #122 should have had a functioning bed alarm in place as ordered.
Resident #30
Review of a facility policy titled Smoking, with a revised date of 05/22 revealed the following in part, Policy: No smoking or use of smoking materials will be allowed inside the building or in facility vehicles. This includes all e-cigarette devices. Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Evaluation Tool.
Review of Resident #30's medical record revealed an admit date of 07/02/2024 with diagnoses that included in part: Metabolic Encephalopathy, Insomnia, Alcohol Abuse, and Cytomegaloviral Disease.
Review of Resident #30's Quarterly MDS with an ARD of 07/09/2025 revealed a BIMS score of 15, which indicated intact cognition.
On 06/03/2025 at 10:34 a.m., review of Resident #30's Smoking Evaluation Tool dated 03/04/2025 revealed Resident #30 smoked cigarettes.
On 06/03/2025 at 10:42 a.m., review of Resident #30's care plan with a target date of 07/03/2025 revealed Resident #30 was not care planned for smoking.
On 06/03/2025 at 11:07 a.m. Resident #30's care plan was reviewed together with S4 MDS LPN who stated she is responsible for the development and implementation of resident care plans. S4 MDS revealed that all smokers should be care planned for smoking. S4 MDS LPN confirmed she should have developed and implemented a care plan for Resident #30 being a smoker but had not.
Resident #19
A review of facility policy titled, Comprehensive Centered Care Plans with a revision date of 01/2025 revealed in part .
Policy: Each resident will have a person- centered care plan to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care.
Responsibility: All members of the Interdisciplinary Team monitored by the Executive Director .
Procedure: The Comprehensive Person- Centered Care Plan shall be fully developed within 7 days after completion of the admission MDS Assessment .
A review of Resident # 19's medical record revealed an admission date of 04/30/2025 with diagnoses that included Schizophrenia, Anxiety Disorder, Alcoholic Hepatic Failure without come, Alcohol induced Acute Pancreatitis without necrosis or infection, Alcoholic Cirrhosis of liver without ascites, Depression, Chronic Obstructive Pulmonary Disease, Esophageal Varices with bleeding, and Anemia in other chronic diseases classified elsewhere.
Review of Resident #19's Annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 05/07/2025, revealed Resident #19 had a BIMS score of 15, which indicated intact cognition.
On 06/02/2025 at 11:30 a.m. review of Resident #19's care plan revealed only one care plan area with generalized interventions. Resident #19's entire care plan revealed one care area of general disease management with interventions that included: Resident #19 will be up to date on all immunizations, administer necessary immunizations unless contraindicated or allergic per provider order, alert provider of any condition alerts identified during resident evaluations, if resident is determined to be at risk, initiate plan to minimize risk, obtain immunization history, perform clinical admission evaluation, perform risk evaluations, perform scheduled clinical evaluations per facility's protocol.
On 06/03/2025 at 09:50 a.m. Resident #19's care plan was reviewed with S4 MDS LPN. S4 MDS LPN confirmed the facility did not develop and implement a comprehensive person-centered care plan for Resident #19 in a timely manner and should have.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #172
Review of the Facility's policy dated 11/2017 titled Weekly Skin Audit read in part .Policy: A skin audit will be ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #172
Review of the Facility's policy dated 11/2017 titled Weekly Skin Audit read in part .Policy: A skin audit will be documented on resident weekly. Any identified skin conditions will be documented and treatment initiated. Procedure: 1.Every resident will have a head to toe skin evaluation performed and documented on a weekly basis.
Review of Resident #172 medical record revealed an admit date of 02/11/2025 with diagnoses that included: COPD, Congestive Heart Failure, Atherosclerotic Heart Disease, Depression, and Essential HTN.
Review of Resident #172 Care plan with a review date of 05/20/2025 read in part . Risk for impaired skin integrity related to impaired mobility with interventions for weekly skin audits.
Review of Resident #172 skin assessment dated [DATE] by S10 TX Nurse revealed 3 scabs to forehead area. No bruises noted.
Interview on 06/04/2025 at 9:15 a.m. with S1 Admin revealed she was notified by S21 Marketer that during a hospital visit he was notified by hospital staff that Resident #172 had undisclosed bruising to the corner of his right eye and to his right lower abdomen/hip area. S1 Admin revealed that she was not made aware of any bruising on Resident #172 prior to being notified by S21 Marketer on 05/15/2025. S1 Admin stated that during the facility investigation of the injury S9 LPN stated she observed the bruising on Resident #172' left eye and right lower abdomen/hip area on 05/11/2025. S1 Admin stated that she reviewed S10 TX Nurse body audit that was conducted on 05/12/2025 and there was no documentation of bruising to Resident's right eye or right lower abdomen/hip area.
Interview on 6/04/2025 at 10:00 a.m. with S10 TX Nurse revealed during the 05/12/2025 body audit she observed a little small popped blood vessel in the corner of Resident #172's right eye but did not document it on body audit sheet. S10 TX Nurse stated she did not lift Resident #172's shirt during the body audit so she was not aware of bruise to hip/abdomen area, but should have. S10 TX Nurse stated she was verbally counseled by management staff and was in-serviced on properly completing body audits after the incident.
Resident #34
Review of the facility's policy entitled Weights, revised in 10/2009, revealed in part .all residents are weighted upon admission, readmission, and monthly thereafter to establish weight pattern and monitor for changes. Each resident will be weighed by the 10th of the month. Weights will be entered electronically.
Review of Resident #34's medical record revealed an admission date of 11/06/2020 with diagnoses including, in part .Schizophrenia and Morbid Obesity.
Review of Resident #34's Annual MDS with an ARD of 05/20/2025 revealed, in part .a BIMS Score of 15, indicating intact cognition. Resident #34's weight was not available.
Review of Resident #34's Care Plan Report revealed, in part .noncompliance with diet and morbid obesity, initiated on 11/04/2024. Interventions included monthly weight and notify provider of any significant changes in weight.
Review of Resident #34's Weight Summary revealed the resident was last weighed on 02/07/2025.
Interview with S2 DON on 06/04/2025 at 1:10 p.m. confirmed Resident #34 was supposed to have been weighed monthly, but had not.
Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing:
1. To ensure Physician's Orders were implemented for Resident #69; and
2. To accurately complete a body audit for Resident #172, and
3. To obtain a monthly weight for Resident #34.
Total sample size 29 residents.
Resident #69
Review of Resident #69's medical record revealed an admit date of 04/08/2025 with the following diagnoses in part . Anoxic Brain damage; Acute Respiratory Failure with Hypoxia; Type 2 Diabetes Mellitus; Hypertension; Hyperlipidemia; Acute Myocardial Infarction; Depressive Episodes; Anxiety Disorder; Thyrotoxicosis; and Encounter for Attention to Tracheostomy.
Review of Resident #69's admission MDS with ARD of 04/15/2025 revealed a BIMS summary score not conducted due to Resident #69 was rarely/never understood. Resident #69 was dependent for all ADLs.
On 06/03/2025 at 08:45 a.m. observation of medication administration performed. Observation revealed S5 LPN crushed Resident #69's medication (Baclofen) and mixed with applesauce. Observed S5 LPN administer medication orally to Resident #69 at that time.
Review of Resident #69's Physician Order dated 05/30/2025 read in part .Baclofen Oral Tablet 10mg- give 1 tablet via G-Tube three times a day for Muscle Spasms.
Review of Resident #69's care plan dated 04/11/2025 revealed in part .Resident is at risk for pain and discomfort. Interventions included: Administer pain medications as ordered.
On 06/03/2025 at 12:58 p.m. reviewed Physician Orders with S5 LPN which revealed in part .Administer Baclofen 10mg 1 tablet via G tube three times a day. S5 LPN confirmed medication was crushed, mixed with applesauce, and administered orally to Resident #69. S5 LPN confirmed medication was not administered utilizing the correct route as prescribed by the physician. S5 LPN stated Physician Orders should have been updated by the Unit manager for Resident #69 following a recent swallow study.
Interview on 06/03/2025 at 01:05 p.m. with S6 LPN/Unit Manager revealed Resident #69 had a swallow study performed and diet was upgraded at that time. S6 LPN stated the physician was monitoring Resident #69's tolerance to diet upgrade prior to upgrading medication route. S6 LPN confirmed that Resident #69 should have received medications utilizing the correct route as prescribed by the physician.
Interview on 06/03/2025 at 01:25 p.m. conducted with S1 Admin. S1 Admin notified of the medication error during medication administration. S1 Admin confirmed medication should have been administered utilizing the correct route as prescribed by the physician. S1 Admin confirmed Resident #69 did not receive medication as ordered by the physician.
Feb 2025
4 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #11) of 2 ( Resident #11 and Resident #12) residents reviewed for abuse. The facility failed to ensure Resident #11 was not physically abused by Resident #12.
The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
Review of the facility's undated policy titled Abuse Prevention on 02/18/2025 read in part . The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual. Definitions:
a.
Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident.
d.
Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking.
f.
Neglect defined: A failure of the facility, its employees, or services providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain.
Resident #11
Review of Resident #11's medical records revealed an admit date of 09/09/2022, with diagnoses that included Schizoaffective Disorder, Bipolar Type, Depression, Epilepsy, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Essential (Primary) Hypertension, Personal History of (TBI) Traumatic Brain Injury, Conductive Hearing Loss and Unspecified Abnormal Involuntary Movements.
Review of Resident #11's Quarterly MDS with an ARD of 01/14/2025, revealed a BIMS score of 04, indicating the resident had moderate cognitive impairment. Review of MDS revealed Resident #11 was coded as independent with ambulation.
Review of Resident #11's Care Plan with a review date on 04/14/2025 revealed in part . Potential for mental distress and Impaired thought process related to history of TBI and Bipolar Schizophrenia. Interventions included in part .Monitor/ record/ report to MD prn mood patterns s/s of depression, anxiety, sad mood as per facility behavior protocols.
Resident #12
Review of Resident #12's medical records revealed an admit date of 08/08/2023, with diagnoses that included Schizoaffective Disorder, Bipolar Type, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Gastrostomy, Chronic Pain Syndrome and Bandemia.
Review of Resident #12's Quarterly MDS with an ARD of 02/18/2025, revealed a BIMS score of 15, indicative of intact cognition.
Review of Resident #12's Care Plan with a review date of 02/19/2025, revealed in part Resident #12 is at risk for altered mental status and mood related to diagnosis of schizoaffective disorder, Major Depressive disorder and history of outbursts of profanity and throwing water on the floor. Interventions included in part . Refer to psych services as needed, PEC'd, 1:1 care until admitted to hospital. Initiated 02/03/2025. Resident #12 requires some assistance with ADLs and needs reminding to use wheelchair. Interventions included in part . Resident #12 able to transfer self and self-propels in wheelchair.
Review of Resident #12's Nurses Notes dated 02/03/2025 at 10:11 a.m. by S10 LPN read in part . At approximately 9:40 a.m., this nurse was summoned to common area. Upon arrival noted Resident #12 sitting Indian style on floor in front of his wheelchair. Resident #12 stated another resident was in his face and that he always thinks he's the big bad wolf around here. Resident #12 still did not say how he wound up on the floor. Asked Resident #12 again how got on the floor and stated, I don't remember. This nurse assisted Resident #12 up and into wheelchair and noted active ROM x4 without difficulty. Resident #12 denies pain. Informed unit manager and DON who spoke to Resident #12 and informed them that he hit Resident #11 first due to both of them arguing with one another. Resident #12 placed on 1:1 observation at this time. MD notified and awaiting orders.
Review of a facility's Incident Report documented by S1 Administrator on 02/03/2025 at 10:13 a.m., read in part . Incident occurred on 02/03/2025 at 9:43 a.m., Resident #12 rolled over Resident #11's toes with his wheelchair. Resident #11 tried to push the wheelchair away and Resident #12 stood up from his wheelchair and hit Resident #11 in the shoulder. Resident #12 was immediately placed one on one.
Review of facility's Incident Report prepared by S3 Unit Manager on 02/03/2025 at 2:24 p.m. read in part . At approximately 9:40 a.m. this nurse was called to the day area due to a possible altercation between Resident #11 and Resident #12. Upon arrival to day area, Resident #11 was no longer there and was in his room. S3 Unit Manager went to resident #11's room and assessed him with no injuries noted. Questioned Resident #11 about incident and he stated Resident #12 kept running over his feet with his wheelchair. Resident #11 stated he tried to push the wheelchair away and the other Resident #12 hit him. Resident #11 said he was sitting on the couch and Resident #12 was coming by and ran over my foot a few times then stood up and hit me. Resident #11 stated he had to try to defend himself and tried to hit him back. Review of report, 'Immediate Action Taken revealed Resident #11 went to his room with no further altercations, assessed with no injuries or complaints of pain and kept in view of staff. After review of cameras, it was noted that Resident #11 was not the aggressor. Resident #12 was placed on 1:1 supervision until transferred after he was PEC'd.
Telephone interview on 02/19/2025 at 2:18 p.m. with S10 LPN revealed she was working on the hall when she was summoned to the day room and found Resident #12 sitting on the floor besides his wheelchair. S10 LPN revealed S12 was able to tell her what happened and told her he tripped on his wheelchair after getting mad at the big bad wolf. S10 LPN revealed Resident #12 told the DON that he hit Resident #11. S10 LPN revealed Resident #12 was immediately put on 1:1 supervised monitoring that day after incident until he was sent out to a Behavioral Health Hospital and continued to be on 1:1 supervised monitoring for 3 days when he returned. S10 LPN revealed she had assessed both residents after the incident and were both without physical injury.
In an observation on 02/18/2025 at 2:30 p.m., Resident #11 ambulated in hall to his room. Interview at this time with Resident #11 revealed he had an incident where another resident ran over his foot with his wheelchair and had hit him after he told him to get off of his foot. Resident #11 said he did not hit him and had not hurt anyone here.
Interview on 02/19/2025 at 11:45 a.m. with S9 Central Supply revealed he was assigned to supervise the day room on the morning of 02/03/2025. S9 Central Supply stated the residents were all quiet in the day room and he stepped away to get something down the hall. S9 Central Supply revealed Resident #11 was sitting on the couch and Resident #12 was sitting up in his wheelchair. S9 Central Supply revealed as he returned and rounded the corner, he saw them arguing and saw Resident #12 fell on the floor. S9 Central Supply reported he asked Resident #11 to walk away and he did.
Interview on 02/19/2025 at 11:55 a.m. with Resident #12 revealed he had come back from the hospital and he should not have fussed with Resident #11 and hit him in his condition.
Review of camera surveillance video footage accompanied by S1 Administrator on 02/19/2025 at 3:45 p.m. revealed on the date of 02/03/2025 at 9:41 a.m. revealed findings as documented in facility's investigation. Observation revealed Resident #12 propelling himself in his wheelchair in the day room and rolled over Resident #11's foot unknowingly and looked down at his wheel. Observation revealed Resident #11 pushed wheelchair away from him. Observation revealed Resident #12 swung his left arm towards and hit Resident #11. Observation revealed both Resident #11 and Resident #12 stood up and starting swinging their arms towards each other without physical contact. Observation revealed Resident #12 stepping away backwards after he stood up out of his wheelchair, and lost his balance and fell onto the floor. Observation revealed S9 Central Supply stepped up in-between residents before Resident #12 fell.
Interview on 02/19/2025 at 4:00 p.m. with S9 Central Supply revealed he stepped out of the day room for just a couple of minutes and had not witnessed the incident until he returned and walked into the day room right up at the end when he saw Resident #12 stand up out of his wheelchair, swing at Resident #11 but did not witness physical contact between the residents. S9 Central Supply revealed Resident #11 denied any pain and he asked Resident #11 to meet him in his room while he assisted Resident #12 up from off of the floor and back into his wheelchair. S9 Central Supply revealed Resident #12 said he was okay and denied being hurt. S9 Central Supply revealed Resident #11 ambulated to his room and his nurse followed him to his room.
Interview on 02/19/2025 at 4:05 p.m. with S8 LPN revealed she had walked into day room and witnessed Resident #12 to stand up, swung towards Resident #11, lost balance and fell to the floor. S8 LPN revealed Resident #12 denied injury, pain or discomfort. S8 LPN revealed she had assessed both residents after the incident and both were without injury. S8 LPN revealed Resident #11 had ambulated to his room where she assessed resident with findings of no injuries noted and Resident #11 denied complaints of pain or discomfort and RP/ MD was notified. S8 LPN revealed she assessed Resident #11's feet and did not have any marks, redness or bruising noted.
Interview on 02/20/2025 at 10:25 a.m. with S1 Administrator revealed Resident #12 had a history of behaviors. S1 Administrator confirmed the Resident to Resident altercation between Resident #11 and Resident #12 occurred on 02/03/2025 and the following was put into place: Resident #11 and Resident #12 were immediately separated, Resident #12 was put on 1:1 supervision until sent out to a behavioral hospital, an in-service was initiated for all staff on abuse, and body audits/life safety rounds were completed for all residents on Hall X and Hall Y.
The facility has implemented the following actions to correct the deficient practice:
1.
Resident #11 and Resident #12 were separated, and Resident #12 was placed on 1:1 supervised monitoring immediately.
2.
Both Resident #11 and Resident #12's physician and responsible party were notified regarding the incident.
3.
Nursing staff performed assessments for both Resident #11 and Resident #12 were assessed without injury noted and without complaints of pain voiced. No new physician orders.
4.
New orders from Resident #12's physician for an inpatient psychiatric evaluation. Resident #12 continued 1:1 supervised monitoring until he was admitted to an inpatient behavioral hospital on [DATE].
5.
Life satisfaction interview rounds were conducted on all cognitive residents who resided on Hall X and Hall Y, with no issues noted.
6.
Body audits were conducted by nursing staff for all residents with low cognition who resided on Hall X and Hall Y, with no issues noted.
7.
On 02/03/2025, S3 Unit Manager initiated an In-service/training, reviewed the facility's abuse policy with staff, and educated staff on Residents with combative behaviors. All in services/training completed for facility staff as of 02/04/2025.
Facility correction date of 02/04/2025.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (#1) of 12 (#1-#12) sampled residents reviewed for quality of care. The facility failed to transport Resident #1 to an orthopedic specialist appointment in a timely manner as ordered.
Findings:
Review of Resident #1's medical record revealed an admit date of 09/27/2023 with diagnoses that included in part .Heart Failure, Type 2 DM, Pain, and Unspecified Dislocation of Left Hip.
Review of Resident #1's Quarterly MDS with an ARD of 01/28/2025 revealed the resident had a BIMS score of 8, which indicated moderately impaired cognition. Review of the MDS revealed Resident #1 was dependent with rolling left and right and required substantial to maximal assistance with sitting to lying and toileting hygiene. Resident #1 required setup or clean up assistance with eating.
In an interview on 02/17/2025 at 1:30 p.m., Resident #1 stated his left hip keeps coming out of place. Resident #1 stated he was in the hospital a while ago to get it put back in place and it popped out of place again. Resident #1 stated at the hospital, they referred him to see an orthopedic specialist. Resident #1 stated he was still waiting to see the orthopedic specialist and didn't know when his appointment was scheduled. Resident #1 stated his hip hurts, especially when staff changed his brief. Resident #1 stated he doesn't get out of bed and gets pain medication that doesn't totally relieve his pain.
Review of Resident #1's hospital summary dated 10/23/2024 revealed Resident #1 was admitted with chronic recurrent spontaneous left hip dislocation. He has hardware from remote surgery and twice had hip reduced with almost immediate re-dislocation and (orthopedist) reported he could not put the hip back in the acetabular socket. He recommended consulting Dr. _____ outpatient when Dr. ____ gets back from out of town travel. He will go back to NF and be given prn pain meds as needed, but he does not complain of much pain unless he is moved. His hip is unstable and he will need possible [NAME] resection. Will need appointment with Dr. _____ as soon as he gets back He is now completely immobile and will be in unforeseeable future and will need DVT prophylaxis. Follow-up-Dr._____, Orthopedic Surgery. (Phone number listed). Electronically signed by S7 MD.
Review of a Progress note by S6 NP dated 10/25/2024 revealed Resident #1 was being evaluated for readmission to nursing facility status post inpatient hospitalization secondary to chronic recurrent spontaneous left hip dislocation . Hip is unstable and he will need possible [NAME] resection. Plan: Schedule appointment w/ Dr. ______ as soon as possible.
Review of a Progress note by S7 MD dated 12/09/2024 revealed Resident #1 has a chronic dislocation of left hip and orthopedist had not been able to replace, awaiting appointment with Dr._______. Requires chronic Norco for contraction pain, discussed with him, states pain not effectively controlled on Norco 7.5mg, will order increase, awaiting surgery. Physical Exam: Not ambulating, Left hip dislocated, chronic. Plan: Increase to Norco 10/325 every 6 hours prn pain. Referrals: Ortho Dr. ________.
In an interview on 02/19/2025 at 12:55 p.m., S3 Unit Manager confirmed Resident #1 returned from the hospital in October 2024 with a referral to Dr. ________, Orthopedic Specialist. She said they couldn't schedule it at that time because the doctor was out of town. S3 Unit Manager stated she did get it scheduled for 01/15/2025 and stated she had arranged for Resident #1 to go by ambulance on a stretcher. S3 Unit Manager stated Resident #1 missed the appointment somehow and doesn't know why. S3 Unit Manager stated the ambulance never showed up to pick Resident #1 up on 01/15/2025, and no one caught it. S3 Unit Manager confirmed Resident #1 had missed the appointment with the Orthopedic Specialist and shouldn't have.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of pra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 5 (#1, #2, #3, #4, & R1) of 13 (#1-#12 & #R1) sampled residents out of a total census of 74 residents. The facility failed to ensure controlled medications were administered as ordered and documented correctly.
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
Review of the facility's policy on 02/20/2025 titled, Controlled Medications Administrations which was last reviewed on 08/2016 read in part . When administering controlled medication, the authorized personnel records the administration on the MAR/eMAR and enters all of the following information on the Controlled Drug Record:
a.
Date and time of administration
b.
Amount administered
c.
Signature of the person preparing the dose
d.
Quantity reconciled
Review of the facility's policy on 02/20/2025 titled, Medication Administration-General Guidelines which was last reviewed on 01/2015 read in part .
2. Medications are administered in accordance with written orders of attending physicians .
13. When PRN medications are administered, the following documentation is provided:
a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection
b. Complaints or symptoms for which the medication was given.
c. Results observed from giving the dose and the time results were noted.
d. Resident pain evaluation per facility policy, if applicable.
e. Signature or initials of person recording administration and signature of initials of person recording effects, if different person administering.
Resident #1
Review of Resident #1's medical record revealed an admit date of 09/27/2023 with diagnoses that included in part .Heart Failure, Type 2 DM, Pain, and Unspecified Dislocation of Left Hip.
Review of Resident #1's Quarterly MDS with an ARD of 01/28/2025 revealed the resident had a BIMS score of 8, which indicated moderately impaired cognition. Review of the MDS revealed Resident #1 was dependent with rolling left and right and required substantial to maximal assistance with sitting to lying and toileting hygiene. Resident #1 required setup or clean up assistance with eating.
Review of Resident #1's care plan with a review date of 05/05/2025 revealed a problem with an on set date of 09/27/2024 for resident at risk for pain/discomfort. Interventions included: Medications as ordered, Document pain scale every shift, and use non-pharmacological interventions when needed.
Review of Resident #1's physician's orders revealed the following:
12/11/2024: Norco Oral Tablet 10-325 mg (Hydrocodone-Acetaminophen) Give one tablet by mouth every 6 hours as needed for pain
Review of Resident #1's Controlled Drug Record for Norco 10-325mg revealed the following entries:
01/15/2025 at 7:00 p.m.-a dose was signed out by S4 LPN
01/21/2025 at 7:00 p.m.-a dose was signed out by S4 LPN
01/26/2025-a dose was signed out with no time or signature (last dose signed out 01/26/2025 at 3:00 p.m. by S4 LPN.
Review of Resident #1's 01/2025 eMAR revealed no documentation of the above doses.
Review of S4 LPN's attendance records revealed S4 LPN clocked out on 01/15/2025 at 6:20 p.m. and clocked out on 01/21/2025 at 5:34 p.m. using the time clock.
Resident #2
Review of Resident #2's medical record revealed an admit date of 06/24/2021 with diagnoses that included in part .Dementia, Type 2 DM, Cervicalgia, Major Depressive Disorder, and Epilepsy.
Review of Resident #2's Quarterly MDS with an ARD of 12/03/2024 revealed a BIMS score of 00, which indicated severe cognitive impairment. Review of the MDS revealed the resident was dependent with eating, toileting hygiene, rolling left and right, sitting to lying, lying to sitting, and chair/bed to chair transferring.
Review of Resident #2's current care plan with a review date of 04/03/2025 revealed Resident #2 was at risk for pain/discomfort with interventions that included: Medication as ordered, Notify MD of uncontrolled pain, Document pain scale every shift, and reassess pain after medication administered.
Review of Resident #2's physician's orders revealed the following in part:
09/19/2024: Ativan (Lorazepam) 0.5mg Give one tablet orally every 4 hours as needed for anxiety.
03/14/2024: Norco (Hydrocodone-Acetaminophen) 10-325mg Give one tablet orally every 4 hours as needed for pain.
Review of the Controlled Drug Record for Resident #2's Norco 10-325mg q 4 hours prn revealed in part:
01/21/2025 at 7:00 p.m.-a dose was signed out by S4 LPN.
01/26/2025-two doses were signed out with no time given and no signature by a nurse.
Review of the Controlled Drug Record for Resident #2's Ativan 0.5mg q 4 hours prn revealed:
01/21/2025 at 7:00 p.m.-a dose was signed out by S4 LPN.
Review of Resident #2's 01/2025 eMAR revealed none of the above doses were documented as given.
Review of S4 LPN's attendance records revealed S4 LPN clocked out on 01/21/2025 at 5:34 p.m. using the time clock.
Resident #3
Review of Resident #3's medical record revealed an a admit date of 05/08/2020 with diagnoses that included Chronic Systolic (Congestive) Heart Failure, Osteoarthritis, Type 2 DM, and Pain, unspecified.
Review of Resident #3's Quarterly MDS with an ARD of 12/17/2024 revealed a BIMS score of 9, which indicated moderately impaired cognition. Review of the MDS revealed Resident #3 required setup or clean up assistance with eating and Resident #3 was dependent with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transferring.
Review of Resident #3's current care plan with a review date of 03/19/2025 revealed the resident was at risk for pain and discomfort. Interventions included administering pain medication as ordered, reposition as needed, evaluate and treat for pain, monitor for non-verbal signs of pain, and use of non-pharmacological intervention when needed.
Review of Resident #3's physician's orders revealed the following:
09/01/2024: Norco (Hydrocodone-Acetaminophen) Tab 10-325mg Give one tablet orally every 4 hours as needed for pain.
Review of Resident #3's Controlled Drug Record for Ativan 1mg q 4 hours prn revealed:
01/15/2025 at 7:00 p.m.-a dose was signed out by S4 LPN
01/21/2025 at 7:00 p.m.-a dose was signed out by S4 LPN and S5LPN with a note spit out meds-behaviors
Review of Resident #3's Controlled Drug Record for his Norco 10-325mg po q 4 hours prn revealed:
Two doses were signed out on 01/26/2025 with no time or nurse signature
Review of Resident #3's 01/2025 eMAR revealed none of the above doses were documented as given.
Review of S4 LPN's attendance records revealed S4 LPN clocked out on 01/15/2025 at 6:20 p.m. and clocked out on 01/21/2025 at 5:34 p.m. using the time clock.
Resident #4
Review of Resident #4's medical record revealed an admit date of 11/24/2021 with diagnoses that included in part .Heart Failure, Spinal Stenosis, Gout, and Pain, Unspecified.
Review of Resident #4's Quarterly MDS with an ARD of 12/31/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed the resident required supervision or touching assistance with eating, was dependent with rolling left and right, and refused chair/bed to chair transferring.
Review of Resident #4's care plan initiated on 12/17/2024 with a review date of 03/17/2025 revealed the resident was at risk for pain related to spinal stenosis. Interventions included assess for pain at least every 12 hours, attempt non-medication pain relief before medication administration, and monitor for nonverbal signs of pain and address accordingly.
Review of Resident #4's physician's orders revealed the following:
12/13/2024: Ativan Oral Tablet 1mg (Lorazepam) give one tablet by mouth every 4 hours as needed for anxiety
04/05/2024: Norco (Hydrocodone-Acetaminophen) 10-325mg give one tablet orally every 4 hours as needed for pain.
Review of Resident #4's Controlled Drug Record for Ativan 1mg po q 4 hours prn revealed:
01/15/2025 at 7:00 p.m. a dose was administered by S4 LPN
01/21/2025 at 7:00 p.m. a dose was administered by S4 LPN
Review of Resident #4's Controlled Drug Record for Norco 10-325mg po every 4 hours prn revealed:
01/15/2025 at 7:00 p.m.-a dose was administered by S4 LPN
01/21/2025 at 7:00 p.m.-a dose was administered by S4 LPN
01/26/2025-2 doses were signed out without documenting a time or a signature by a nurse
Review of Resident #4's 01/2025 eMAR revealed the above doses were not documented as given.
Review of S4 LPN's attendance records revealed S4 LPN clocked out on 01/15/2025 at 6:20 p.m. and clocked out on 01/21/2025 at 5:34 p.m. using the time clock.
Resident #R1
Review of Resident #R1's medical record revealed an admit date of 06/05/2024 with diagnoses that included in part .Anemia, Hypertension, and Pain, Unspecified.
Review of Resident #R1's current care plan revealed a problem with an onset date of 11/04/2024 for resident being at risk for discomfort related to pain. Interventions included: Document pain scale every 12 hours and notify MD of uncontrolled pain.
Review of Resident #R1's physician's orders revealed the following:
06/14/2024: Tramadol HCL Tab 50mg Give one tablet orally every 12 hours every day and night shift for pain.
Review of Resident #R1's Controlled Drug Record for Tramadol 50mg revealed S4 LPN signed out a dose on
01/15/2025 at 7:00 pm.
Review of S4 LPN's attendance records revealed S4 LPN clocked out on 01/15/2025 at 6:20 p.m.
In an interview on 02/19/2025 at 3:00 p.m., S2 DON confirmed S4 LPN documented giving the above controlled medications to Residents #1, #2, #3, #4, and #R1 at times after she had already clocked out for the day on 01/15/2025 and 01/21/2025. S2 DON stated when she asked S4 LPN about it, S4 LPN reported she pulled those medications early and administered them to the residents because they were hurting or needed them. S2 DON confirmed S4 LPN did not follow physician's orders, administered controlled medications early, and falsely documented the medication administration times.
In an interview on 02/19/2025 at 3::05 p.m., S2 DON confirmed the doses that were signed out on 01/26/2025 with no date, time, and/or signature were done so by S4 LPN during her shift. S2 DON stated the narcotic logs were brought to her attention at approximately 7:30 p.m. on 01/26/2025 by S5 LPN, the oncoming night nurse who had relieved S4 LPN at 7:00 p.m. S2 DON stated she called S4 LPN back to the facility on [DATE] and S4 LPN admitted she had given the medications on 01/26/2025 that had no date, time, and/or signature documented, but, she couldn't say what time she gave them. S2 DON stated S4 LPN wrote a statement that read I pre-pulled narcotic medication pertaining to residents and administered before they were due. S2 DON confirmed S4 LPN was suspended immediately on 01/26/2025 pending her investigation and was terminated on 01/31/2025. S2 DON confirmed S4 LPN had signed out controlled medications without documenting the date, time, and/or signature, as required.
The facility has implemented the following actions to correct the deficient practice:
1. Performed drug tests on all nurses who had been on the medication cart for 72 hours. All tests were negative.
2. DON assessed all residents who had been affected by S4 LPN's false documentation or early administration. No deficits were found. No pain or facial grimacing was noted. Pain was reported controlled by all and stated they had received their pain medication, when requested. Medical Director notified. RPs notified, if applicable.
3. A 100% narcotic audit was initiated. All narcotic counts were correct.
4. Suspended S4 LPN on 01/26/2025 and terminated her employment on 01/31/2025.
5. An in-service was initiated and conducted with all nursing on prn narcotic medication administration per order and documenting and administering prn narcotics as ordered, pre-pulling of medications (not to) and completion of narcotic counts accurately.
6. A random sample of residents from each hall were interviewed to see if they were getting their pain medication when requested and was their pain controlled. All residents interviewed stated their pain was controlled and were given their pain medication when requested.
7. Unit Managers completed a 100% audit of prn narcotic medication administration, documentation, and narcotic counts daily from the previous day. Unit managers are monitoring for and documenting narcotic count was completed each shift correctly, including the number of pages, contained 2 nurse signatures present at count and that narcotics that are pulled are signed for, given per order, and signed in the eMAR. Completed daily by unit managers, Monday-Friday, including the three previous days audited on Monday. This is ongoing.
8. A complaint concerning S4 LPN was entered into the Louisiana State Board of Practical Nurse Examiners Portal on 01/27/2025.
Facility correction date of 01/27/2025.
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 F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure pain management was provided to residents by failing to assess for pain medication effectiveness after administration for 5 (#1, #2,...
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Based on record review and interview, the facility failed to ensure pain management was provided to residents by failing to assess for pain medication effectiveness after administration for 5 (#1, #2, #3, #4, and #R1) of 5 sampled residents reviewed for pain.
Findings:
Review of the facility's policy on 02/20/2025 titled, Medication Administration-General Guidelines reviewed or revised on 01/2015 read in part .
When prn medications are administered, the following documentation is provided:
a.
Date and time of administration, dose, route of administration (if other than oral), and if applicable injection site.
b.
Complaints or symptoms for which the medication was given.
c.
Results observed from giving the dose and the time results were noted.
d.
Resident pain evaluation per facility policy, if applicable.
e.
Signature or initials of person recording administration and signature or initials of person recording effects, if different from person administering.
Resident #1
Review of Resident #1's medical record revealed an admit date of 09/27/2023 with diagnoses that included in part .Heart Failure, Type 2 DM, Pain, and Unspecified Dislocation of Left Hip.
Review of Resident #1's Quarterly MDS with an ARD of 01/28/2025 revealed the resident had a BIMS score of 8, which indicated moderately impaired cognition. Review of the MDS revealed Resident #1 was dependent with rolling left and right and required substantial to maximal assistance with sitting to lying and toileting hygiene.
Review of Resident #1's care plan with a next review date of 05/05/2025 revealed a problem with an onset date of 09/27/2024 for resident at risk for pain/discomfort. Interventions included: Medications as ordered, Document pain scale every shift, and use non-pharmacological interventions when needed.
Review of Resident #1's Controlled Drug Record for Norco 10-325mg every 4 to 6 hours as needed for pain revealed Resident #1 received a dose on 01/15/2025 at 7:00 p.m., 01/21/2025 at 7:00 p.m., and a dose on 01/26/2025 with no time documented.
Review of Resident #1's medical record revealed there was no pain assessment documented prior to administering the pain medication or after administration to assess its effectiveness. Review of Resident #1's 01/2025 eMAR revealed these doses were not documented on the eMAR.
In an interview on 02/20/2025 at 9:53 a.m., S2 DON confirmed there was no documentation of Resident #1 being assessed/monitored for the effectiveness of the pain medication but should have been.
Resident #2
Review of Resident #2's medical record revealed an admit date of 06/24/2021 with diagnoses that included in part .Dementia, Type 2 DM, Cervicalgia, Major Depressive Disorder, and Epilepsy.
Review of Resident #2's Quarterly MDS with an ARD of 12/03/2024 revealed a BIMS score of 00, which indicated severe cognitive impairment. Review of the MDS revealed the resident was dependent with eating, toileting hygiene, rolling left and right, sitting to lying, lying to sitting, and chair/bed to chair transferring.
Review of Resident #2's current care plan with a review date of 04/03/2025 revealed Resident #2 was at risk for pain/discomfort with interventions that included: Medication as ordered, Notify MD of uncontrolled pain, Document pain scale every shift, and reassess pain after medication administered.
Review of the Controlled Drug Record for Resident #2's Norco 10-325mg q 4 hours prn revealed Resident #2 received a dose on 01/21/2025 at 7:00 p.m. and received two doses on 01/26/2025 with no times given and no signatures by a nurse.
Review of Resident #2's 01/2025 eMAR revealed none of the above doses were documented as given.
Review of Resident #2's medical record revealed there was no pain assessment documented prior to administering the pain medication or after administration to assess its effectiveness.
In an interview on 02/20/2025 at 9:53 a.m., S2 DON confirmed there was no documentation of Resident #2 being assessed/monitored for the effectiveness of the pain medication but should have been.
Resident #3
Review of Resident #3's medical record revealed an a admit date of 05/08/2020 with diagnoses that included Chronic Systolic (Congestive) Heart Failure, Osteoarthritis, Type 2 DM, and Pain, unspecified.
Review of Resident #3's Quarterly MDS with an ARD of 12/17/2024 revealed a BIMS score of 9, which indicated moderately impaired cognition. Review of the MDS revealed Resident #3 required setup or clean up assistance with eating and Resident #3 was dependent with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transferring.
Review of Resident #3's current care plan with a review date of 03/19/2025 revealed the resident was at risk for pain and discomfort. Interventions included administering pain medication as ordered, reposition as needed, evaluate and treat for pain, monitor for non-verbal signs of pain, and use of non-pharmacological intervention when needed.
Review of Resident #3's Controlled Drug Record for his Norco 10-325mg po q 4 hours prn revealed:
Two doses were signed out on 01/26/2025 with no times or nurse signatures documented.
Review of Resident #3's 01/2025 eMAR revealed the above doses were not documented as given.
Review of Resident #3's medical record revealed there was no pain assessment documented prior to administering the pain medication or after administration to assess its effectiveness.
In an interview on 02/20/2025 at 9:53 a.m., S2 DON confirmed there was no documentation of Resident #3 being assessed/monitored for the effectiveness of the pain medication but should have been.
Resident #4
Review of Resident #4's medical record revealed an admit date of 11/24/2021 with diagnoses that included in part .Heart Failure, Spinal Stenosis, Gout, and Pain, Unspecified.
Review of Resident #4's Quarterly MDS with an ARD of 12/31/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed the resident required supervision or touching assistance with eating, was dependent with rolling left and right, and refused chair/bed to chair transferring.
Review of Resident #4's care plan initiated on 12/17/2024 with a review date of 03/17/2025 revealed the resident was at risk for pain related to spinal stenosis. Interventions included assess for pain at least every 12 hours, attempt non-medication pain relief before medication administration, and monitor for nonverbal signs of pain and address accordingly.
Review of Resident #4's Controlled Drug Record for Norco 10-325mg po every 4 hours prn revealed Resident #4 received a dose on 01/15/2025 at 7:00 p.m., 01/21/2025 at 7:00 p.m. and 2 doses on 01/26/2025 without the nurse documenting a time or a signature.
Review of Resident #4's 01/2025 eMAR revealed the above doses were not documented as given.
Review of Resident #4's medical record revealed there was no pain assessment documented prior to administering the pain medication or after administration to assess its effectiveness.
In an interview on 02/20/2025 at 9:53 a.m., S2 DON confirmed there was no documentation of Resident #4 being assessed/monitored for the effectiveness of the pain medication but should have been.
Resident #R1
Review of Resident #R1's medical record revealed an admit date of 06/05/2024 with diagnoses that included in part .Anemia, Hypertension, and Pain, Unspecified.
Review of Resident #R1's current care plan revealed a problem with an onset date of 11/04/2024 for resident at risk for discomfort related to pain. Interventions included: Document pain scale every 12 hours and notify MD of uncontrolled pain.
Review of Resident #R1's Controlled Drug Record for Tramadol 50mg revealed S4 LPN signed out a dose on 01/15/2025 at 7:00 pm.
Review of Resident #R1's 01/2025 eMAR revealed the above dose was not documented on the eMAR.
Review of Resident #R1's medical record revealed there was no pain assessment documented prior to administering the pain medication or after administration to assess its effectiveness.
In an interview on 02/20/2025 at 9:53 a.m., S2 DON confirmed there was no documentation of Resident #R1 being assessed/monitored for the effectiveness of the pain medication but should have been.
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3 and Resident #4) sampled residents. The facility failed to ensure Resident #4 was not physically abused by Resident #3.
Findings:
Review of the facility's policy titled Abuse Prevention, with a review date of 10/2022, revealed in part .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual.
Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident.
Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking.
Resident #3
Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses that included in part .Schizoaffective Disorder, Bipolar type, and Major Depressive Disorder.
Review of Resident #3's Quarterly MDS with an ARD of 08/26/2024, revealed Resident #3 had a BIMS score of 13, indicating intact cognition. The MDS revealed Resident #3 required supervision with bed mobility, transfers, toilet use, and was independent with eating.
Review of Resident #3's care plan with a target date of 11/27/2024, read in part .
1. Resident at risk for Altered Mental Status and Mood related to diagnoses of Schizoaffective Disorder and Major Depressive Disorder. History of outbursts of profanity, and history of throwing water on the floor. Approaches included: Monitor behaviors, redirect and re-educate resident as needed.
2. At risk for behavior related to Schizophrenia Disorder, Depressive Type Major Depression recurrent with psych symptoms. Curses at staff when he doesn't get his way, or if in heavily congested areas, with approaches that included: Assist resident to quiet environment when exhibiting behaviors to provide low stimuli.
Resident #4
Review of the clinical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses that included in part .Parkinson's Disease, Major Depressive Disorder, and Dementia on other Diseases Classified Elsewhere, Moderate with Anxiety.
Review of Resident #4's Quarterly MDS with an ARD of 08/06/2024, revealed Resident #4 had a BIMS score of 12, indicating moderate cognitive impairment. The MDS revealed Resident #4 required limited assistance with bed mobility, transfers, toilet use, and eating.
Review of Resident #4's Instant Care Plan developed 08/26/2024, read in part .Behaviors that included resident to resident altercation, with approaches to refer to Social Services, redirect if inappropriate, and re-enforce positive behaviors.
Review of a facility Incident Report documented by S1 Administrator, and dated 08/24/2024, revealed in part .at 12:12 p.m., Resident #3 stood up from his wheelchair and swung at Resident #4. Staff was present and intervened. No injuries.
Interview on 09/018/2024 at 1:25 p.m. with S1 Administrator, revealed on 08/24/2024 at 12:00 p.m., S2 CNA was passing trays on Hall X, when Resident #3 attempted to grab another resident's food tray. S2 CNA told Resident #3 to stop. Resident #4, who was present in the dayroom sitting on a sofa, told Resident #3 to stop and leave the food tray alone. Resident #3 propelled himself over to Resident #4, and stood up from wheelchair. Resident #4 stood up from the sofa, and Resident #3 proceeded to hit Resident #4's head with a closed fist. Resident #3 and Resident #4 then began to hit each other. Resident #3 grabbed Resident #4 by the front of his shirt, and both Residents #3 and #4 fell to the floor. S2 CNA then intervened and separated Resident #3 and Resident #4. Resident #3 sustained a skin tear to the top of his right hand. Resident #4 was assessed and had no injuries.
Interview on 09/18/2024 at 1:50 p.m. with Resident #3, revealed he remembered the altercation with Resident #4, which occurred on 08/24/2024 in the dayroom. Resident #3 revealed he was speaking to a CNA (did not know a name) when Resident #4 got in his personal space, and started hollering at him. Resident #3 said he felt threatened and hit Resident #4, and they both fell to the floor. Resident #3 stated I know I was wrong to hit him (Resident #4).
Interview on 09/18/2024 at 2:17 p.m. with S2 CNA, revealed the following: S2 CNA stated she was the CNA for Hall X, which is connected to the dayroom. S2 CNA revealed she was passing lunch in the dayroom on 08/24/2024, sat a resident's tray on the table, and turned to assist that resident to the table. Resident #3 propelled himself over to the table, and grabbed the other resident's tray. S2 CNA revealed she told Resident #3 three times to stop, and to put the tray back on the table because it wasn't his. S2 CNA revealed she hollered for help at that time. Resident #4, who was sitting on the sofa in the dayroom, told Resident # 3 m**********r, put the tray back. S2 CNA revealed Resident #3 propelled himself over to Resident # 4, and stood up from his wheelchair. S2 CNA revealed Resident #4 then stood up from the sofa, and Resident #3 hit Resident #4's head with his fist. Resident #3 and Resident #4 both started hitting each other. S2 CNA revealed Resident #3 grabbed Resident #4 by the front of his shirt, and both Resident #3 and Resident #4 fell to the floor. S2 CNA stated she intervened and separated Resident #3 and Resident #4.
Interview on 09/18/2024 at 2:45 p.m. with Resident #4, revealed he remembered Resident #3 hit him in the head with his fist, because he told Resident #3 to put a tray of food back on the table in the dayroom. Resident #4 revealed after Resident #3 hit him, he had a knot on his head (Resident #4 pointed to an area right above his right ear).
Interview on 09/18/2024 at 3:37 p.m. with S1 Administrator, revealed Resident #3 had a history of resident to resident altercations. S1 Administrator confirmed Resident #4 was a victim of resident to resident physical abuse by Resident #3 on 08/24/2024.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a resident with a PEG tube maintained acceptable parameters of nutritional and hydration status consistent with the res...
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Based on observation, interview, and record review the facility failed to ensure a resident with a PEG tube maintained acceptable parameters of nutritional and hydration status consistent with the resident's comprehensive assessment for 1 (#2) of 8 (#2, #R1, #R2, #R3, #R4, #R5, #R6, and #R7) sampled residents who received nutrition and hydration via PEG tube. The total sample size was 12.
Findings:
Review of the facility's policy titled: Tube Feeding dated 07/2018 read in part . Residents with a Nasogastric, Gastrostomy, or Jejunostomy tube will be provided nutrition and hydration via the feeding tube. 2. Check Physicians orders and/or treatment record for amount and type of feeding. 7. Label the feeding bag with the resident's name, formula ordered and date. For gravity (intermittent) and continuous pump feedings, each time a feeding is administered into the bag, the amount of formula hung and the time it was hung must be noted on the feeding bag. 8. Administer the feeding as ordered via continuous pump feeding. F. Set the rate as ordered and begin the infusion.
Review of Resident #2's medical record revealed an admit date of 04/24/2024. Resident #2 had diagnoses that included in part . Urinary Tract Infection, Acute Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus, Seizures, Pain, Chronic Obstructive Pulmonary Disease, Cerebrovascular Disease, Gastrostomy Status, Tracheostomy Status, Dependence on Respirator (Ventilator) Status, Aphasia, Pneumonia, and Chronic Kidney Disease-Stage 3.
Review of Resident #2's Significant Change MDS with an ARD date of 07/23/2024 revealed in part . Resident #2's cognitive pattern was not assessed due to rarely/never being understood. Resident #2 was totally dependent on staff for eating. Resident #2 had a feeding tube. Resident #2 required special treatments for oxygen therapy, suctioning, trach care, and mechanical ventilation.
Review of Resident #2's care plan revealed in part . Nutrition altered related to tube feeding. Interventions: Administer tube feeding as ordered. Water flushes as ordered. 07/23/2024 Glucerna 1.5 at 50ml/hr x 24 hours and 50ml/hr flush times 24 hrs.
Review of Resident #2's 07/2024 physician's orders revealed in part .
NPO Order date: 04/26/2024
Glucerna 1.5 at 50ml/hr continuously via pump Order date: 07/24/2024
H20 flush at 50ml/hr continuously via pump Order date: 07/24/2024
Review of Resident #2's Departmental Notes documented by S3 RD on 07/23/2024 revealed in part . Recommended Glucerna 1.5 at 50ml/hr times 24 hours with 50ml water flush every hour via pump.
Observation on 07/29/2024 at 10:50 a.m. revealed Resident #2 was receiving tube feeding of Glucerna 1.5 via pump at 40ml/hr, and a water flush was set on pump for 30ml every 3 hours. Observation revealed the Glucerna 1.5 feeding and water flush bag were not labeled with Resident #2's name, and date and time feeding and flush were hung.
Observation on 07/29/2024 at 1:00 p.m. revealed Resident #2 was receiving tube feeding Glucerna 1.5 via pump at 40ml/hr, and a water flush was set on pump for 30ml every 3 hours. Observation revealed the Glucerna 1.5 feeding and water flush bag were not labeled with Resident #2's name, and date and time feeding and flush were hung.
Interview on 07/29/2024 at 2:02 p.m. with S2 LPN confirmed Glucerna 1.5 feeding was set at a rate of 40ml/hr and water flush 30ml every 3hrs for Resident #2. Review of Resident #2's current 07/2024 MAR with S2 LPN confirmed Resident #2's Glucerna 1.5 feeding should be set at a rate of 50ml/hr and water flush 50ml/hr, but had not been. S2 LPN revealed when feedings and water flushes are hung they should be labeled with the Residents name, and the date and time they were hung. S2 LPN confirmed Resident #2's feeding had not been labeled, but should have been.
Interview on 07/29/2024 at 3:20 p.m. with S1 DON revealed nurses were to check each Resident's MAR to ensure the correct feeding and water flush rates were set to the feeding pump when they sign off on a Resident's MAR. S1 DON revealed when S3 RD made a recommendation to adjust a Resident's feedings, an order is put in for those recommendations, and staff should follow through to implement the order. S1 DON confirmed staff had not implemented Resident #2's feeding and flush rate, but should have when S3 RD made changes to the rates on 07/24/2024.
Apr 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #17) of 1 resident reviewed for dignity by failing to ensure a female resident was free of fa...
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Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #17) of 1 resident reviewed for dignity by failing to ensure a female resident was free of facial hair.
Findings:
Review of the Facility's policy titled Shaving- Male and Female read in part Resident will be free of facial hair- both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan.
Review of Resident #17's medical record revealed an admit date of 01/16/2020 with diagnoses that included: Unspecified Dementia, Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Anxiety Disorder, and Dysphagia.
Review of Resident #17's Care plan with review date of 05/28/2024 read in part .
Resident requires total assistance with all activities of daily living. Allow for independence as tolerated by resident such as brushing hair and teeth, washing face and assistance with bed mobility.
Observation on 04/02/2024 at 11:29 a.m. revealed Resident #17 had ¼ inch facial hair to her chin.
Interview on 04/02/2024 at 11:32 a.m. with S9 RN confirmed Resident #17 had long facial hair. S9 RN stated that it should have been shaved, but had not been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Coun...
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Based on record review and interview, the facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting for 1 (02/13/2024) of 3 (01/09/2024, 02/13/2024, and 03/14/2024) meetings reviewed. Findings:
Review of the facility's undated policy titled Resident Council on 04/02/2024 at 3:05 p.m. read in part . The Social Services Director or designee will facilitate the organization and maintenance of a facility Resident Council.
Review of the facility's undated policy titled Grievance/Missing Property on 04/02/2024 at 3:05 p.m. read in part .Purpose: To provide an opportunity for residents, resident representatives, and/or family to present concerns or grievances to the proper authorities at the facility and to receive responses to the issue(s) raised.
Review of the facility's Resident Council Department Response Form read in part . Date of council meeting: 02/13/2024. Date this form was distributed to Department Head: 02/14/2024. Date response due back to Resident Council Representative: 02/23/2024. Department: Nursing. Concern: Resident can't lay down when she wants to when agency CNA's work, Resident's not receiving a bath, and CNA's not passing out ice. Further review of the form revealed the Department Response and Departmental Response presented to Resident Council had no documented evidence of an investigation into the concerns.
Interview on 04/02/2024 at 2:19 p.m. with S7 Activity Director revealed she was responsible for assisting the Resident Council with setting up meetings, keeping meeting minutes, and providing department heads with any documented concerns voiced during meetings. S7 Activity Director stated the Resident Council voiced several concerns about CNA's during the 02/13/2024 meeting, and she had given the DON the documented concerns. S7 Activity Director confirmed the DON had not provided a follow up, or spoken to the Resident Council about the documented concerns, but should have.
Interview on 04/02/2024 at 2:21 p.m. with members of the Resident Council revealed the residents stated the facility did not follow up on their voiced concerns regarding CNA's.
Interview on 04/02/2024 at 3:45 p.m. with S2 DON confirmed a follow up to the Resident Council's concerns during 02/13/2024 meeting should have been provided, but had not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure services were provided according to the resident's Comprehens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure services were provided according to the resident's Comprehensive Plan of Care for 1 (Resident #268) of 1 (Resident #268) residents sampled for tube feeding. The facility failed to ensure Resident #268's nutritional needs were met.
Findings:
Review of the clinical record revealed Resident #268 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure, Anoxic Brain Damage, Rhabdomyolysis, Metabolic Encephalopathy, Tracheostomy status, and Hypertension.
Review of Resident #268's Comprehensive Plan of Care with target date 06/22/2024 revealed in part .Requires PEG tube for adequate nutritional intake. Goals include .nutritional needs will be met thru enteral feedings. Approaches include .Dietician to evaluate current nutritional status.
Observation on 04/02/24 at 11:03 a.m. revealed Resident #268 awake in bed, nonverbal. Tube feeding infusing per dual pump of Jevity 1.5 at 50ml per hour with 50ml H20 flushes every 6 hours.
Observation on 04/03/2024 at 9:06 a.m. revealed Resident #268 asleep in bed. Tube feeding infusing per dual pump of Jevity 1.5 at 50ml per hour with 50ml H20 flushes every 6 hours.
Review of Resident #268's Registered Dietician Nutrition assessment dated [DATE] by S14 Regional Dietician revealed in part .Current Estimated Nutritional Needs based on initial goal weight of 150# (2045-2380kcal/68-78g protein/2045-2380ml fluid); Therefore recommend changes enteral feeding to Jevity 1.5 at 62ml per hour times 24 hours with 42ml/hour flush continuous q hour to provide: 1488ml formula, 2232 calories, 95g protein/day, 1131ml free water+1008ml flush=2139ml/day for hydration.
Observation of Resident #268 on 04/03/2024 at 4:17 p.m. accompanied by S12 Corporate RN revealed Resident #268 tube feeding settings of Jevity 1.5 cal at 50ml per hour with 50ml H20 flushes every 6 hours. Interview on 04/03/2024 at 4:19 p.m. with S12 Corporate RN during the observation confirmed Resident #268 was not receiving enough tube feedings to meet his nutritional needs in accordance with dietician recommendations and plan of care and should be.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure that the nurse staffing information was posted daily.
Findings:
Observation on 04/02/2024 at 9:30 a.m. revealed the daily nurse staffi...
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Based on observation and interview, the facility failed to ensure that the nurse staffing information was posted daily.
Findings:
Observation on 04/02/2024 at 9:30 a.m. revealed the daily nurse staffing information posted was dated 03/29/2024.
Interview on 04/02/2024 at 11:56 a.m. with S2 DON confirmed the daily nurse staffing information posted was dated 03/29/2024. S2 DON confirmed the nurse staffing information posted should have been updated daily, and was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 3 (#11, #17, and #48) of 3 Residents w...
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Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 3 (#11, #17, and #48) of 3 Residents who were ordered and served pureed diets. Findings:
Review of the facility's approved 2024 Lunch Menu revealed the facility was on Week: 4, Day: Tuesday: Roasted Turkey, Mashed Potatoes, Turnip Greens, Bread Roll, Dessert- Sugar cookie, and a Beverage.
Review of the facility's approved recipe for Pureed Roast Turkey read in part . Ingredients: 3 oz. Roast Turkey, [NAME] Sliced Bread, Water, and Chicken Base. Instructions: Combine chicken base and water to make chicken broth. Place prepared turkey and bread in a washed and sanitized food processor. Gradually add liquid and blend until smooth. Note: Follow any facility policy/procedures, such as the puree volume method procedure, to ensure a correct portion is served.
Review of the facility's approved recipe for Pureed Turnip Greens read in part . Ingredients: Turnip greens, Margarine, and [NAME] Sliced Bread. Instructions: Place prepared vegetables, bread, and margarine in a washed and sanitized food processor, blend until smooth. Note: Follow any facility policy/procedures, such as the puree volume method procedure, to ensure a correct portion is served.
Review of the facility's current policy titled Pureed Food Preparation on 04/02/2024 at 4:04 p.m. read in part . Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value. Standardized recipes will be used to prepare all pureed foods.
Interview on 04/02/2024 at 11:25 a.m. with S6 Dietary revealed she had prepared the pureed turkey. S6 Dietary stated she placed turkey in blender, added milk, and bread. S6 Dietary stated she did not have a recipe to refer to, and added the unmeasured items until it was blended well. S6 Dietary stated she never referred to a recipe to prepare pureed food items.
Interview on 04/02/2024 at 11:43 a.m. with S5 DM confirmed dietary staff should refer to recipes when cooking and preparing all meals, including pureed meals. S5 DM confirmed staff did not have a recipe for pureed food items to refer to, but should have. S5 DM removed the pureed turkey and turnip greens prepared by S6 Dietary, and stated she would prepare the pureed food items.
Observation on 04/02/2024 at 11:48 a.m. revealed S5 DM accessed the dining manager program, and printed recipes for turnip greens and roasted turkey. S5 DM placed an unmeasured amount of turkey and gravy into the blender and pureed the food items. S5 DM then placed the pureed turkey on the steam line to serve residents. S5 DM confirmed she did not refer to the recipe for pureed roasted turkey, but should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. T...
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Based on observation, interview and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of an infectious communicable disease. The facility failed to ensure all staff adhered to Enhanced Barrier Precautions for 1 (Resident #6) of 6 (Resident #6, Resident #56, Resident #59, Resident #218, Resident #268, and Resident #269) residents reviewed for infection control.
Findings:
Review of the facility policy titled: Enhanced Barrier Precautions, revealed in part .Enhanced Barrier Precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Enhanced Barrier Precautions only require use of gown/gloves when performing high contact resident activities: dressing, bathing/showering, transferring, AM/PM care, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, or ventilator, and wound care: any skin opening requiring a dressing.
Observation on 04/02/2024 at 9:45 a.m. revealed a red, enhanced barrier precautions sign with instructions to wear gloves and a gown for high-contact resident care activities, which included bathing/showering, and changing linens, taped to the outside of Resident #6's room door. A caddy was also observed hanging on the outside of Resident #6's door that contained ABHR, isolation gowns, gloves, and a box of mask.
Observation on 04/02/2024 at 9:46 a.m. upon entering Resident #6's room revealed S8 Hospice CNA changing the pad on Resident #6's bed and helping Resident #6 put on a hospital gown. S8 Hospice CNA was noted dressed in scrubs and wearing disposable gloves. Resident #6 was observed to have a tracheostomy and was being mechanically ventilated. Interview at the time of observation with S8 Hospice CNA revealed she had just bathed Resident #6 and a pan of water was observed on Resident #6's over-bed table.
Interview on 04/02/2024 at 9:47 a.m. with S8 Hospice CNA, revealed she saw the signage on Resident #6's door but she was not sure what it was for. S8 Hospice CNA stated she was told by facility staff the sign and equipment had been placed on Resident #6's door because state was in the building. When asked if she had read the signage, S8 Hospice CNA responded No.
Observation on 04/02/2024 at 9:50 a.m. of Resident #6 accompanied by S3 RT confirmed S8 Hospice CNA was providing direct care and not wearing Enhanced Barrier Precaution PPE. Interview with S3 RT at the time of observation confirmed that S8 Hospice CNA was not wearing the appropriate PPE for direct care and should be.
Interview on 04/02/2024 at 9:55 a.m. with Resident #6's nurse, S4 LPN, revealed the expectation is that hospice staff will read residents' door signage and follow the posted instructions and/or precautions. S4 LPN stated he was not sure if all hospice staff had been made aware of new precautions but they should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment.
The facility failed to ensure:
1. The floor in Rooms a, b, and c were clean, san...
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Based on observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment.
The facility failed to ensure:
1. The floor in Rooms a, b, and c were clean, sanitary and free of dust, trash and dead insects.
2. The ceiling tiles Rooms a and b were not loose with exposed insulation, and did not have brown stained and holes ceiling tiles were securely in place without exposed insulation and were clean without brown stains.
3. The over bed wall mounted lights were operational in Room b over both beds a and b; and
4. The window pane in Room a was cleaned and allowed resident to see the outside view.
Findings:
Rooms a
Observations of Room a on 04/02/2024 at 12:20 p.m. and 04/03/2024 at 8:35 a.m., revealed a large amount of dust, trash, and dead insects in the corner of the room between the bed and the window. The window pane was noted to have a large amount of mildew, green and brown substance along with a film on the inside of the pane. The outside view was not clearly visible. The ceiling tiles in the room were loose with exposed insulation and brown stains.
Room b
Observations of Room b on 04/02/2024 at 1:16 p.m. and 04/03/2024 at 8:50 a.m., revealed a large amount of dust, trash, and dead insects in the corner of the room between the bed and the window. There were brown stained loose ceiling tiles with exposed insulation. The over bed lights wall mounted lights were not functional over both of the beds.
Room c
Observations of Room c on 04/02/2024 at 1:30 p.m. and 04/03/2024 at 9:10 a.m., revealed a large amount of dust, trash, and dead insects in the corner of the room between the bed and the window.
Observations of Rooms a, b, and c on 04/03/2024 from 9:22 a.m. to 9:40 a.m., accompanied by S10 Maintenance confirmed the above findings. S10 Maintenance confirmed Rooms a, b, and c had dead insects and trash in the corners, and had not been properly cleaned and should have been. S10 Maintenance stated the ceiling tiles in Rooms a and b needed to be replaced, repaired and/or painted. S10 Maintenance reported the light bulbs in Room b needed to be replaced and the window pane in Room a should have been cleaned to allow the resident an outside view.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure services were provided by the facility to meet quality prof...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #43) of 5 (Resident #10, Resident #43, Resident #45, Resident #56 and Resident #57) residents reviewed for unnecessary medication and 1 (Resident #268) of 1 resident reviewed for tube feeding. The facility failed to:
1. Ensure labs were obtained as ordered by the physician for Resident #43.
2. Notify the physician of a dietician's recommendation to meet the nutritional needs of Resident #268.
Findings:
Resident #43
Review of Resident #43's medical record revealed an admit date of 09/10/2021 with diagnoses that included: Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus, Essential Hypertension, Viral Hepatitis C, and Paroxysmal Atrial Fibrillation.
Review of Resident #43's 04/2024 Physician Order's read in part .
Draw CMC, CMP, HGAIC, IRON, MAG Q3 months in December, March, June and September.
(Start Date 12/07/2021)
Review of Resident #43's medical record revealed no labs for 12/2023 in the chart or Echart.
An interview on 04/04/2024 at 10:00 a.m. with S2 DON confirmed Resident #43's Q3 month labs due to be obtained in 12/2023 were not collected as ordered by physician, but should have been.
#268
Review of the clinical record revealed Resident #268 was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure, Anoxic Brain Damage, Rhabdomyolysis, Metabolic Encephalopathy, Tracheostomy status, and Hypertension.
Review of Resident #268's Comprehensive Plan of Care with target date 06/22/2024 revealed in part .Requires PEG tube for adequate nutritional intake. Goals include .nutritional needs will be met thru enteral feedings. Approaches include .Dietician to evaluate current nutritional status.
Observation on 04/02/2024 at 11:03 a.m. revealed Resident #268 awake in bed, nonverbal. Tube feeding infusing per dual pump of Jevity 1.5 at 50ml per hour with 50ml H20 flush every 6 hours.
Observation on 04/03/2024 at 9:06 a.m. revealed Resident #268 asleep in bed. Tube feeding infusing per dual pump of Jevity 1.5 at 50ml per hour with 50ml H20 flush every 6 hours.
Review of Resident #268's Registered Dietician Nutrition assessment dated [DATE] by S14 Regional Dietician revealed in part .Current Estimated Nutritional Needs based on initial goal weight of 150# (2045-2380kcal/68-78g protein/2045-2380ml fluid); Therefore recommend changes enteral feeding to Jevity 1.5 at 62ml per hour times 24 hours with 42ml/hour flush continuous q hour to provide: 1488ml formula, 2232 calories, 95g protein/day, 1131ml free water+1008ml flush=2139ml/day for hydration.
Review of Resident #268's March 2024 nurses' notes revealed there was no documentation the PCP had been notified of Resident #268's dietician recommendations to meet nutritional needs.
Observation of Resident #268 on 04/03/2024 at 4:17 p.m. accompanied by S12 Corporate RN revealed Resident #268 tube feeding settings of Jevity 1.5 cal at 50ml per hour with 50ml H20 flush every 6 hours.
Interview on 04/03/2024 at 4:19 p.m. with S12 Corporate RN revealed nurses were responsible for communicating the dieticians' recommendations to the physicians. S12 Corporate RN confirmed there was no documentation Resident #268's PCP had been notified of the dieticians' recommendations and she should have been.
Telephone interview on 04/03/2024 at 4:35 p.m. with S11 PCP revealed she was Resident #268's PCP. S11 PCP stated she had not been notified of Resident #268's dietician recommendations and should have been. S11 PCP stated the issue of not being notified was concerning. S11 PCP stated she would call the facility immediately to order labs to ensure Resident #268 was not dehydrated and in need of IV fluids.
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 observation, interview, and record review the facility failed to ensure that residents who were unable to carry out ADL's (Activities of Daily Living) received the necessary services to maint...
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Based on observation, interview, and record review the facility failed to ensure that residents who were unable to carry out ADL's (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure Residents #1 and Resident #4 were free from facial hair and failed to provide nail care to dependent residents for Residents #11, Resident #17, Resident #21, Resident #38, Resident #48 and Resident #62 in a total sample of 10 residents reviewed for ADL care.
Findings:
Resident #1
Review of Facility's policy titled Shaving- Male and Female read in part Resident will be free of facial hair- both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan.
Review of Resident #1 medical record revealed an admit date of 09/18/2023 with diagnoses that included: Cerebral Infarction, Hemiplegia following Cerebral infarction affecting left nondominant side, Unspecified Dementia, Bipolar Disorder, Post Traumatic Stress disorder, Schizophrenia, and Anoxic Brain Damage.
Review of Resident #1's care plan with a review date of 06/20/2024 read in part .
Resident requires assistance with ADL's related to hemiplegia secondary to CVA. Resident requires staff x 1 assist with transfers, dressing, bathing and grooming.
Observation on 04/02/2024 at10:30 a.m. revealed Resident #1 sitting in the day room with long facial hair. Interview with Resident #1 at the time of observation revealed he had asked several staff members to shave him but had not been. Resident #1 stated he could not recall the last time he had been shaved.
Observation on 04/02/2024 at 2:40 p.m of Resident #1 accompanied by S4 LPN revealed Resident #1 had long facial hair. Interview with S4 LPN at the time of observation revealed that Resident #1 typically liked to keep a clean shave. S4 LPN confirmed Resident #1 had long facial hair that needed to be shaved and had not been.
Resident #17
Review of Resident #17's medical record reveals an admit date of 01/16/2020 with diagnoses that included: Unspecified Dementia, Schizoaffective Disorder, Anxiety Disorder, and Dysphagia.
Review of Resident #17's Care plan with review date of 05/28/2024 read in part . Resident requires total assistance needed with all ADL's. Assist resident with ADLs care daily.
Observation on 04/02/2024 at 11:29 a.m. revealed the fingernails on Resident #17's right hand were ½ inch in length with brown substance under the nails.
Interview on 04/02/2024 at 11:32 a.m. with S9 RN confirmed Resident #17's fingernails were long with brown substance and should have been trimmed and cleaned but had not been.
Resident #48
Review of Resident #48's medical record revealed an admit date of 01/16/2022 with diagnoses that included: Hemiplegia following cerebral infarction affecting right dominant side, Chronic Obstructive Pulmonary Disease, Dysphagia , Generalized anxiety Disorder, Seizure Disorder, Depression, Dysphagia, and Atrial Fibrillation.
Review of Resident #48's Care plan with the review date of 05/01/2024 read in part Resident requires assistance with ADLS due to weakness, unsteady gait, and Hemiplegia.
Observation on 04/02/2024 at12:22 p.m. revealed Resident #48's fingernails were ½ inch in length and jagged. Resident #48 stated he did not like his nails long and he wanted to have them cut.
Interview on 04/02/2024 at 2:29 p.m. with S4 LPN confirmed Residents #48's fingernails were long, jagged, and needed to be cut but had not been.
Resident #4
Review of Resident #4's EHR revealed an admit date of 10/02/2023 with diagnoses that included: Type 2 Diabetes Mellitus, Major Depressive Disorder, and COPD (Chronic Obstructive Pulmonary Disease).
Review of Resident #4's Care Plan with a target date of 05/28/2024 revealed Resident #4 required assistance with ADLs with interventions that included: assist with ADLs, and assist resident with bathing as schedule and prn.
Review of Resident #4s Re-entry MDS with an ARD of 03/22/2024 revealed a BIMS score of 15 (cognition intact).
Observation on 04/02/2024 at 1:30 p.m. revealed Resident #4 with stubble thick gray facial hair, and jagged fingernails ½ inch in length with dark brown substance underneath the nail beds. Interview with Resident #4 revealed he needed to be shaved, and his fingernails were too long and dirty and needed to be trimmed.
Observation on 04/03/2024 at 9:25 a.m. revealed Resident #4 with stubble thick gray facial hair, and jagged fingernails ½ inch in length with dark brown substance underneath the nail beds. Interview with Resident #4 revealed it had been weeks since his nails had been cleaned and trimmed, and over a week since he had been shaved.
Observation of Resident #4 on 04/03/2024 at 9:55 a.m. accompanied by S2 DON confirmed Resident #4 needed to be shaved and his fingernails needed to be cleaned and trimmed.
Resident #11
Review of Resident #11's EHR revealed an admit date of 09/06/2021 with diagnoses that included: Schizoaffective Disorder Bipolar type, Anoxic Brain damage, Seizures, and SOB.
Review of Resident #11's Care Plan with a target date of 05/28/2024 revealed Resident #11 required assistance with ADLs with interventions that included: 2 x assist with transfer and one person assist with ADLs.
Review of Resident #11's Quarterly MDS with an ARD of 02/17/2024 revealed a BIMS was not conducted as resident was unable to complete interview, with no behaviors, and required partial/moderate assistance with tub/shower.
Observation on 04/02/2024 at 12:20 p.m. revealed Resident #11 fingernails and toenails were long and untrimmed.
Observation on 04/03/2024 at 8:35 a.m. revealed Resident #11's fingernails and toenails were long and untrimmed.
Observation of Resident #11 on 04/03/2024 at 9:45 a.m., accompanied by S2 DON confirmed Resident #11 fingernails and toenails were long and needed to be trimmed.
Resident #21
Review of Resident #21's EHR revealed an admit date of 08/25/2021 with diagnoses that included: Parkinson's Disease, Type 2 Diabetes Mellitus, Essential (primary) Hypertension, and Major Depressive Disorder.
Review of Resident #21's Care Plan with a target date of 05/09/2024 revealed Resident #21 required assistance with bathing and grooming with an intervention, of one person assist with ADLs.
Review of Resident #21's Annual MDS with an ARD of 02/08/2024 revealed a BIMS score of 9 (moderately impaired cognition).
Observation on 04/02/2024 at 1:45 p.m. revealed Resident #21 with long, untrimmed nails. Interview with Resident #21 revealed his fingernails were too long and needed to be trimmed.
Observation on 04/03/2024 at 9:00 a.m. revealed Resident #21 with long, untrimmed fingernails.
Observation of Resident #21 on 04/03/2024 at 9:58 a.m., accompanied by S2 DON confirmed Resident #21 fingernails were long and needed to be trimmed. Interview with S2 DON confirmed that Resident #21's fingernails should have been trimmed by the nurse, but were not.
Resident #38
Review of Resident #38's EHR revealed an admit date of 11/06/2020 with diagnoses that included: Schizophrenia, Morbid Obesity, Essential (primary) Hypertension, and Depressive Episodes.
Review of Resident #38's Care Plan with a target date of 06/28/2024 revealed the resident had impaired mobility and needed assistance for care below the hip with interventions that included: assist resident with ADL care daily such as combing/brushing hair or teeth, washing face, and assisting with bed mobility.
Review of Resident #38's Quarterly MDS with an ARD of 02/22/2024 revealed a BIMS score of 9 (moderately impaired cognition) with no behaviors and required 1-2 person assist with ADLs.
Observation on 04/02/2024 at 3:09 p.m. revealed Resident #38 with long, untrimmed fingernails and toenails. Interview with Resident #38 revealed his fingernails and toenails were too long and he would like to have his fingernails and toenails trimmed.
Observation on 04/03/2024 at 9:25 a.m. revealed Resident #38 with long, untrimmed fingernails and toenails. Interview with Resident #38 revealed he still would have liked to have his fingernails and toenails trimmed.
Observation of Resident #38 on 04/03/2024 at 9:35 a.m. accompanied by S2 DON confirmed Resident #38's fingernails and toenails needed to be trimmed.
Resident #62
Review of Resident #62's EHR revealed an admit date of 11/17/2023 with diagnoses that included: Schizoaffective Disorder Depressive type, Cocaine Abuse, and Intervertebral Disc Disorder.
Review of Resident #62's Care Plan with a target date of 05/28/2024 revealed Resident #62 required assistance with ADLs with interventions that included: 2 person assist with transfer and one person assist with ADLs.
Review of Resident #62's Quarterly MDS with an ARD of 02/17/2024 revealed a BIMS score of 10 (moderately impaired cognition) with no behaviors, and required partial/moderate assistance with tub/shower bath.
Observation on 04/02/2024 at 2:54 p.m. revealed Resident #62's fingernails long and untrimmed with a dark substance underneath nails beds. Interview with Resident #62 revealed his fingernails were dirty, and needed to be cleaned and trimmed.
Observation on 04/03/2024 at 8:58 a.m., revealed Resident #62 with long, untrimmed and uncleaned fingernails. Interview with Resident #62 revealed it had been a while (unable to recall) since his fingernails had be cleaned and trimmed.
Observation of Resident #62 on 04/03/2024 at 10:00 a.m., accompanied by S2 DON confirmed Resident #62 fingernails were uncleaned, long and needed to be cleaned and trimmed.
Feb 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #5) of 7 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents.
This deficient practice resulted in an Actual Harm for Resident #5 on 02/05/2024 at 2:20 p.m., when Resident #6 hit Resident #5 in the left eye two times with a closed fist. Resident #5 received first-aid treatment in the facility for multiple abrasions and bruising to the face. Resident #5 was sent to a local emergency department where he received treatment for a left periorbital/facial contusion.
Findings:
Review of the facility policy titled Abuse Prevention revealed in part .
The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual.
Abuse defined:
Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident.
Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking.
Resident #5
Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses that included in part .Hemiplegia following Cerebral Infarction affecting left non-dominant side, Depressive Episodes, Human Immunodeficiency Virus, Mental Disorder, Chronic Viral Hepatitis C, and Pain Unspecified.
Review of Resident #5's Quarterly MDS with an ARD of 01/05/2024, revealed Resident #5 had a BIMS of 14, indicating no cognitive impairment. The MDS revealed Resident #5 required assistance for dressing; and was independent with eating, toileting, hygiene, shower/bath, and toilet transfer. The MDS revealed Resident #5 had impairment in functional range of motion to the upper and lower extremities on one side, and utilized a manual wheelchair for mobility.
Review of Resident #5's care plan read in part .Socially inappropriate behavior-Resident calling another resident inappropriate names, attention seeking behavior and paranoia about diseases and disease process, with approaches that included: Re-direct inappropriate behaviors, Notify MD if behavior worsens or escalates, monitor for inappropriate behaviors and address promptly.
Review of Resident #5's 24 hour progress note dated 02/06/2024 read in part .Bruise purple/red in color under left eye on cheek bone. Scratch noted to left temple extending to bruise on left cheek bone under eye.
Review of an Emergency Department record dated 02/05/2024 at 3:20 p.m., revealed in part .Chief complaint: Left Periorbital/Facial Contusion. Patient with complaints of left periorbital facial swelling and pain. He was punched with a fist by another nursing home resident. Location: face.
Review of a Radiology report dated 02/05/2024 read in part .
Exam: CT Facial Bones
History: Trauma over left eye/altercation and abrasions of face.
Impression: Old incompletely united impacted nasal bone fracture. No definite acute facial bone fractures are identified.
Review of Resident #5's February 2024 Treatment Record revealed a treatment to cleanse abrasion under left eye with normal saline, pat dry. Apply triple antibiotic ointment and leave open to air daily until healed. Monitor abrasion under left eye for signs and symptoms of infection daily until healed.
Resident #6
Review of Resident #6's clinical record revealed an admission date of 11/07/2014, with diagnoses that included in part .Unspecified Dementia unspecified severity with other behavioral disturbance, Schizoaffective Disorder, Anxiety Disorder, and Schizoid Personality Disorder.
Review of Resident #6's Quarterly MDS with an ARD of 01/11/2024, revealed Resident #6 had a BIMS score of 7, indicating severe cognitive impairment. The MDS revealed Resident #6 required supervision with oral hygiene and bathing; and was independent with eating, personal hygiene, dressing of upper/lower body, and chair/bed-to-chair transfer. Resident #6 had no range of motion limitations to the upper and lower extremities, and utilized a manual wheelchair for mobility.
Review of Resident #6's care plan with a target date of 05/04/2024, revealed in part .
Resident is a hoarder and has behaviors. Attention seeking behaviors, tells false stories on peers and will lash out on staff/residents with interventions that included: Monitor for inappropriate behaviors and address promptly and re-direct inappropriate behaviors.
Review of a facility incident report documented by S2 DON, and dated 02/05/2024, revealed in part . on 02/05/2024 at 2:20 p.m. while out on the smoking deck, Resident #5 and Resident #6 were involved in a resident to resident altercation.
Review of the facility's investigation, documented by S1 Administrator, revealed in part . on 02/05/2024 at 2:12 p.m., Resident #5 reported that Resident #6 stood up from his wheelchair and hit Resident #5 on the side of his face. Resident #5 then grabbed Resident #6's face to fend him off. S4 COTA was walking by the door to the smoking deck, and saw Resident #6 and Resident #5 making physical contact with each other.
Observation on 02/07/2024 at 11:15 a.m. with Resident #5 revealed he had a left black eye, with periorbital bruising and swelling.
Interview on 02/07/2024 at 12:12 p.m. with S1 Administrator, revealed on 02/05/2024 at 2:20 p.m., while on the smoker's deck, Resident #6 stood up from his wheelchair and hit Resident #5 in the face, causing a left black eye. S1 Administrator stated Resident #5 was sent to the emergency room after the resident to resident altercation.
Interview with Resident #5 on 02/08/2024 at 8:31 a.m., revealed on 02/05/2024, he was outside on the smoker's patio when Resident #6 kept asking him for a cigarette, but he (Resident #5) didn't have any to give him. Resident #5 stated Resident #6 stood up from his wheelchair and punched him in the eye two times with his fist. Resident #5 stated his eye still hurt.
Observation on 02/08/2024 at 8:39 a.m. with Resident #6 revealed he had several superficial scratches to his face. Interview with Resident #6 revealed he did not remember having a fight with another resident a few days ago.
Interview on 02/08/2024 at 1:17 P.M. with S4 COTA, revealed on 02/05/2024, he witnessed Resident #6 stand up from his wheelchair and punch Resident #5 two times in the face with his fist. S4 COTA stated he immediately intervened.
Interview on 12/12/204 at 1:23 p.m. with S1 Administrator confirmed Resident #5 was a victim of resident to resident physical abuse by Resident #6 on 02/05/2024.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident, and the resident's representative, for 1 (#7) of 7 (Resident #1, Resident #2...
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Based on interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident, and the resident's representative, for 1 (#7) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled Residents.
Findings:
The Facility's Policy Titled Grievance/Missing Property read in part .
Procedure:
1. Respective Department Head, Executive Director and/or Grievance Official will follow-up on issues noted.
Review of Resident #7's medical record revealed an admit date of 07/26/2017, with diagnoses that included: Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease, Morbid severe Obesity with Alveolar Hypoventilation, Chronic Systolic Heart Failure, Sleep Apnea Unspecified, Cardiomegaly, and Unspecified Asthma Uncomplicated.
Review of Resident #7's Quarterly MDS with an ARD 11/10/2023, revealed Resident #7 had a BIMS score of 1? (indicating intact cognition); required partial/moderate assistance for dressing and personal hygiene; independent with eating; and dependent for toileting hygiene.
Observation of Resident #7 on 02/08/2024 at 1:25 p.m., revealed her in bed with oxygen per nasal cannula in progress. Resident #7 revealed another resident who resided on her hall, had entered her room naked in a wheelchair (did not remember the date). Resident #7 stated she knew the resident because he visited her daily in her room. Resident #7 revealed she was not afraid of the resident, but didn't want him in her room naked.
Telephone interview with Resident #7's sister revealed she called S1 Administrator on 02/02/2024, and verbalized the following concerns: Resident #7 was no longer on the respiratory unit, Resident #7's Bi-pap was not being put on at night, and a naked man being in Resident #7's room.
Interview on 02/08/2024 at 2:15 p.m. with S1 Administrator revealed she had spoken to Resident #7's sister earlier in the week (couldn't remember the date), and she had voiced the following concerns: Resident #7 was no longer on the respiratory unit, Resident #7's Bi-pap was not being put on at night, and a naked resident being in Resident #7's room. S1 Administrator confirmed she had not completed a grievance form on the complaints, and had not made an effort to investigate and resolve the sister's complaints.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #7) of 7 (Resident #1, Resident #2, Resident #...
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Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #7) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled Residents. The facility failed to ensure respiratory equipment was properly changed, labeled and contained.
Findings:
Review of the Facility's Policy Titled Oxygen Therapy read in part .
Procedure:
9. Date tube when changed (weekly).
Review of Resident #7's medical record revealed an admit date of 07/26/2017, with diagnoses that included: Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease, Morbid severe Obesity with Alveolar Hypoventilation, Chronic Systolic Heart Failure, Sleep Apnea Unspecified, Cardiomegaly, Unspecified Asthma Uncomplicated.
Review of Resident #7's Physician orders dated 02/2024 revealed in part . oxygen per concentrator, and to keep oxygen saturation equal to or greater than 90%. Bi-pap wear at night and during the day while napping.
Review of Resident #7's care plan with a target date of 03/19/2023, revealed the following problems in part .
1. At risk for altered airway exchange related to Chronic Respiratory Failure, due to diagnoses of Morbid Obesity, Sleep Apnea, Congenital Central Alveolar Hypoventilation, Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Asthma, Chronic Respiratory Failure with Hypercapnia, and History of refusing to wear Bi-pap throughout the night.
2. History of Tracheostomy and Ventilator dependent status with approaches to wear oxygen and Bi-pap as ordered.
Observation of Resident #7 on 02/08/2024 at 1:25 p.m., revealed Resident #7 lying in bed, with oxygen per nasal cannula via concentrator in place. Resident #7's oxygen tubing and humidifier bottle were not labeled, and her Bi-pap oxygen tubing was not labeled, and was on the floor. Interview with Resident #7 at that time revealed she wore her oxygen all the time, and her Bi-pap at night.
Observation on 02/08/2024 at 1:35 p.m., accompanied by S3 LPN in Resident #7's room, revealed the following: Resident #7's oxygen tubing and humidifier bottle were not labeled, and her Bi-pap oxygen tubing was not labeled, and was on the floor. Interview with S3 LPN at that time confirmed these findings.
Interview on 02/08/2024 at 3:27 p.m. with S2 DON revealed oxygen tubing should be changed weekly. S2 DON confirmed all oxygen tubing should be dated and initialed, and properly contained.
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure an allegation of staff to resident verbal abuse was reported immediately, but not later than 2 hours after the allegation was made, ...
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Based on interview and record review, the facility failed to ensure an allegation of staff to resident verbal abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.
Findings:
Review of the facility's policy titled Abuse Prevention revealed in part .
Investigation:
The Executive Director, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required.
Protection:
l. Any allegation of abuses, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.
2. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion or crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others).
Review of the facility's Supervisor Investigation Summary Form for Resident #1 revealed in part .
Date of the event: 10/12/2023
Investigation:
On the morning of 10/12/2023, S1 Administrator received 2 text messages from Resident #1's responsible party. S1 Administrator immediately went to Resident #1's room to assure she was safe. Resident #1 verbalized to S1 Administrator that last night S2 CNA spoke louder than usual when she asked her to turn to the right along with her left leg so that she could assist with changing the adult brief. Resident #1 also reported S2 CNA told her not to grab her neck when she was assisting her to standing position, or returning her back into her bed and said Don't touch me. You are going to make me fall. At this time, S1 Administrator suspended S2 CNA pending an investigation.
Interview on 01/12/2024 at 9:57 a.m. with S1 Administrator revealed she received texts messages the morning of 10/12/2023 (specific time unknown) from Resident #1's responsible party. S1 Administrator reported she started an investigation on 10/12/2023 at 1:06 p.m. when she determined the allegation was verbal abuse.
Review of documentation on the SIMS report revealed the abuse allegation was not entered until 4:41 p.m. on 10/12/2023.
Interview on 01/12/2024 at 10:16 a.m. with S1 Administrator confirmed she should have entered the allegation of verbal abuse into the SIMS (Statewide Incident Management System) within 2 hours after determining the allegation but did not enter it into the system until 4:41 p.m. on 10/12/2023.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to have evidence that allegations of abuse were thoroughly investigated for 3 allegations of abuse involving 4 (Resident #1, Resident #2, Resi...
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Based on interview and record review, the facility failed to have evidence that allegations of abuse were thoroughly investigated for 3 allegations of abuse involving 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.
Findings:
Review of the facility's policy titled Abuse Prevention revealed in part .
Protection:
2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families and/or representative, and as required by state guidelines.
Resident #1
Review of the facility's Supervisor Investigation Summary Form for Resident #1 revealed in part .
Date of event: 10/12/2023
Investigation:
On the morning of 10/12/2023, S1 Administrator received 2 text messages from Resident #1's responsible party. S1 Administrator immediately went to Resident #1's room to assure she was safe. Resident #1 verbalized to S1 Administrator that last night S2 CNA spoke louder than usual when she asked her to turn to the right along with her left leg so that she could assist with changing the adult brief. Resident #1 also reported S2 CNA told her not to grab her neck when she was assisting her to standing position, or returning her back into her bed and said Don't touch me. You are going to make me fall. At this time, S1 Administrator suspended S2 CNA pending an investigation.
Resident #1 participated in the Trauma Assessment on 10/12/2023 during the interview with this writer. LPN assigned to Resident #1's hall completed the Trauma Assessment on 10/13/2023, 10/14/2023, and 10/15/2023.
All cognitive residents on Resident #1's hall were interviewed on 10/12/2023.
Head to toe body audits were completed on all residents that reside on Resident #1's hall.
Interview on 01/09/2024 at 10:50 a.m. with S1 Administrator and S4 Corporate Nurse revealed they only had the Supervisor Investigation Summary for the incident on 10/12/2023.
Interview on 01/11/2024 at 1:45 p.m. with S1 Administrator confirmed she had no other supporting documentation to provide evidence that the allegation of staff to resident abuse was fully investigated. S1 Administrator stated she should have had the documentation.
Resident #2
Review of the facility's Supervisor Investigation Summary Form for Resident #2 revealed in part .
Date of event: 10/19/2023
Time: 9:00 a.m.
How and when was event discovered: #R1 reported that Resident #2 came to his door asking him to, Call 911 because she had been raped.
Investigation:
NP was notified at approximately 9:10 a.m. to report this allegation; NP gave order to send Resident #2 to the hospital for evaluation/rape kit. S1 Administrator called the local police department at approximately 9:10 a.m. to report that this event has been reported to facility staff.
All residents at the facility had a body audit performed following this reportable event. All cognitive residents denied any knowledge of abuse or neglect.
Interview on 01/09/2024 at 10:50 a.m. with S1 Administrator and S4 Corporate Nurse revealed they only had the Supervisor Investigation Summary for the incident on 10/19/2023.
Interview on 01/11/2024 at 1:45 p.m. with S1 Administrator confirmed she had no other supporting documentation to provide evidence that the allegation of sexual abuse was fully investigated. S1 Administrator stated she should have had the documentation.
Resident #3 and Resident #4
Review of the facility's Supervisor Investigation Summary Form for Resident #3 vs. Resident #4 revealed in part .
Date of event: 10/22/2023
Time: 7:20 p.m.
Briefly describe incident: Resident #3 became upset, started yelling telling Resident #4 to get away from him, to stop punching him.
Investigation:
Resident #3 continued to state after getting to his room and calming down that Resident #4 had punched him 5 times. A full body audit was completed on Resident #3.
A body audit was performed on Resident #4.
Interview on 01/09/2024 at 10:50 a.m. with S1 Administrator and S4 Corporate Nurse revealed they only had the Supervisor Investigation Summary for the incident on 10/22/2023.
Interview on 01/18/2024 at 1:25 p.m. with S1 Administrator confirmed she had no other supporting documentation to provide evidence that the allegation of resident to resident physical abuse was fully investigated. S1 Administrator stated she should have had the documentation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #5) of 5 (Resident...
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Based on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to ensure Resident #5 had a bed alarm applied to prevent falls after sustaining a fall with major injury.
Findings:
Review of Resident #5's clinical record revealed an admit date of 07/11/2023 with diagnoses that included: Acute Respiratory Failure, Aphasia, Dysphagia, Unspecified Convulsions, Non-traumatic Intracranial Hemorrhage, Other symptoms and signs with cognitive functions following Cerebral Infarctions, and Insomnia.
Review of Resident #5's MDS with an ARD of 11/01/2023 revealed a BIMS was not conducted as Resident #5 was rarely/never understood and Resident #5 had severely impaired skills for daily decision making. Review of the MDS revealed Resident #5 was dependent with sit to lying, lying to sitting on the side of the bed, sit to stand, and chair/bed to chair transfer.
Review of Resident #5's care plan with a target date of 02/01/2024 revealed a problem of at risk for falls due to impaired mobility, incontinence, impaired cognition, poor decision making, cerebral infarctions, and convulsions. Interventions included in part .12/11/2023 fall on floor with Subdural Hemorrhage noted on CT scan as well as old infarcts: continue low bed, alarm, and fall mat.
Review of Resident #5's 12/2023 Flow Sheet revealed no documentation the bed alarm was in place and monitored for proper functioning.
Review of Resident #5's 01/2023 Flow Sheet revealed the bed alarm was not placed on the flow sheet until 01/12/2023.
Interview on 01/12/2024 at 1:53 p.m. with S3 CNA revealed Resident #5 did not have a bed alarm on his bed. S3 CNA stated she provided care to Resident #5 earlier that day and there was no bed alarm on his bed. S3 CNA reported she did not recall Resident #5 ever having a bed alarm. Observation at that time of S3 CNA checking Resident #5's bed for a bed alarm revealed there was no bed alarm in place.
Interview on 01/12/2024 at 2:02 p.m. with S4 Corporate Nurse revealed the low bed was an intervention that was in place prior to Resident #5's fall on 12/11/2023 and the bed alarm and fall mat were used as the interventions after.
Observation on 01/12/2024 at 2:05 p.m. of S4 Corporate Nurse checking at Resident #5's bed revealed there was no bed alarm in place. Interview at that time with S4 Corporate Nurse confirmed there should have been a bed alarm on Resident #5's bed.
Interview on 01/18/2024 at 2:25 p.m. with S4 Corporate Nurse revealed the bed alarm should have been on Resident #5's flow sheet for the nurses to sign off to ensure the alarm was in place. S4 Corporate Nurse confirmed it was not on the flow sheet until 01/12/2024, but it should have been there since 12/15/2023 when he returned from the hospital after the fall with the head injury.
Aug 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review the Facility failed to ensure each Resident had the right to be free from abuse by other Residents. The Facility failed to protect 1 Resident (#4) of 7 (#1, #2, #3...
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Based on interview and record review the Facility failed to ensure each Resident had the right to be free from abuse by other Residents. The Facility failed to protect 1 Resident (#4) of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled Residents from being physically abused by another Resident.
Findings:
Review of the facility's Abuse Prevention Policy read in part .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff or other residents .
Protection: (3) It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect or mistreatment.
Resident #4
Review of Resident #4's medical record revealed an admit date of 04/07/2023 with diagnoses which included: Hemiplegia Left Non-Dominant Side, Mental Disorder Not other specified, HIV, Acute Bronchitis, Chronic Viral Hepatitis C, Idiopathic Neuropathy and Chronic Obstructive Pulmonary Disease.
Review of Resident #4's Quarterly MDS with an ARD of 07/13/2023 revealed resident had a BIMS score of 15 (indicating intact cognition), and was able to understand others and to make himself understood. The MDS revealed Resident #4 was coded as requiring one person physical assist for transfers, toilet use, bed mobility, dressing and personal hygiene. Resident #4's MDS revealed he had impaired range of motion on one side of both upper and lower extremities.
Review of Resident #4's Care Plan with a review date of 10/11/2023 revealed resident is at risk for falls due to diagnosis of left Hemiplegia secondary to Cerebrovascular Accident with approaches to remind resident not to ambulate or transfer without assistance.
Resident #5
Review of Resident #5's medical record revealed an admit date of 06/30/2023 with diagnoses which included: Depression Unspecified, Bipolar Disorder, Paranoid Schizophrenia, Diabetes due to underlying condition with Kidney condition, Chronic Kidney Disease, Dialysis, and Secondary Hypertension.
Review of Resident #5's AM5 MDS with an ARD of 07/07/2023 revealed resident had a BIMS score of 5 (indicating severe cognitive impairment), and was coded as requiring no set up or help from staff with bed mobility, transfers, locomotion on unit, and toilet use; supervision needed for bathing. Resident #5's MDS revealed he had no impairment to upper or lower extremities.
Review of Resident #5's Baseline Care Plan revealed Mental Health needs for Schizoaffective Disorder, Bipolar and Depression with concerns for intellectual deficits.
Review of an incident report dated 07/20/2023 at 3:40 p.m. read in part . S3 LPN heard Resident #4 hollering for help in the TV room. Resident #5 came walking down hallway and punched Resident #4 then got him a choke hold and threw him to the floor. Resident #5 was quickly diverted from situation and sat on the floor. Resident #4 was lying on the floor with his wheelchair turned over, had complaints of pain 7/10 to his head and neck. Orders obtained to send Resident #4 to the ER for evaluation and treatment. Resident #5 placed on 1:1 supervision after incident.
Interview on 08/29/2023 at 9:17 a.m. with S2 DON revealed on 07/20/2023 Resident #5 came out of his room into the dayroom and was mumbling he was going to hit Resident #4. A this time Resident #4 came out of his room and Resident #5 proceeded to hit Resident #4 on the head with his fist and dragged him by the neck out of his wheelchair. S2 DON stated both residents were separated and assessed. S2 DON stated Resident #4 went out to the ER and Resident #5 was placed on 1: 1 supervision, and then later went to the ER. S2 DON stated Resident #5 did not return back to the facility after incident.
Review of Resident #4's hospital progress notes dated 07/20/2023 read in part .Contusion to the scalp, cervical and lumbar sprain. Lortab 10 MG PO now and discharge to return to Nursing Home with follow up tomorrow with primary care physician.
Observation and interview on 08/29/2023 at 2:15 p.m. revealed Resident #4 sitting in his room in a wheelchair. Resident #4 stated he remembered the altercation with Resident #5 on 07/20/2023. Resident #4 stated he had left out of his room to go to the dayroom to watch television. Resident #4 stated as soon as he reached the dayroom, Resident #5 jumped up from the sofa and grabbed him by his neck and pulled him from the wheelchair. Resident #4 stated he hit the back of his head on the floor and went out to the ER because his head was hurting. Resident #4 stated he had not seen Resident #5 since that day.
Interview on 08/29/2023 at 4:08 p.m. with S3 LPN revealed on the evening of 07/20/2023 she was in her office and heard Resident #4 say someone help me. S3 LPN stated she stepped into the hallway and could see Resident #4 on the floor with his wheelchair turned over and Resident #5 was sitting on the floor leaned against the wall. S3 LPN stated Resident #4 stated Resident #5 caught him by the neck and pulled him out of his wheelchair causing him to hit the back of his head on the floor. S3 LPN stated both residents were assessed at that time and Resident #5 was immediately put on 1:1 supervision; and Resident #4 was sent to the ER.
Interview on 08/30/2023 at 12:45 p.m. with Resident #6 who had a BIMS score of 15 (indicating intact cognition) revealed he was in the dayroom on 07/20/2023 when the altercation between Resident #4 and Resident #5 occurred. Resident #6 stated Resident #4 came out of his room in his wheelchair to the dayroom and Resident #5 who was sitting on the sofa in the dayroom, jumped up from the sofa and went over to Resident #4 and grabbed him around his neck and pulled him from the wheelchair to the floor.
Interview on 08/30/2023 at 1:45 p.m. with Resident #7 who had a BIMS score of 12 (indicating moderately impaired cognition) revealed he was in the dayroom on 07/20/2023 when the altercation between Resident #4 and Resident #5 occurred. Resident #7 stated Resident #4 was sitting in his wheelchair in the dayroom when Resident #5 got up from the couch and told Resident #4 you ain't going to fool with me. Resident #7 stated Resident #5 then grabbed Resident #4 around his neck and pulled him from his wheelchair to the floor.
Interview on 08/31/2023 at 9:00 a.m. with S1 Administrator confirmed Resident #4 was a victim of resident to resident physical abuse by Resident #5 on 07/20/2023.
Apr 2023
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
Resident #6
Interview and observation on 04/17/2023 at 10:14 a.m. revealed Resident #6's Geriatric Chair cushion had multiple tears on the corners and top portion of cushion, making it non-intact. Res...
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Resident #6
Interview and observation on 04/17/2023 at 10:14 a.m. revealed Resident #6's Geriatric Chair cushion had multiple tears on the corners and top portion of cushion, making it non-intact. Resident #6 stated she gets out of bed with assistance and uses her Geriatric Chair at least three times per week.
Observation on 04/18/2023 at 9:15 a.m. revealed Resident #6 lying in bed with Geriatric Chair positioned in her room near the door. The Geriatric Chair was noted to have multiple tears on the corners and top portion of cushion.
Observation on 04/19/2023 at 11:50 a.m. revealed Resident #6 was sitting up in her Geriatric Chair in the dining room. Interview conducted with S2 DON at time of observation. S2 DON confirmed that after inspecting the Geriatric Chair for Resident #6, the Geriatric Chair was in need of repairs and or needed to be replaced.
Based on observations and interviews the Facility failed to maintain a safe, clean, sanitary and comfortable homelike environment for Residents. The Facility failed to ensure:
1.
Equipment was in good repair for Hall #1 Whirlpool and Resident #6
2.
Privacy curtains were clean and maintained in a sanitary manner
This deficient practice had the potential to affect all 57 Residents who resided in the Facility.
Findings:
Hall #1 Whirlpool
Observation of Hall #1 Whirlpool on 04/19/2023 at 11:43 a.m. revealed the whirlpool cushion and back rest were damaged with a piece of cushion missing from the back rest and seat exposing internal foam and metal.
Staff interview with S2 DON on 04/19/2023 at 2:12 p.m. confirmed the cushions on the backrest and seat of whirlpool chair were missing parts of the cushion exposing metal and were in need of replacement to ensure the safety of residents who use the whirlpool.
#24
Observation on 04/17/23 at 10:05 a.m. of Resident #24's room revealed a privacy curtain hanging next to Resident #24's bed. The privacy curtain was noted to have several large rust colored stains as well as several stains that appeared to be dried blood.
Observation on 04/18/23 at 9:08 a.m. of the privacy curtain in Resident #24's room revealed multiple stained areas that appeared to be dried blood stains and several larger, rust colored circular stains.
Observation on 04/18/2023 at 11:49 a.m. of Resident #24's room accompanied by S6 CNA revealed the stained privacy curtain was still present. S6 CNA confirmed the stains appeared to be dried blood and S6 CNA stated was not sure what the larger, rust colored stains were.
Interview on 04/18/2023 at 11:55 a.m. with S4 LPN confirmed the privacy curtain stains were visible from the door, appeared to blood and should have been removed.
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 observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maint...
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Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 2 (Resident #13 and Resident #21) of 23 Residents sampled.
Findings:
Review of the facility policy titled: Fingernail/Toenail Care, revealed in part . Nail care includes daily cleaning and regular trimming.
#13
Review of Resident #13's Comprehensive Plan of Care revealed in part
Risk for decline in ADL functions related to debility due to diagnosis of Dementia.
Observation on 04/18/2023 at 1:24 p.m. of Resident #13's bilateral feet during a wound observation accompanied by S4 LPN revealed the nails on Resident #13's bilateral fourth toes were 1/2 inch in length or longer and jagged. S4 LPN confirmed the findings at the time of observation and stated Resident #13's toenails needed to be trimmed.
Review of Resident #13's 04/2023 TAR (Treatment Administration Record) revealed in part .
Diabetic Nailcare to be performed 2x monthly and prn per nurse. Review of the TAR also revealed Resident #13 received wound care to the right foot on 04/14/2023 and 04/17/2023.
Interview on 04/18/2023 at 1:33 p.m. with S2 DON confirmed Resident #13's needed to be trimmed. S2 DON also confirmed Resident #13's toenails should have been trimmed when wound care to the Resident's right foot was performed on 04/14/2023 or 04/17/2023 and had not been.
#21
Review of Resident #21's Comprehensive Plan of Care revealed in part
Resident requires assistance with all ADL's secondary to Chronic Obstructive Pulmonary Disease, Heart Failure.
-Staff to ensure resident is clean, dry and well kept daily.
Observation on 04/17/23 at 09:49 a.m. revealed Resident #21 awake in bed with feet uncovered. Resident #21's toenails were noted be long, thickened and jagged in appearance.
Observation on 04/18/2023 at 9:03 a.m. revealed Resident #21 awake in bed conversing with therapy staff. Resident #21's toenails remain long, thick and jagged. Bilateral great toenails were approximately 1/2 inch in length.
Observation on 04/18/2023 at 1:40 p.m. accompanied by S4 LPN revealed Resident #21's toenails were long, thick, jagged and needed to be cut.
Interview on 04/18/2023 at 1:41 p.m. with S6 CNA and review of the pocket care guide revealed there was no information about nail care for Resident #21.
Review of Resident #21's Physicians Orders, Pocket Care Guide and TAR revealed no orders for nail care.
Observation on 04/18/2023 at 1:42 p.m. of Resident #21 accompanied by S2 DON confirmed the observations of Resident #21's toenails. S2 DON confirmed Resident #21 had not received toenail care regularly and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the Facility failed to provide activities designed to meet the interest of and support the physical, mental and psychosocial well-being for 1 (Reside...
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Based on observation, interview and record review, the Facility failed to provide activities designed to meet the interest of and support the physical, mental and psychosocial well-being for 1 (Resident #29) of 21 sampled Residents by failing to provide activities according to a Residents' person- centered care plan.
Findings:
Review of the Facility's policy titled Activities and Social Events read in part .
5. The activity program is to be designed to encourage restoration to self-care and maintenance of normal activity which is geared to the individual residents' needs.
14. The following records, as a minimum, are maintained by activity department personnel:
A. Activities/Recreation Services Assessment
B. Attendance records
C. Calendar of Events
D. Interdisciplinary progress notes
E. Record of reviews and updates
F. Other recordkeeping reports as necessary and appropriate
Review of Resident #29's medical record revealed an admit date of 02/13/2023 with diagnoses which included: Anxiety Disorder, Major Depressive Disorder, Shortness of Breath and Acute and Chronic Respiratory Failure with Hypoxia.
Review of Resident #29's care plan with a target date of 06/09/2023 revealed a potential for social isolation related to Resident #29 prefers to stay in her room but RAD (Resident Activities Director) will provide in-room activities such as one on one visit, music therapy, bible reading and watching with interventions to document resident response to interventions, provide in-room activities and supplies for resident and post activity calendar in room.
Review of Resident #29's admissions MDS with an ARD of 02/20/2023 revealed a BIMS score of 9 (indicating moderately impaired cognition), Section F-preferences for customary routine and activities-not assessed. Resident #29 required extensive assistance of 2 persons with bed mobility, transfers and toileting; Total dependence for bathing.
Observation on 04/17/2023 at 9:46 a.m. revealed Resident #29 in bed with her husband at her bedside. Resident #29 stated she did not participate in activities because she did not know about them. Observation at time of interview revealed no activity calendar posted in Resident #29's room. Resident #29's husband stated sometimes they announce things over the intercom but my wife can't distinguish what is being said.
Record review revealed no documentation of participation or activity notes for Resident #29.
Interview on 04/18/2023 at 2:07 p.m. Interview with S13 RAD revealed she had been Activities Director since December 2022. S13 RAD stated for new admits she completed an activity/recreation service assessment to determine activity preferences past and present. S13 RAD stated there were currently no activity calendars in Residents' rooms because they are still at the printing shop (outside vendor). S13 RAD revealed she had not been documenting Resident participation in activities.
Observation and interview on 04/19/2023 at 9:12 a.m. revealed Resident #29 in her room sitting in a wheelchair with her hand under her chin. Observation revealed no music or television was on, and no activity calendar in room. Resident #29 revealed staff does not do any in-room activities with her and she does not go to outside activities.
Telephone interview on 04/19/2023 at 9:50 a.m. with Resident #29's husband revealed he visits his wife several times every day and had never witnessed any staff in Resident #29's room doing activities with his wife.
Interview on 04/19/2023 at 10:10 a.m. with S13 RAD revealed she had not done any in-room activities with Resident #29 and had no documentation of Resident #29's participation in any activities.
Interview on 04/19/2023 at 10:17 a.m. with S1 Administrator revealed she was aware of the Facility not having activity calendars posted. S1 Administrator stated the Facility uses an outside vendor for printing the calendars and the vendor had not gotten the calendars back in a timely manner. S1 Administrator revealed she was not aware of Residents participation in activities not being documented and confirmed they should have been documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the Facility failed to ensure 1 (Resident #13) of 1 sampled Residents reviewe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the Facility failed to ensure 1 (Resident #13) of 1 sampled Residents reviewed for Pressure Ulcers, received the necessary treatment and services to prevent and promote the healing of pressure ulcers. The Facility failed to implement preventive measures for pressure ulcers timely.
Findings:
Review of the clinical record revealed Resident #13 admitted to the facility on [DATE] with diagnoses that included Vascular dementia, and Type II Diabetes Mellitus.
Review of Resident #13's 04/2023 Treatment Administration Record revealed Resident #13 received treatments to an Unstageable wound to the left inner buttock as well as treatments to arterial ulcers on Resident #13's right lateral malleolus and right lateral midfoot.
Observation on 04/17/23 at 10:11 a.m. revealed Resident #13 seated in a geri-chair in the activity room of the secure unit. Resident #13 was observed wearing a blue shirt, grey sweat pants and socks. No heel protectors observed in use.
Observation on 04/18/2023 at 8:59 a.m. revealed Resident #13 asleep in a reclined geri-chair in the secure unit, day area. Resident #13 was observed wearing a burgundy shirt, grey sweatpants and striped socks, no heel protectors observed in use.
Observation on 04/18/2023 at 1:24 p.m. of Resident #13's right foot accompanied by S4 LPN revealed intact dressings to Resident #13's right malleolus and right lateral foot. Observation of Resident #13's left foot revealed the presence of an intact blister on the left medial heel. Interview with S4 LPN at the time of observation revealed she was not aware Resident #13 had a blister on his left heel. S4 LPN stated she had performed Resident #13's body audit last week and had not observed any skin impairments on Resident #13's left heel. S4 LPN stated Resident #13 had been seen by a wound care Practitioner last week. No heel protectors were observed in use at this time.
Interview on 04/18/2023 at 3:15 p.m. with S5 Unit Manager revealed Resident was seen by nurse practitioner from a wound care clinic last Friday (04/14/2023). S5 Unit Manager stated the nurse practitioner ordered antibiotics for Arterial Ulcers on Resident #13's rights foot. S5 Unit Manager stated the nurse practitioner assessed Resident #13's left foot on 04/14/2023 and the left heel was red at the time but blanching. S5 Unit Manager stated treatment orders were given for the right foot and an US was recommended to evaluate RLE vascularity. S5 Unit Manager stated the only interventions recommended for Resident #13's left heel on 04/14/2023 was heel protectors.
Observation on 04/18/2023 at 3:30 p.m. revealed Resident #13 asleep on bed. No heel protectors observed in use.
Review of a wound care progress note dated 04/14/2023 and documented by S8 NP revealed recommendations that included: no circumferential tape. Offload/reposition Q2HWA (every 2 hours while awake), low air loss mattress and heel protectors.
Interview on 04/18/2023 at 3:35 p.m. with S4 LPN confirmed Resident #13 did not have heel protectors in use. S4 LPN stated she was unaware of Resident #13 ever wearing heel protectors or that he needed any.
Interview on 04/18/2023 at 3:40 p.m. with S6 CNA and S7 CNA revealed Resident #13 did not have heel protectors on his pocket care guide nor were they aware he was supposed to be wearing any. S6 CNA and S7 CNA stated they had never seen heel protectors on Resident #13's feet.
Interview on 04/18/2023 at 3:52 p.m. with S5 Unit Manager confirmed she did not transcribe the recommendation for heel protectors written on 04/14/2023 and should have. S5 Unit Manager stated she overlooked the recommendation.
Interview on 04/19/2023 at 2:57 p.m. with S8 NP revealed the resident had blanchable redness along the medial side of left foot and heel when examined on 04/14/2023. S8 NP revealed he felt the blister formation was vascular in origin. S8 NP confirmed heel protectors should have been implemented as a preventive measure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that a Resident maintained sufficient fluid intake to maintain proper hydration and health by failing to follow physic...
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Based on observation, interview, and record review, the facility failed to ensure that a Resident maintained sufficient fluid intake to maintain proper hydration and health by failing to follow physicians orders for 1 (#259) of 1 Resident reviewed for hydration. The total sample size was 21.
Findings:
A review of the facility's policy titled: Tube Feeding read in part . Residents with a Nasogastric, Gastrostomy, or Jejunostomy tube will be provided nutrition and hydration via the feeding tube.
2. Check Physicians orders and/or treatment record for amount and type of feeding.
12. Document amount of each water flush given in cc's. The 24-hour total amount of H20 flush will also be documented on the Physician's Orders for Tube Feed Administration Record.
A review of Resident #259's record revealed an admit date of 03/17/2023 and a readmit date of 04/05/2023 with diagnoses that included in part . Acute Respiratory Failure, Paranoid Schizophrenia, Anxiety, Dementia, Neuromuscular Dysfunction of Bladder, Major Depressive Disorder, and Epilepsy.
A review of Resident #259's Minimum Data Set with an ARD date of 03/24/2023 revealed in part . Resident #259's cognitive patterns were not assessed. Resident #259 was totally dependent when eating and Resident #259 had a feeding tube. Resident #259 required special treatments for oxygen therapy, suctioning, trach care, and mechanical ventilation.
A review of Resident #259's care plan revealed in part . Resident is at risk for impaired nutritional status and fluid maintenance secondary to NPO. Resident has PEG tube. Approaches included in part . Flush peg with 30cc of water before and after meds/feedings. Flush tube feeding with 240mls of water every 4 hours.
A review of Resident #259's April 2023 physician's orders revealed in part .
NPO Status 4/5/23.
Glucerna 1.5 @ 45ml/hr continuous for 22 hours and off for 2 hours. 4/5/23
Flush peg tube with 30cc of water before and after medications. 4/5/23
Flush tube feeding with 240ml water every 4 hours. 4/5/23
Observation of Resident #259 on 04/17/2023 at 10:20 a.m. revealed Resident was receiving tube feeding via pump at 45ml/hr, and a flush was set on pump for 50ml every 2 hours. Resident was observed with dry lips and dry mouth.
Interview on 04/18/2023 at 9:00 a.m. with S10 LPN revealed Resident #259 was fairly new to the facility and had a hospitalization from 03/29/2023- 04/05/2023 due to Resident having fever and dehydration. S10 LPN stated Resident #259 received nutrition and hydration via peg tube. S10 LPN stated Resident #259 is to receive flushes at the amount that is currently set via pump (50ml every 2 hours). S10 LPN stated he gives Resident #259 medications via peg tube and administers flushes of 30cc before and after medication.
Observation on 04/18/2023 at 9:08 a.m. revealed Resident #259 awake lying in bed, non-verbal due to trach. Resident #259 was receiving feedings via peg tube at a rate of 45ml/hr. H20 flush bag observed and Resident's pump was set to receive flushes at a rate of 50ml every 2 hours.
Observation on 04/19/2023 at 09:00 a.m. revealed Resident #259 was awake lying in bed. Resident was observed receiving tube feeding via pump at a rate of 45ml/hr. H20 flush bag observed and pump was set for 50ml flush every 2 hours.
Interview with S11 LPN on 04/19/2023 at 12:01 p.m. revealed Resident #259 was receiving tube feeding via pump at 45ml/hr, and H20 flushes at 50ml every 2 hours. S11 LPN stated she would have to double check the physician's orders, but the settings observed on the pump should be correct. S11 LPN stated she does not always check the settings programed on the pump against the physician's orders when she assumes care of Resident, but she should. S11 LPN confirmed she did not check the current physicians order for Resident #259's flushes, and the amount of fluid Resident was receiving via pump was incorrect.
Interview with S2 DON on 04/19/2023 at 12:06 p.m. revealed Resident #259 was receiving tube feeding at a rate of 45ml/hr and H20 flushes were set at a rate of 50ml every 2 hours via pump. S2 DON confirmed nursing staff should check the settings on pump according to the current physician's order or MAR. S2 DON confirmed the flushes should be set at the current physician's orders, and it was not.
Interview with S2 DON on 04/19/2023 at 2:15 p.m. revealed Resident #259's April 2023 intakes recorded were less than the amount ordered by physician, and the intakes were not consistently documented by staff according to facility policy. S2 DON confirmed the documented intake amounts were less than what physician ordered, and there were no documented intakes provided by night shift, but there should be.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation and interview the Facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of h...
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Based on observation and interview the Facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #8) out of a total or 21 sampled Residents by failing to ensure a Resident had adequate clothing.
Findings:
Review of Resident #8's medical record revealed an admit date of 09/06/2021 with diagnoses which included: Schizoaffective Disorder Bipolar Type, Anxiety Disorder, Anemia, and Pain Unspecified.
Review of Resident #8's Care Plan with an onset date of 04/22/2022 revealed a potential for social isolation related to impaired physical mobility, with interventions to accommodate Residents' limited mobility to enable participation in activities outside of her room when possible.
Review of Resident #8's MDS with an ARD of 03/09/2023 revealed a BIMS score of 9 (indicating moderately impaired cognition), and required extensive assistance of 2 persons for bed mobility and transfers. Dressing and personal hygiene not assessed.
Observation and interview on 04/17/2023 at 10:32 a.m. revealed Resident #8 in bed with a hospital gown on. Resident stated she would like to have on clothes but did not have any. Observation of Resident #8's closet revealed no clothes. S12 CNA stated Resident #8 came from a shelter over a year ago and did not have any clothes.
Observation on 04/18/2023 at 8:55 a.m. revealed Resident #8 in bed with a hospital gown on.
Interview on 04/18/2023 at 8:57 a.m. with S10 LPN revealed he provided care for Resident #8. S10 LPN stated Resident #8 did not have any clothes and the facility had not provided her with any. S10 LPN revealed Resident #8 always had on a hospital gown when he provided care for her.
Interview on 04/18/2023 at 9:01 a.m. with S12 CNA revealed Resident #8 participated in bingo sometimes and wore a hospital gown with a sheet around her to play.
Interview on 04/18/2023 at 9:10 a.m. with S5 LPN and S2 DON revealed Resident #8 had family who the facility can contact at times. S5 LPN stated Resident #8 gets up in a Geri-chair sometimes and when up she is in a hospital gown. S5 LPN confirmed Resident #8 did not have any personal clothes to wear. S2 DON confirmed Resident #8 should have personal clothes to wear.
Feb 2023
4 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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
#5
Review of Resident #5's clinical record revealed an admission date of 09/10/2021 with diagnoses that included: Chronic Respiratory Failure with Hypoxia, Encounter for Attention to Tracheostomy, Mus...
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#5
Review of Resident #5's clinical record revealed an admission date of 09/10/2021 with diagnoses that included: Chronic Respiratory Failure with Hypoxia, Encounter for Attention to Tracheostomy, Muscular Dystrophy, and Paroxysmal Atrial Fibrillation.
Review of Resident #5's Significant Change MDS with an ARD of 01/02/2023 revealed a BIMS of 15 indicating intact cognition. Resident #5 required oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilation.
Review of Resident #5's 02/2023 Physician's orders revealed the following in part .
12/07/2021 Ok to change trach to #6 Shiley cuffed when changed Q3months and PRN
12/17/2021 Vent Setting: AC 500/16/+5
04/05/2022 Change #6 Shiley inner cannula BID and PRN
Review of Resident #5's Care Plan with a Target Date of 03/30/2023 revealed a problem of potential for inadequate airway exchange due to history of respiratory failure. Approaches included change #8 Shiley trach Q3months and PRN, Change #8 inner cannula Qshift and PRN, and vent setting: 400/18/+5.
Interview on 02/22/2023 at 9:55 a.m. with S5 LPN revealed Resident #5's care plan read to change #8 Shiley trach, Change #8 inner cannula, and vent setting: AC 400/18/+5 and Resident #5's orders were for a #6 Shiley and vent setting: AC 500/16/+5. S5 LPN confirmed Resident #5's care plan was not updated when the orders were changed, but should have been.
Based on interview and record review, the facility failed to ensure the Comprehensive Resident Centered Plan of Care was reviewed and revised for 2 (Resident #4 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.
Findings:
#4
Review of Resident #4's clinical record revealed an admit date of 09/09/2022. Resident #4 was noted to have diagnoses that included: Schizoaffective Disorder Bipolar Type, Epilepsy, Type II Diabetes Mellitus, Anxiety Disorder, Hyperlipidemia, unspecified Atrial Flutter, and Essential Hypertension.
Review of Resident #4's Comprehensive Plan of Care with target date of 03/30/2023 revealed Resident #4 was at risk for abnormal bleeding and bleeding related to taking Eliquis. Approaches included administering medications as ordered by physician and observe for and document any adverse side effects.
Review of Resident #4's February 2023 Medication Administration Records revealed there were no orders for or administration of Eliquis or any other anticoagulants. A monitor for signs and symptoms of bruising and bleeding such as tarry stools, bright red urine or coffee ground emesis was noted on Resident #4's MAR.
Review of hospital discharge orders dated 12/27/2022 revealed instructions to discontinue Eliquis.
Interview on 02/20/2023 at 3:00 p.m. with S3 Corporate RN revealed Resident #4's Eliquis had been discontinued on 12/27/2022. S3 Corporate RN confirmed Resident #4's Care Plan and MAR had not been updated to reflect Resident #4 was no longer on the anticoagulant Eliquis and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure that a Resident received treatment and care in accordance with professional standards of practice and the Comprehensive Person-Center...
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Based on interview and record review the facility failed to ensure that a Resident received treatment and care in accordance with professional standards of practice and the Comprehensive Person-Centered Care Plan for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled Residents. The facility failed to ensure Physician's Orders for wound care were transcribed and implemented.
Findings:
Review of Resident #3's Clinical Record revealed an admit date of 11/09/2022 and a readmit date of 01/27/2023. Resident #3 was noted to have the following diagnoses: Hemiplegia following Cerebral Infarction, Dysphagia following Cerebral Infarction, Aphasia following Cerebral Infarction, Acute Respiratory Failure with Hypoxia, Encephalopathy, Contractures, Permanent Atrial Fibrillation, GERD, and Tracheostomy.
Review of wound care clinic note dated 02/01/2023 revealed in part .
Head (Right side) unstageable 2.4cm x 1.5cm x 0.1cm.
Dressing to be changed daily and prn soiled or non-intact.
Cleanse wound with wound cleanser or saline.
Apply Betadine to wound bed.
Cover with ABD padding and secure with tape.
Review of Resident #3's February 2023 TAR and Physician's orders revealed no orders for Betadine to Resident #3's head or documented treatment administrations of Betadine to Resident #3's head.
Interview on 02/20/2023 at 1:00 p.m. with S7 Treatment Nurse revealed she had not transcribed Resident #3's wound care orders for Betadine to her head on 02/01/2023 and should have. S7 Treatment Nurse confirmed there was no documentation that treatments had been applied as ordered from 02/01/2023 through 02/16/2023 to Resident #3's right posterior head wound.
Interview on 02/20/2023 at 1:10 p.m. with S4 MD revealed all orders received from the wound care clinic provider should be transcribed upon the Residents return to the facility and implemented as ordered.
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure essential respiratory equipment was maintained in safe operating condition according to the manufacturer's recommendat...
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Based on observation, interview, and record review, the facility failed to ensure essential respiratory equipment was maintained in safe operating condition according to the manufacturer's recommendations for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.
Findings:
Review of the user manual titled Invacare Perfecto2 V Oxygen Concentrator revealed in part
7.3 Cleaning the Cabinet Filter
Caution
Risk of Damage
To avoid damage to the internal components of the unit:
Do not operate the concentrator without the filter installed or with a dirty filter.
There is one cabinet filter located on the back of the cabinet.
Review of Resident #2's clinical record revealed an admission date of 06/10/2022 with diagnoses that included: Heart Failure, Atrial Fibrillation, Type 2 Diabetes Mellitus, and Chronic Kidney Disease Stage 3.
Review of Resident #2's 02/2023 Physician Orders revealed an order for Oxygen 2 L- 4 LPM via NC with an order date of 02/13/2023.
Observation on 02/15/2023 at 1:45 p.m. revealed Resident #2 was lying in bed with oxygen in progress via nasal cannula with the use of an Invacare Oxygen Concentrator. There was no cabinet filter on the back of the concentrator.
Observation on 02/16/2023 at 2:10 p.m. revealed Resident #2 was lying in bed with oxygen in progress via nasal cannula with the use of an Invacare Oxygen Concentrator. There was no cabinet filter on the back of the concentrator.
Observation on 02/17/2023 at 10:11 a.m. revealed Resident #2 was lying in bed with oxygen in progress via nasal cannula with the use of an Invacare Oxygen Concentrator. There was no cabinet filter on the back of the concentrator.
Observation on 02/17/2023 at 10:25 a.m. accompanied by S9 LPN revealed Resident #2 had oxygen in progress via nasal cannula with the use of an Invacare Oxygen Concentrator and the concentrator did not have a cabinet filter on the back. Interview at that time with S9 LPN confirmed there was no filter on the oxygen concentrator, but there should have been. S9 LPN stated she was not sure who handled the filters for the oxygen concentrators.
Interview 02/17/2023 at 1:00 p.m. with S10 RRT revealed Respiratory Therapists were responsible for making sure the filters were in place on all of the oxygen concentrators in the facility.
Observation on 02/17/2023 at 1:07 p.m. accompanied by S10 RRT in Resident #2's room revealed the Invacare Oxygen Concentrator that was in use did not have a cabinet filter on the back. Interview at that time with S10 RRT confirmed there was no filter on the back, but there should have been.
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
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 observation, record review and interview, the facility failed to ensure 1 (Resident #3) of 5 (Resident #1, Resident #2,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled Residents reviewed for Quality of Care/Treatment, received the necessary treatment and services to prevent and promote the healing of pressure ulcers by:
1. Failing to implement treatment for pressure ulcers timely.
2. Failing to follow Physician's orders for treatment to pressure ulcers.
3. Failing to follow policy and procedures for wound treatment/assessment.
4. Failing to implement infection control practices during treatment of a pressure ulcer.
Findings:
Review of the facility policy titled: Guide for wound evaluation revealed in part .
5. Evaluate further interventions that may be indicated to promote healing and prevent infection (See pressure ulcer intervention guide & Support Surface Algorithm).
Review of the facility's Mattress Selection Algorithm revealed in part .
Full thickness. Stage 3 and 4, Multiple 3, 4, Flap/Graft. New: Panacea Convertible (direct supply); Pressure Guard APM2 (Span America).
Review of Resident #3's Clinical Record revealed admit date of 11/09/2022 and a readmit date of 01/27/2023. Resident #3 was noted to have the following diagnoses: Hemiplegia following Cerebral Infarction, Dysphagia following Cerebral Infarction, Aphasia following Cerebral Infarction, Acute Respiratory Failure with Hypoxia, Encephalopathy, Contractures, Permanent Atrial Fibrillation, GERD, and Tracheostomy.
Review of Resident #3's admit skin assessment dated [DATE] revealed Resident #3 had a Stage 3 pressure ulcer to the Sacrum measuring 3.5cm x 4.0cm x 3cm and a Stage 3 pressure ulcer to the Left Hip measuring 4.8cm x 5cm x 2cm.
Review of Resident #3's Comprehensive Plan of Care with a target date of 02/28/2023 revealed Resident #3 had altered skin integrity related to pressure ulcers. Approaches included administering treatments as ordered by the physician and document.
Observation on 02/15/2023 at 12:35 p.m. revealed S8 CNA entered Resident #3's room and proceeded to reposition Resident #3. Interview with S8 CNA at the time of observation revealed Resident #3 had an abscess on the back of her head, a break on her right inner ear, and a wound on her right hip. Further observation of Resident #3 revealed an undressed wound to Resident #3's right posterior head and an undressed wound to Resident #3's right inner ear.
Review of Resident #3's February 2023 Treatment Administration Record revealed the following orders :
Cleanse area of trauma to RLE shin with w/c or normal saline. Pat dry, apply Manuka soaked gauze to wound bed, cover with abdominal pad and secure with tape. Change q day and prn until resolved. Order date 02/01/2023.
Cleanse Stage 4 to Sacrum with w/c or normal saline, pat dry, apply Manuka soaked gauze to wound bed, cover with abdominal pad and secure with tape. Change q day and prn until resolved. Order date 02/01/2023.
Cleanse Stage 3 to right ear with wound cleanser or normal saline, pat dry, apply calcium alginate and Manuka to wound bed, cover with abdominal pad and secure with tape. Change q day and prn until resolved. Order date 02/01/2023.
Cleanse Stage 3 to left hip with wound cleanser or normal saline, pat dry, apply calcium alginate and Manuka to wound bed, cover with abdominal pad, secure with tape, change q day and prn until resolved. Order date 02/01/2023.
Cleanse Stage 4 to Right hip with wound cleanser or normal saline, pat dry, apply Manuka soaked gauze to wound bed, cover with abdominal pad and secure with tape. Change q day and prn until resolved. Order date 02/01/2023.
Observation on 02/16/2023 at 2:45 p.m. of wound care performed by S6 LPN and S5 LPN Unit Manager revealed as follows . S6 LPN removed dressing from Resident #3's left hip revealing a large circular wound with an eschar wound bed. S6 LPN removed his gloves, placed the soiled dressing inside the gloves and placed the soiled dressing and gloves on Resident #3's chest of drawers. S6 LPN donned new gloves and swabbed Resident #3's left hip wound with betadine and applied a border dressing. At 3:04 p.m. S6 LPN donned a new pair of gloves and removed the dressing from Resident #3's right ankle/shin area. S6 LPN then removed his gloves and placed the soiled dressing in the soiled gloves and placed them on Resident #3's over-bed table. S6 LPN applied a clean pair of gloves and cleansed Resident #3's ankle wound with wound cleanser, applied Manuka and calcium alginate and covered the wound with a border gauze. At 3:20 p.m. S6 LPN donned gloves and removed the dressing from Resident #3's sacrum revealing a large wound with slough, tunneling and undermining from 12 to 12 positions. S6 LPN removed his soiled gloves and placed the soiled sacral dressing and gloves on a pillow at the foot of Resident #3's bed. S6 LPN donned new gloves, cleansed the sacral wound with wound cleanser, applied Manuka honey, gauze and covered the wound with a border dressing. At 3:27 p.m. S5 LPN Unit Manager, assisted with repositioning Resident #3 onto her left side. S6 LPN then removed the dressing on Resident #3's right hip revealing a large circular wound with foul odor and yellow drainage. S6 LPN removed his soiled gloves and placed the gloves and soiled dressing on the bed pad underneath Resident #3. S6 LPN donned another pair of gloves and applied a treatment of Dakins soaked gauze left in place for 10 minutes, followed by Manuka honey, gauze and a cover dressing. At 3:45 p.m. S6 LPN donned new gloves and cleaned Resident #3's right ear and right posterior head with wound cleanser and a foam dressing was applied to both areas. Interview at the time of observation with S6 LPN and S5 LPN Unit Manager revealed Resident #3 did not have treatment orders for her right ear and posterior head wounds. S6 LPN stated a foam dressing was applied to prevent friction to the areas. At 3:54 p.m. S6 LPN and S5 LPN Unit Manager performed incontinent care on Resident #3 and repositioned the resident. At 3:56 p.m. peg tube site care was performed by S6 LPN. At 3:58 p.m. soiled dressing and gloves were removed from the pillow at the foot of the bed by S6 LPN. S5 LPN Unit Manager then picked up the pillow and placed the pillow under the feet of Resident #3. The soiled dressings were then picked up from Resident #3's bedpad, overbed table and chest of drawers and thrown away by S6 LPN. At 3:50 p.m. Resident #3 was covered by S5 LPN Unit Manager.
Interview on 02/16/2023 at 4:30 p.m. with S5 LPN Unit Manager, revealed Resident #3 did not receive pressure ulcer treatments as ordered to her Right Ear and RLE. S5 LPN Unit Manager confirmed there were currently no treatment orders on the TAR or Physician's orders for the wound on Resident #3's posterior head in accordance with her wound clinic treatment orders dated 02/14/2023 and there should be. S5 LPN Unit Manager confirmed infection control practices had not been followed during Resident #3's wound care. S5 LPN confirmed that all soiled gloves and dressings should have been placed in a red biohazard bag for disposal after removal and not placed on any surfaces in Resident #3's room.
Review of wound clinic progress notes revealed Resident #3 received wound care to the following areas on 02/14/2023: Right Ear Pressure Ulcer Stage 3, Sacrum Pressure Ulcer Stage 4, Left hip, Right hip (Pressure Ulcer Stage 4), Right lower shin, Head right side Unstageable. Further review revealed the following wound care orders:
Wound #1 Location: Right ear (Pressure ulcer stage 3) 2.2 cm x 0.6cm x 0.2cm, Wound #9 Location: Head (right side) Unstageable 1.8cm x 1.4cm x 0.2cm.
Dressings to be changed daily and prn soiled or non-intact.
Cleanse wound with wound cleanser or saline.
Apply Calcium Alginate with Manuka to wound bed.
Cover with ABD dressing, Secure with tape.
Wound #8 Location; Right hip (Pressure ulcer Stage 4) 4.0cm x 5.0cm x 2.6cm, undermining 12-12 at 6.0 cm.
Dressing to be changed daily and prn soiled or non-intact.
Cleanse wound with wound cleanser or saline.
Apply Dakins soaks for 10 minutes with dressing changes.
Apply Manuka soaked gauze loosely in wound bed.
Cover with ABD padding and secure with tape.
Wound #2 Location: Left hip 3.8cm x 4.9 cm x 0.2cm.
Dressing to be changed daily and prn soiled or non-intact.
Cleanse wound with wound cleanser or saline.
Apply Betadine to wound.
Cover with ABD padding and secure with tape.
Interview on 02/16/2023 at 4:30 p.m. with S5 LPN Unit Manager, revealed Resident #3 did not receive pressure ulcer treatments as ordered to her Right Ear and Right Lower Leg. S5 LPN Unit Manager confirmed there were currently no treatment orders on the TAR or Physician's orders for the wound on Resident #3's posterior head in accordance with her wound clinic treatment orders dated 02/14/2023 and there should be. S5 LPN Unit Manager confirmed infection control practices had not been followed during Resident #3's wound care. S5 LPN confirmed that all soiled gloves and dressings should have been placed in a red bag for disposal after removal and not placed on any surfaces in Resident #3's room.
Interview on 02/16/2023 at 4:50 p.m. with S2 DON revealed the 02/14/2023 wound care orders for treatments to Resident #3's Posterior head did not get transcribed on 02/14/2023. She confirmed the new wound care orders for treatments to Resident #3's posterior head ordered at the 02/14/2023 wound care clinic visit should have been entered and started on 02/15/2023 and they had not been.
Review of wound assessments and TAR's for 01/27/2023-02/16/2023 revealed no documentation of treatment applications to Resident #3's right posterior head.
Review of wound care clinic note dated 02/01/2023 revealed in part .
Head (Right side) unstageable 2.4cm x 1.5cm x 0.1cm.
Dressing to be changed daily and prn soiled or non-intact.
Cleanse wound with wound cleanser or saline.
Apply Betadine to wound bed.
Cover with ABD padding and secure with tape.
Review of the February 2023 TAR and Physician's orders revealed no orders for Betadine to Resident #3's head or documented treatment administrations of Betadine to Resident #3's head.
Interview on 02/20/2023 at 1:00 p.m. with S7 Treatment Nurse revealed she had not transcribed Resident #3's wound care orders for Betadine to her head on 02/01/2023 and should have. S7 Treatment Nurse confirmed there was no documentation that treatments had been applied as ordered from 02/01/2023 through 02/16/2023 to Resident #3's right posterior head wound.
Interview on 02/20/2023 at 1:10 p.m. with S4 MD revealed all orders received from the wound care clinic provider should be transcribed upon the Residents return to the facility and implemented as ordered.
Observation of Resident #3's bed on 02/22/2023 at 10:15 a.m. accompanied by S1 Administrator revealed the presence of a Direct Supply Panacea Support mattress. Interview with S1 Administrator at the time of observation revealed Resident #3 should have been placed on either the Panacea Convertible or Pressure Guard APM 2 mattress on admission due to the presence of multiple stage 3 pressure ulcers.
Interview on 02/22/2023 at 11:00 a.m. with S2 DON confirmed Resident #3 was admitted to the facility with (2) Stage 3 pressure ulcers. S2 DON confirmed that according to facility policy and facility mattress selection algorithm Resident #3 should have been placed on either a Panacea Convertible mattress or Pressure Guard APM 2 mattress on admission and had not been.
Interview on 02/22/2023 at 11:05 a.m. with S3 Corporate Nurse revealed the treatment nurse was responsible for initiating wound care/pressure ulcer prevention orders on admission and she had not.
Interview on 02/22/2023 at 12:40 p.m. with S5 LPN Unit Manager revealed Unit Managers were responsible for performing wound care when the Treatment Nurse was out or unavailable. S5 LPN Unit Manager she brought the Treatment cart and binder with TAR's down the hall with her to perform treatments. S5 LPN Unit Manager stated she reviewed the TARS for orders before gathering supplies and going into the rooms. S5 LPN revealed she had not reviewed the treatment orders before performing wound care on Resident #3 on 02/16/2023 and she should have.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 1 harm violation(s), $38,851 in fines. Review inspection reports carefully.
- • 43 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $38,851 in fines. Higher than 94% of Louisiana facilities, suggesting repeated compliance issues.
- • Grade F (10/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Jena Nursing And Rehabilitation Center, Llc's CMS Rating?
CMS assigns Jena Nursing and Rehabilitation Center, LLC 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 Jena Nursing And Rehabilitation Center, Llc Staffed?
CMS rates Jena Nursing and Rehabilitation Center, LLC's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 62%, which is 16 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Jena Nursing And Rehabilitation Center, Llc?
State health inspectors documented 43 deficiencies at Jena Nursing and Rehabilitation Center, LLC during 2023 to 2025. These included: 1 that caused actual resident harm and 42 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Jena Nursing And Rehabilitation Center, Llc?
Jena Nursing and Rehabilitation Center, LLC 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 NORBERT BENNETT & DONALD DENZ, a chain that manages multiple nursing homes. With 108 certified beds and approximately 67 residents (about 62% occupancy), it is a mid-sized facility located in JENA, Louisiana.
How Does Jena Nursing And Rehabilitation Center, Llc Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Jena Nursing and Rehabilitation Center, LLC's overall rating (1 stars) is below the state average of 2.4, staff turnover (62%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Jena Nursing And Rehabilitation Center, Llc?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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 substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Jena Nursing And Rehabilitation Center, Llc Safe?
Based on CMS inspection data, Jena Nursing and Rehabilitation Center, LLC has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Jena Nursing And Rehabilitation Center, Llc Stick Around?
Staff turnover at Jena Nursing and Rehabilitation Center, LLC is high. At 62%, the facility is 16 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Jena Nursing And Rehabilitation Center, Llc Ever Fined?
Jena Nursing and Rehabilitation Center, LLC has been fined $38,851 across 1 penalty action. The Louisiana average is $33,467. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Jena Nursing And Rehabilitation Center, Llc on Any Federal Watch List?
Jena Nursing and Rehabilitation Center, LLC 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.