COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV
For profit - Limited Liability company
92 Beds
Independent
Data: November 2025
Trust Grade
48/100
#68 of 264 in LA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Courtyard Manor Nurse Care Center & Assisted Living in Lafayette, Louisiana holds a Trust Grade of D, indicating below average care with some concerns. They rank #68 out of 264 facilities in the state, placing them in the top half, and #3 out of 10 in Lafayette County, meaning only two local options are better. While the facility has shown improvement, reducing issues from 13 in 2023 to 8 in 2024, staffing is a weakness with a rating of 2 out of 5 stars and a high turnover rate of 63%, significantly above the state average. A concerning incident involved a resident with diabetes who received inadequate blood glucose monitoring, resulting in a severe health crisis, highlighting potential gaps in care. Despite these issues, the facility has average RN coverage and a fine of $24,065, suggesting some financial penalties but not alarming compared to others in the area.
- Trust Score
- D
- In Louisiana
- #68/264
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 63% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $24,065 in fines. Higher than 89% of Louisiana facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 10 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 25%
Needs review
13 → 8 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 13 issues
2024: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Above Louisiana average (2.4)
Meets federal standards, typical of most facilities
Staff Turnover: 63%
17pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $24,065
Below median ($33,413)
Minor penalties assessed
Staff turnover is elevated (63%)
15 points above Louisiana average of 48%
The Ugly 29 deficiencies on record
1 actual harm
Oct 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure reasonable accommodation of resident's needs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure reasonable accommodation of resident's needs for 1 (#12) out of 29 sampled residents as evidenced by Resident #12's easy touch call light device outside of her reach.
Findings:
On 10/30/2024, a review of the facility's policy titled Call System, Residents with no revision date, read in part residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.
Review of Resident #12's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hemiplegia and Hemiparesis, Non-traumatic Intracranial Hemorrhage Affecting Left Non-dominant Side, Contracture Left and Right hand, and Right Mastectomy.
Review of Resident #12's October 2024 physician's orders revealed an order dated 11/15/2023 which read in part .ensure flat soft touch call bell is within reach at all times, every shift.
Review of Resident #12's comprehensive care plan, dated 11/15/2023, revealed in part, resident bilateral hand contractures. I had a flat soft touch call bell that I was able to use accurately. Intervention - ensure the flat soft touch call bell is within my reach at all time.
On 10/28/2024 at 9:49 a.m., an observation was made of Resident #12's call bell position The soft touch call bell was located on the right side of the resident near her hip. When the resident was asked if she was able to reach her call bell, she stated she did not know where it was. The surveyor pointed to the call bell and the resident stated she was unable to reach it.
On 10/29/2024 at 7:45 a.m., a second observation was made of Resident #12's call bell position. The resident's soft touch call bell was hanging on the bed rail, and not within the resident's reach.
On 10/29/2024 at 7:48 a.m., an observation and interview was conducted with S1ADM (Administrator) who stated the call bell should have been clamped to the resident's sheet to ensure the resident was able to reach and use the call bell. She stated staff should have ensured the resident was able to reach and press the call bell prior to leaving the room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify a resident's representative when a resident had a significa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify a resident's representative when a resident had a significant change in condition for 1 (#18) resident out of 29 sampled residents.
Findings:
A review of the facility's policy titled, Change in a Resident's Condition or Status with a last reviewed date of 03/15/2024, read in part, . Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status; 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status.
Review of Resident #18's record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Cerebral Infarction, Aphasia, and Alzheimer's disease.
Review of Resident #18's progress notes revealed a note dated 10/11/2024 by S15LPN (Licensed Practical Nurse) that read in part, Resident started throwing up a lot in his bed. No morning medications administered.
Review of Resident #18's progress notes revealed a note dated 10/17/2024 by S15LPN that read in part, Resident vomited twice on yesterday so medications were held.
Review of Resident #18's progress notes revealed a note dated 10/22/2024 by S15LPN that read in part, Resident throwing up again this morning. Holding medications.
Review of Resident #18's progress notes revealed a note dated 10/23/2024 by S15LPN that read in part, Resident has thrown up three times this week. He has been unable to keep his food and medications down. He was weak afterwards and didn't put up a fight .
On 10/30/2024 at 10:27 a.m., a phone interview was conducted with S15LPN. S15LPN stated she did not recall notifying Resident #18's responsible party of his episodes of vomiting during the month of October 2024. S15LPN confirmed that she should have notified the responsible party of Resident #18's change in condition.
On 10/30/2024 at 2:27 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that Resident #18's episodes of vomiting that occurred on 10/11/2024, 10/17/2024, 10/22/2024 and 10/23/2024 were considered a change in condition. She confirmed that the S15LPN had not notified the responsible party after each episode of vomiting and should have done so.
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 observations, record reviews and interviews, the facility failed to ensure that services were provided as outlined in t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 1 (#12) of 29 sampled residents as evidenced by staff failing to turn Resident #12 every two hours.
Findings:
Review of the resident's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Unspecified Site of Female Breast, Aphasia, Contracture of Muscle, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Contracture Left and Right Hand, and Alzheimer's Disease.
Review of the resident's current physician's orders revealed an order dated 04/29/2023 which read, Turn every two hours every shift.
Review of the resident's MAR (Medication Administration Record) for October 2024 read in part .turn every two hours every shift.
Review of the resident's care plan dated 03/07/2024 read in part .at risk for impaired skin integrity related to incontinence, and immobility. Intervention - encourage/assist with turning and reposition every two hours.
On 10/28/2024 at 9:00 a.m., an observation was made of Resident #12 in her room. The resident was lying on her back with a pillow under her head, and her bilateral above the knee amputation stumps were elevated on a cushion.
On 10/28/2024 at 12:00 p.m., a follow up observation was made of Resident #12's room, which revealed the resident was lying on her back with one pillow under her head, and both stumps elevated on a cushion. Further observation revealed no other positional cushions or pillows on the resident's side of the room.
On 10/29/2024 at 7:37 a.m., another observation was made of Resident #12 in her room which revealed the resident was lying on her back, with one pillow under her head, and bilateral stumps elevated on a cushion. Further observations were conducted at 8:20 a.m., 11:32 a.m., 1:29 p.m., and 4:00 p.m. The resident was in the same position for all observations.
On 10/30/2024 at 8:25 a.m., an interview was conducted with S9CNA (Certified Nursing Assistant), S11TX (Treatment Nurse), S3ADON (Assistant Director of Nursing). S11TX stated that Resident #12 was on a turn schedule, and was supposed to be turned every two hours. S3ADON confirmed that staff should have had positioning cushions or extra pillows to assist with the repositioning of the resident and did not.
On 10/30/2024 at 11:05 a.m., an interview was conducted with S6LPN (Licensed Practical Nurse) who confirmed that staff had not been repositioning Resident #12 every two hours as per physician orders and comprehensive care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#57) of 3 (#12, #47 and #57) residents reviewed for ADLs.
Findings:
Review of Resident #57's clinical record revealed he was admitted to the facility on [DATE] with the following diagnoses, in part, Hemiplegia and Hemiparesis following other non traumatic intracranial hemorrhage affecting left non-dominant side, Contracture to left and right hand, and Contracture to left and right leg.
Review of the Minimum Data Set (MDS) dated [DATE] read in part .Brief Interview for Mental Status (BIMS) score was 9, which indicated he had moderate cognitive impairment.
Review of the resident's care plan dated 08/27/2024 read in part At risk for bowel and bladder incontinence related to immobility, Benign Prostatic Hyperplasia (BPH), Overactive bladder. I am incontinent of bowel and bladder, and I require total assistance with perineal care. Incontinent checks every two hours with perineal care.
I require assistance with activities of daily living for a history related to Cerebrovascular accident with left hemiparesis, immobility, bowel and bladder incontinence, and bilateral upper and lower extremity contractures. Perineal care provided per staff every two hours and as needed.
On 10/28/2024 at 9:09 a.m., an observation and interview was conducted with Resident #57. He stated staff got him up this morning at 5 a.m. and they had not performed perineal care on him since 5 a.m. Resident #57 stated that when the staff gets him up in the mornings, no one comes back put him in bed until after lunch and that is when they usually perform perineal care again.
On 10/28/2024 at 11:05 a.m., an observation and follow-up interview was conducted with the resident. He stated that staff had not perform perineal care on him since put him in his geri (geriatric) chair. Resident #57 was observed with a strong urine and feces odor.
On 10/28/2024 at 12:26 p.m., Resident #57 was observed in the dining room being assisted with his meal by S10CNA (Certified Nursing Assistant). During the lunch meal, the resident still had a strong urine and feces odor.
On 10/28/2024 at 12:56 p.m., S10CNA and S11TX (Treatment Nurse) was observed assisting Resident #57 back to bed. Further observation revealed the resident was soiled with a large amount of urine and feces. S10CNA confirmed she had not performed perineal care prior to the resident going to the dining room.
On 10/28/24 at 1:08 p.m., Resident #57 stated, in the presence of S10CNA, this was the second time he received perineal care since he was put in his geri chair at 5 a.m. S10CNA confirmed that the night shift put the resident in his geri chair around 5 a.m., or 6 a.m. S10CNA also confirmed that the resident should have received perineal care prior to bringing him to the dining room and every two hours, as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents (#46) investigated for respiratory care out of a finalized sample of 29 residents by failing to label and properly store Resident #46's CPAP (continuous positive airway pressure) mask.
Findings:
Resident #46 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Cerebral Infarction, Congestive Heart Failure, Acute and Chronic Respiratory Failure with Hypercapnia, Sleep Apnea and Morbid (Severe) Obesity.
Review of Resident #46's physician orders revealed an order initiated on 01/26/2024 that read Change CPAP humidifier chamber and full mask with head gear every 6 months and prn (as needed.)
Review of Resident #46's care plan revealed in part . I am at risk for respiratory complications r/t (related to) chronic respiratory failure, sleep apnea and obesity. I require O2 (oxygen) therapy and I use a CPAP during sleep to assist with breathing. Interventions: CPAP as ordered; follow directions to keep it clean.
On 10/28/2024 at 12:26 p.m., an observation and interview was conducted with S3ADON (Assistant Director of Nursing) of Resident #46's CPAP mask. Resident #46's CPAP mask was observed to be unlabeled and stored in an unlabeled plastic bag. S3ADON confirmed that the mask or storage bag should have been labeled with the date it was changed and was not.
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 observations and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 83.
Findings:
On 10/29/2024 at 10:15 a.m., an o...
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Based on observations and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 83.
Findings:
On 10/29/2024 at 10:15 a.m., an observation of the daily posted staffing information revealed a date of 10/28/2024.
On 10/29/2024 at 10:16 a.m., an observation of the daily posted staffing information and an interview was conducted with S14WC (Ward Clerk). She stated that she was responsible for posting the staffing information on a daily basis. S14WC confirmed the date of 10/28/2024 on the posting and stated that they have always posted the staffing information for the previous day.
On 10/29/2024 at 10:50 a.m., an interview was conducted with S1ADM (Administrator). She confirmed that the staffing information posted was from the previous day (10/28/2024). She stated the information had always been posted with the prior, and not the current date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
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 honor and accommodate food preferences for 2 (#17 a...
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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 honor and accommodate food preferences for 2 (#17 and #23) out of 6 (#17, #23, #26, #49, #72, and #379) residents reviewed for dining. This deficient practice had the potential to affect 78 residents who consumed meals from the kitchen.
Resident #17
Review of Resident #17's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Type 2 Diabetes Mellitus and Muscle Wasting and Atrophy.
Review of Resident #17's most recent Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 8, indicating his cognition was moderately impaired.
Review of Resident #17's meal ticket, read in part, . meal note: No [NAME] Leafy foods.
On 10/29/2024 at 12:40 p.m. and observation and interview was conducted with Resident #17. Resident #17 was observed to have iceberg lettuce on his meal tray. Resident #17 stated that he did not like lettuce and he had removed the lettuce from his hamburger.
On 10/29/2024 at 12:40 p.m., an observation of Resident #17's meal tray was conducted with S4DM (Dietary Manager). S4DM confirmed that iceberg lettuce was served on Resident #17's meal tray.
On 10/30/2024 at 10:39 a.m., an observation and interview was conducted with S4DM (Dietary Manager). S4DM confirmed that Resident #17's meal ticket stated that the resident's preference included no green leafy foods. S4DM confirmed that iceberg lettuce should not have been served on Resident #17's meal tray on 10/29/2024.
Resident #23
Review of Resident #23's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Type II Diabetes Mellitus, Hyperlipidemia, and Age-Related Osteoporosis.
Review of Resident #23's most recent State Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating her cognition was severely impaired. Section G: Functional Status read in part, Eating was coded as 1 (supervision-oversight, encouragement or cueing).
Review of Resident #23's comprehensive plan of care, read in part, I am at risk for complications/injury r/t (related to) Osteoporosis with interventions . dated 08/14/2023; encourage intake of dairy products . enriched with calcium and vitamin D .
Review of Resident #23's meal ticket, read in part, . meal note: milk with lunch meal.
On 10/28/2024 at 12:13 p.m., Resident #23 was observed consuming her lunch meal. Her meal tray did not have milk on it. The resident stated, I would like some milk with my lunch, but they never bring any milk with lunch.
On 10/28/2024 at 12:16 p.m., an observation and interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN confirmed that Resident #23's meal ticket stated that the resident's preference was to receive milk with all lunch meals and she had not.
On 10/30/2024 at 10:31 a.m., an interview and a review of Resident #23's meal ticket was conducted with S4DM (Dietary Manager) who confirmed that Resident #23 should receive milk with all lunch meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that nursing staff possessed competencies an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that nursing staff possessed competencies and skill sets necessary to provide nursing services to meet the residents' needs safely, and attain or maintain the highest practicable physical well-being for 1(#12) of 00 sampled residents as evidenced by nursing staff failing to properly maintain and record output from a Jackson Pratt (JP) drain for Resident #12.
Findings:
On 10/30/2024, a review of the facility's assessment with no revision date, read in part Before any new diagnoses is accepted into the facility the facility ensures the staff is competent of taking care of the resident. If a new diagnosis occurs then the facility would seek education and resources to ensure that the facility is able to care for the resident and new diagnoses, through this process. Further review revealed a review of clinical competencies within the clinical department is done on hire, annually and as needed based on need to ensure new protocols and procedures are performed adequately.
Review of Resident #12's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Unspecified Site of Female Breast, Aphasia, Contracture of Muscle, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Contracture Left and Right Hand, and Alzheimer's Disease.
Review of Resident #12's Treatment Administration Record (TAR) dated October 2024 read in part monitor JP drain to right breast surgical incision site, for placement, color and drainage amount in milliliters.
Review of Resident #12's discharge summary from a local hospital titled Drain Instructions and dated 10/17/2024, read in part instructions for emptying the drain- squeeze the container making it flat and close it. Keeping the container flat, helps to remove drainage from under the skin. Record the date, time, and the amount of drainage on the bottom of the sheet. Empty the container three times a day-morning, noon, and night.
On 10/28/2021 at 2:21 p.m., a Review of Resident #12's physician's orders dated October 2024 prior to the facility staff changing the order read in part record JP drain output and record.
Review of Resident #12's care plan dated 10/17/2024, read in part .right breast mastectomy due to breast cancer - follow post-operative orders as ordered by physician, monitor and record drainage from JP drain as ordered, monitor incision site of s/s (signs/symptoms)of infection, and bring to follow up appointment.
On 10/28/2024 at 2:21p.m., an observation of Resident #12's JP drain revealed an uncompressed bulb with light red colored fluid in the drain. An immediate observation and interview was conducted with S3ADON (Assistant Director of Nursing) who stated that S5LPN (Licensed Practical Nurse) should have emptied the drain. S3ADON confirmed that the drain bulb should have been compressed. S3ADON emptied the JP drain and discarded 75 ml (Milliliters) of drainage which compressed the bulb. Further observation revealed an additional 65 ml was emptied from the JP drain immediately. S3ADON confirmed that S5LPN should have been monitoring the JP drainage every shift and as needed.
On 10/28/2024 at 2:30 p.m., S2DON (Director of Nursing) entered the resident's room and presented the recorded output for the JP drain since its insertion on 10/17/2024. A review of the document revealed on 10/19/2024, 10/20/2024, 10/21/2024, and 10/25/2024, staff had failed to record output on the 6 a.m. to 6 p.m. shift.
10/29/2024 at 1:29 p.m., an interview was conducted with S7LPN who stated when the resident returned to the facility on [DATE] she had two forms for recording output in her discharge packet. One was to complete and return to physician office at the time of follow up. The other form was for care of the JP drain, and to empty 3 times daily and record amount and color. S7LPN stated drainage was recorded every shift and not three times daily.
On 10/29/2024 at 4:00 p.m., an interview was conducted with S7LPN who stated that S12LPN worked with Resident #12 on 10/19/2024 and 10/20/2024 and S5LPN worked with the resident on 10/21/2024. S13LPN worked with her on 10/25/2024. Review of the staff skills checklist with S7LPN, revealed no evidence staff were trained or had knowledge of the care and maintenance of a JP drain.
On 10/30/2024 at 8:28 a.m., an interview was conducted with S7LPN who stated the S2DON should have completed an in-service training on the care of the JP drain.
On 10/30/24 at 11:00 a.m., an interview was conducted with S2DON who confirmed she did not complete an in-service on the care and maintenance of the JP drain with staff.
On 10/30/2024 at 4:05 p.m., a follow up observation of Resident #12's JP drain was conducted. The JP drain was observed not compressed. An observation and interview was immediately conducted with S7LPN confirmed the bulb was not compressed. S6LPN was called into the resident's room by S7LPN, and when asked if she had compressed the bulb of the drain after emptying the drain, S6LPN did not have a response. S7LPN confirmed that the JP bulb was to remain compressed.
Sept 2023
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to ensure each resident's plan of care and clinical re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to ensure each resident's plan of care and clinical record accurately reflected their advanced directives for 1 (#65) out of 41 sampled residents. This deficient practice had the potential to affect the entire census of 79 residents.
Findings:
A review of the facility's policy titled Advance Directives read, in part .If the resident has an Advance directive .4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive .
Resident #65 was admitted to the facility on [DATE] with diagnoses including: Acute Respiratory Failure with Hypoxia, Benign Prostatic Hyperplasia, and Acute Lymphoblastic Leukemia.
A review of Resident #65's care plan revealed he had an Advanced Directive with a DNR (Do Not Resuscitate) status.
A review of Resident # 65's record revealed an Advanced Directive with no circled beside DNR and no also circled beside CPR (Cardio Pulmonary Resuscitation).
On [DATE] at 12:20 p.m., an interview was conducted with S5SSD (Social Service Director). S5SSD confirmed that no was circled for DNR status and stated that yes should have been circled.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the nurse informed each resident's RP (Responsible Party) of...
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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 the nurse informed each resident's RP (Responsible Party) of a significant change in condition as evidenced by:
1. Failing to notify Resident #6's RP when the resident was transferred to the hospital and;
2. Failing to notify Resident #69's RP when the resident had an unwitnessed fall for 2 (#6, #69) out of 41 sampled residents.
Findings:
1. Resident #6. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Atherosclerotic Heart Disease, Diabetes, and Hypertension.
Review of the resident's Nurses Note dated 04/11/2023 at 19:23 (7:23 p.m.) revealed: Alerted by CNA (Certified Nursing Assistant) that resident was lethargic. Upon entering the patient room noticed that the resident was not being herself and she had a wet cough. Checked blood sugar, CBG (Capillary Blood Glucose) was 44. Attempted to get resident to drink orange juice with no success. Ambulance and S7NP (Nurse Practitioner) contacted. There was no evidence the resident's RP was notified.
On 09/26/2023 at 11:05 a.m., an interview was conducted with S8LPN (Licensed Practical Nurse). He confirmed that there was no evidence in the clinical records the resident's responsible party was notified of the resident's change of condition and transfer to the hospital.
2. Resident #69. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Senile Degeneration of Brain, Major Depressive Disorder, Anxiety Disorder, Bipolar Disorder, and Schizoaffective Disorder.
Review of the resident's quarterly MDS (Minimum Data Set) dated 07/20/2023 revealed the resident's BIMS (Brief Interview Mental Status) score was 5 which indicated the resident was severely impaired for cognition.
Review of the resident's nurse's note dated 09/05/2023 at 19:40 (7:40 p.m.) revealed: Late entry: CNA (Certified Nursing Assistant) made writer aware that resident was on side of her bed praying on her knees and now would like something for pain. Writer then went to assess patient and ask what's hurting. Resident states her knees hurts, rating 8 out of 10 and would like something for pain . Resident also stated that she had an unwitnessed fall . There was no evidence the RP (Responsible Party) was notified.
On 09/26/2023 at 4:15 pm, a telephone interview was conducted with S2DON (Director of Nursing). S2DON stated on 09/05/2023, the resident was found on the floor on hands and knees. S2DON stated the incident was not witnessed. S2DON confirmed the nurse did not notify the RP of the incident.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #65
Review of the facility's policy titled, Oxygen Administration read in part .Purpose: The purpose of this procedu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #65
Review of the facility's policy titled, Oxygen Administration read in part .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
Resident #65 was admitted to the facility on [DATE] with diagnoses in part: Acute Respiratory Failure with Hypoxia, and Acute Lymphoblastic Leukemia Not Having achieved Remission.
A review of the Physician's Orders revealed an order written on 08/21/2023 at 16:00 (4:00 p.m.) for O2 (oxygen) at 3L (Liters) NC (Nasal Cannula).
On 09/25/2023 at 9:00 a.m., an observation was made of Resident #65 in his room. The resident was lying in his bed and receiving o2 via nasal cannula at a set rate of 2.5L as observed on the o2 concentrator.
On 09/25/2023 at 2:47 p.m., a second observation was made of Resident #65 in his room. The resident was lying in his bed and receiving o2 via nasal cannula at a set rate of 2.5L from the o2 concentrator.
On 09/25/2023 at 4:20 p.m., an interview was conducted with S9LPN (Licensed Practical Nurse). S9LPN checked the resident's orders on her computer and confirmed that Resident #65 was ordered to receive 3L o2 via nasal cannula.
On 09/25/2023at 4:23 p.m., an observation of Resident #65's room was conducted with S9LPN, who confirmed the O2 setting on the resident's oxygen concentrator was at a set rate of 2.5L and stated it should have been set at 3L as the physician ordered.
Based on observations, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#39, and #65) of 2 (#39 and #65) residents reviewed for respiratory care in a final sample of 41 residents.
The facility failed to ensure:
1. Respiratory equipment was properly stored when not in use
2. Resident #65 received oxygen as ordered by the physician.
Findings:
Review of the facility's policy titled, Oxygen Administration read in part .Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Caring for equipment 1. Oxygen tubing must be changed weekly for residents utilizing oxygen. 2. Humidifier bottles must be changed weekly for residents utilizing oxygen. 3. Oxygen tubing must be kept in a bag while not in use.
1. Resident # 39
Review of Resident #39's record revealed she was admitted to the facility on [DATE] with diagnoses including Shortness of Breath, Acute Respiratory Failure, and Unspecified with Hypoxia or Hypercapnia.
Review of Resident #39's current physician's orders read in part, Change humidifier every three days.
Review of Resident #39's care plan read in part, The resident has risk for altered respiratory status or decline in oxygen saturation especially during exertion. Interventions: Change o2 (oxygen) tubing and clean o2 filter every Saturday. Change o2 humidifier q (every) 3 days and prn (as needed).
On 09/25/2023 at 9:49 a.m., Resident #39's nasal cannula was visualized, not in use and on the floor of the resident's room.
On 09/26/2023 at 11:39 a.m., Resident # 39's nasal cannula was visualized draped over the oxygen concentrator, not in use, open to air, and not in a bag. The resident's nasal cannula was dated 09/09/2023 and the humidifier bottle was labeled 09/14/2023.
On 09/26/2023 at 11:44 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse). She confirmed Resident #39's nasal cannula was not in use and not stored in a bag. She also confirmed the resident's nasal cannula was dated 09/09/2023 and the humidifier bottle was dated 09/14/2023. S9LPN stated the resident's nasal cannula was supposed to be changed out every Saturday and the humidifier was supposed to be changed out every 3 days. She confirmed they were not changed per the resident's care plan orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the nurse failed to perform hand hygiene after removing gloves during wound ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the nurse failed to perform hand hygiene after removing gloves during wound care 1 (#7) out of 1 residents investigated for pressure ulcers in a final sample of 41 residents.
Findings:
Review of the facility's policy titled, Hand Washing and Hand Hygiene Policy read in part .7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations b. before and after direct contact with residents, i. after contact with a resident's intact skin, k. after handling used dressings, l. after contact with objects in the immediate vicinity of the resident, m. after removing gloves.
Review of Resident #7's electronic medical record revealed he was admitted to the facility on [DATE]. Resident #7's pertinent medical conditions, included in part: Fracture of unspecified part of neck of right femur, Acute Cholecystitis, Dysphagia, and Heart Failure.
Review of Resident #7's September 2023 physician orders revealed the following: Cleanse stage 1 sacrum with NS (Normal Saline), pat dry, apply Calmoseptine and collagen, LOA (Leave Open to Air) until resolved; Cleanse right hip staples with wound cleanser. Pat area dry. Apply island dressing daily and prn (as needed) soilage until resolved; Monitor abrasion left knee qshift (every shift) until resolved.
On 09/26/2023 at 08:39 a.m., an observation was made of S13LPNWC (Licensed Practical Nurse, Wound Care) perform Resident #7's wound care. Upon completion of the sacral wound care, S13LPNWC removed her gloves and did not sanitize her hands. She proceeded to reposition the resident in the bed, then measured the Resident's left knee abrasion without sanitizing her hands or putting on gloves.
On 09/26/2023 at 09:23 a.m., an interview was conducted with S13LPNWC. She stated she should have sanitized her hands after removing her gloves, and before measuring Resident #7's abrasion on his left knee.
On 09/26/2023 at 12:49 p.m., an interview was conducted with S3ADONIP (Assistant Director of Nursing, Infection Preventionist). She confirmed S13LPNWC should have not handled the Resident or measured his left knee abrasion without sanitizing her hands between tasks.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
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 maintain a system of accounting of each resident's personal funds e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a system of accounting of each resident's personal funds entrusted to the facility on the resident's behalf by failing to provide quarterly statements for 1 (# 49) of 1 resident investigated for personal funds out of a finalized sample of 41 residents.
Findings:
A review of the facility's policy titled Resident Trust Fund, read in part .Policy Interpretation and Implementation. Should a resident decide to deposit into a resident trust fund it should consist of the items below .4. Quarterly statements reflecting the interest earned and balance of the account are to be mailed to all residents and or responsible party.
Resident #49 was admitted to the facility on [DATE]. The resident had a BIMS (Brief Interview of Mental Status) score of 14, indicating that her cognition was intact.
On 09/26/2023 at 8:00 a.m., an interview was conducted with Resident #49. The resident stated that she should have $38.00 left over after her bills were paid each month but she never received a statement from the facility.
On 09/26/2023 at 8:32 a.m., an interview was conducted with S4BOM (Business Office Manager). S4BOM stated that Resident #49's daughter was her (RP) Responsible Party, and that the facility had been sending the quarterly statements to the resident's RP.
On 09/26/2023 at 7:00 p.m., a phone interview was conducted with Resident #49's RP. She stated that she received one statement of Resident #49's funds from the facility a long time ago. Resident #49's RP further stated that the only statement she had received for the year of 2023 was given to her when she went to the facility to visit her mother this evening.
On 09/27/2023 at 8:50 a.m., an interview was conducted with S4BOM. S4BOM was asked for receipts that quarterly statements had been sent to Resident #49 and/or the resident's RP for the year of 2023. She stated she was unable to provide the requested information and confirmed that she provided the resident's RP with a statement on yesterday 09/26/2023 when the RP visited the facility. S4BOM explained the statement was provided after the facility learned that Resident #49 voiced concerns to the survey team of not receiving statements.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected multiple residents
Resident #18
A review of Resident #18's record revealed an admission date of 08/10/2018 with diagnoses including Major Depressive Disorder, Unspecified Severity without Behavioral Disturbance, Psychot...
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Resident #18
A review of Resident #18's record revealed an admission date of 08/10/2018 with diagnoses including Major Depressive Disorder, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Psychotic Disturbance, and Mood Disturbance.
Further review of Resident #18's record revealed a Level I PASARR dated 08/07/2018. No evidence that a Level II PASARR request had been submitted to the appropriate state-designated authority by the facility was noted in the resident's record.
On 9/27/2023 at 09:16 a.m., an interview was conducted with S5SSD. She confirmed that Resident #18 had diagnoses including Major Depressive Disorder, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Psychotic Disturbance, and Mood Disturbance upon admit on 8/10/2018. S5SSD confirmed that the facility failed to ensure that a request for a Level II PASARR determination was submitted to the appropriate state-designated authority and that the request should have been submitted upon the resident's admission with those diagnoses.
Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 (#1, #18) of 4 (#1, #18, #53, #62) residents investigated for PASARR in a final sample of 41 residents.
Resident #1
A review of Resident #1's record revealed an admission date of 04/24/2012. Further review revealed he was diagnosed with Schizophrenia on 06/04/2015.
A review of the Resident #1's current physician's orders September 2023 revealed he had been prescribed the antipsychotic medication Seroquel 25mg (milligrams) related to the diagnosis of Schizophrenia.
Further review of Resident #1's record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 06/22/2010. No PASARR Level II was noted in Resident #1's record.
On 09/27/2023 at 10:50 a.m., an interview conducted with S5SSD (Social Service Director), who stated that when a resident is diagnosed with a new mental disorder, the facility sends a determination letter to the appropriate state-designated authority, to determine if a Level II PASARR should be conducted. S5SSD confirmed that the facility failed to notify the appropriate state-designated authority when Resident #1 was diagnosed with Schizophrenia on 06/04/2015, and that they should have.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #49
Resident #49 was admitted to the facility on [DATE] with diagnoses in part: Acute Kidney Failure, Morbid Obesity, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #49
Resident #49 was admitted to the facility on [DATE] with diagnoses in part: Acute Kidney Failure, Morbid Obesity, and Diabetes Mellitus.
A review of Resident #49's Physician's orders revealed an order written on 06/07/2023 for a Renal Dialysis diet, Regular Texture, Thin Consistency, extra gravy.
A review of a dietary note written on 08/17/2023 at 11:03 a.m. stated .resident is on same renal diet.
On 09/26/2023 at 8:40 a.m., an observation was made of Resident #49 in her room. The resident's unfinished breakfast of white toast, grits, scrambled eggs and a glass of orange juice was on her over bed table. A review of the menu card on the resident's tray revealed that she should have received a renal diet. Resident #49 stated she is supposed to get apple or cranberry juices and they keep bringing her orange juice.
On 09/26/2023 at 12:32 p.m., an interview was conducted with S6DM (Dietary Manager). S6DM stated that S11DA (Dietary Aide) placed the food on the resident's tray this morning and she should not have had orange juice because she is on renal diet.
On 09/26/2023 at 12:36 p.m., an interview was conducted with S11DA. S11DA confirmed that he placed orange juice on the resident's breakfast tray and should not have because the resident is on a special diet.
Based on observation, record review and interview, the facility failed to ensure the resident's comprehensive plan of care was implemented for 2 (#6 and #49) residents out of 41 sampled residents as evidenced by:
1.
Failing to follow the physician's standing orders to address a blood sugar reading of 44 for Resident #6 and
2.
Failing to ensure Resident #49 received a renal diet.
Findings:
Resident #6
Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's Disease, Peripheral Vascular Disease, Chronic Kidney Disease, Atherosclerotic Heart Disease, Diabetes, and Hypertension.
Review of the resident's care plan revealed the resident was at risk for unstable blood glucose related to Diabetes. The care plan included an intervention for diabetic medication as ordered by physician.
Review of the resident's physician's standing orders revealed in part: For CBG (Capillary Blood Glucose) results in the range of 0-64 Give 4 ounce orange juice or glucose gel 24 g (grams) and repeat CBG in 15 minutes. CBG below 64 and patient unable to swallow or unresponsive, give Glucagon 1 mg (milligram) IM (Intramuscular) stat and notify MD (Medical Doctor).
Review of the resident's Nurses Note dated 04/11/2023 at 19:23 (7:23 p.m.) revealed: Alerted by CNA (Certified Nursing Assistant) that resident was lethargic. Upon entering the patient room noticed that the resident was not being herself and she had a wet cough. Checked blood sugar, CBG (Capillary Blood Glucose) was 44. Attempted to get resident to drink orange juice with no success. There was no evidence the nurse attempted to administer Glucagon 1 mg IM.
On 09/26/2023 at 2:45 p.m., an interview was conducted with S8LPN (Licensed Practical Nurse). He stated on 4/11/2023 when the resident had a change in mental status and was lethargic, he checked the resident's blood sugar. S8LPN stated the resident's blood sugar result was 44 and that he attempted to give the resident some orange juice with sugar but she could not drink it. S8LPN stated that he did not attempt to administer Glucagon.
On 09/26/2023 at 2:50 p.m., an interview was conducted with S4NP (Nurse Practitioner). He stated if the resident's blood sugar was 44, the nurse should have followed the physician's standing orders. S4NP stated if the resident was lethargic and unable to drink the orange juice, then the standing orders for Glucagon 1 mg IM should have been administered for blood sugar result of 44.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure that dietary staff utilize the...
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Based on observation and interview, the facility failed to serve food in accordance with professional standards for food service safety as evidenced by failing to ensure that dietary staff utilize the appropriate hair covering when not covering a beard with a beard restraint to prevent hair from contacting food. This deficiency had the potential to affect the entire census of 79 residents, who consumed food that was prepared in the kitchen.
Findings:
A review of the facility's Policy and Procedure titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices was conducted. The policy included, in part: Policy Statement: Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent spread of foodborne illnesses.
Hair Nets: 15 Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.
On 09/25/2023 at 09:43 a.m., an observation was conducted of S10DA (Dietary Aide) working in the kitchen as food was being prepared for the lunch meal. S10DA was observed with no beard restraint covering on his beard. S6DM was present during this observation.
On 09/25/2023, between 11:00 a.m. and 12:00 p.m., multiple observations were conducted of S10DA as he worked in and around the food service line area. He was observed handling the trays that held food and drink as he prepared the carts that held lunch trays for delivery to residents. No beard restraint was noted on S10DA's face. S6DM was present during these observations.
On 09/26/2023 at 10:45 a.m., an observation was conducted of S10DA handling the trays that held food and drink as he prepared a food cart for the residents' lunch trays. No beard restraint was noted on S10DA's face. S6DM was present during this observation.
On 09/26/2023 at 09:30 a.m., an interview was conducted with S6DM. She confirmed that S10DA should have worn a beard restraint over his beard and had failed to do so while working in the kitchen and food service area on 09/25/2023 and 09/26/2023.
On 09/26/2023 at 09:35 a.m., an interview was conducted with S1ADM. She confirmed that S10DA should have been wearing a beard restraint over his beard while he was in kitchen and/or food service area.
Jul 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 observation, interview and record review, the facility failed to ensure an alleged violation of staff to resident physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an alleged violation of staff to resident physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#5) out of 5 (#1, #2, #3, #4, #5 ) sampled residents.
Findings:
Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating read in part .All reports of resident abuse .are reported to local, state, and federal agencies as required by current regulations .2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .
Resident #5 was admitted to the facility on [DATE] with diagnoses in part: Parkinson's disease, Muscle Wasting and Atrophy, Unspecified Dementia, and Aphasia.
Review of facility's incident report dated 06/25/2023 at 5:00 p.m. revealed the following in part:
Incident Location: Resident's Room.
Incident Description: Resident's family reported that resident had a bruise on her left foot that was not there yesterday when she visited. Upon assessment resident did have a bruise on her left inner foot, measuring 3cm (centimeters) x 2cm x 0 cm with a bluish purple color. When asking the resident what happened she stated, she threw the remote at my foot .CNA (Certified Nursing Assistant) stated that when they were transferring the resident to the bed from the lifter, the resident's foot hit the wheelchair and caused a bruise.
Mental Status: Oriented to Person, Oriented to Situation
On 07/06/2023 at 9:30 a.m., an observation was made of Resident #5 with S6LPN (Licensed Practical Nurse). Resident #5 allowed the S6LPN to remove her socks. A bluish/purplish bruise was observed to her inner left foot near her heel. The bruise was approximately an inch long. When questioned about what happened to her foot, Resident #5 stated, that girl knocked me on my foot.
On 07/06/2023 at 10:24 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated Resident #5's responsible party called him and notified him of a bruise to the resident's left inner foot that was not there the day before. S2DON stated he immediately came to the facility and assessed Resident #5's foot. S2DON stated that he observed that the resident's bruise was half crescent in shape and purplish in color. He further stated that Resident #5's responsible party reported to him that Resident #5 said the CNA hit her on her foot with the remote. The resident identified the CNA as S5CNA, who was employed by an agency.
Attempts to inteview S5CNA by telephone were made with no success.
On 07/06/2023 at 11:33 a.m., an interview was conducted with S1Administrator and S2DON. S1Administrator explained that the alleged abuse was not reported to the State Survey Agency when Resident #5 and her responsible party reported that S5CNA hit the Resident on her foot with the remote because there was no abuse. S1Administrator further stated that although the resident alleged the abuse, there was no evidence of abuse when S2DON conducted his investigation. S1Administrator stated that this incident was not abuse, there was no suspected abuse, and there was no reason to report to the State Survey agency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure each resident with pressure ulcers received th...
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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 each resident with pressure ulcers received the necessary treatment and services to promote healing as evidence by the staff failing to follow physician's orders for wound care for 1 (Resident #2) out of 3 (Residents #1, #2, #3) residents investigated with pressure ulcers.
Findings:
Review of Resident #2's clinical record revealed she was admitted to the facility on [DATE] with diagnosis which included, but were not limited to, Other Specified Viral Infections Characterized By Skin And Mucous Membrane Lesions, Dementia, Edema, and Type 2 Diabetes Mellitus.
Review of the resident's Q (Quarterly) MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating her cognition was severely impaired. Section M-Skin Conditions revealed the resident has an open lesion.
Review of facility's Pressure Ulcer Wound Status Report dated 06/28/2023, revealed in part, Resident #2 admitted with pressure wound to upper mid back on 03/09/2023.
Review of residents current physician's order list revealed an order dated 07/06/2023 Cleanse midback wound with Dakins, apply Collagen Powder and CA (Calcium) Alginate to wound bed, apply Calmoseptine to surrounding skin of wound edges, cover with super absorbent dressing, secure with absorbent silicone dressing daily, every day shift.
Review of resident's comprehensive care plan revealed on 06/28/2023 resident continues to have an opened area to her back with intervention to administer treatments as ordered.
On 07/06/2023 at 8:45 a.m., an observation of S3ADON (Assistant Director of Nursing) performing wound care to Resident #2's wound on her midback was conducted with S2DON (Director of Nursing) present. S4LPN (Licensed Practical Nurse) was also present during this time, reading the physician's order for wound care to S3ADON. S3ADON did not apply Calmoseptine to the surrounding skin of wound the edges as ordered.
On 07/06/2023 at 9:15 a.m., an interview and review of Resident #2's physician orders was conducted with S3ADON. S3ADON confirmed she did not apply Calmoseptine to surrounding skin of wound edges while performing wound care to Resident #2's midback.
On 07/06/2023 at 9:17 a.m., an interview was conducted with S2DON. S2DON confirmed he did not observe S3ADON apply Calmoseptine to surrounding skin of wound edges to Resident #2's wound as listed on Resident #2's physician's orders.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 record review and interviews, the facility failed to protect the resident's (#3) right to be free from physical abuse b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the resident's (#3) right to be free from physical abuse by another resident (#6) for 1 (#3) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents when Resident #6 slapped Resident #3 in the face.
Findings:
A review of the provider's policy titled Resident Rights and Dignity revealed in part:
1. Abuse of any kind against residents is strictly prohibited. 4. Abuse is defined as the willful infliction of injury, confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. 5. Abuse toward a resident can occur as: A. resident to resident abuse; 1. Physical abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking.
Resident #6.
Resident #6 was admitted to the facility on [DATE] with diagnoses that include Diabetes Mellitus Type 2, Major Depressive Disorder, Schizoaffective Disorder Bipolar type 2, and Hypertension.
Review of Resident #6's Minimum Data Set (MDS), assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated the resident had severe cognitive impairment.
Review of Resident #6's care plan revealed problems and interventions including I'm at risk for exhibiting behaviors related to Schizoaffective Disorder Bipolar Type, Depression. I am at risk for aggressive behavior, Goals: the resident will have no aggressive behaviors. New interventions added on 02/26/23 included I have a history of hitting other residents, separate me from the resident I was physically aggressive towards and assess me for injury. I physically assaulted another resident, send me to psych facility for evaluation and treatment.
Review of Resident #6's nurse notes revealed:
02/25/23 at 9:01 a.m. read resident is having behavioral disturbances and has to be redirected frequently for behaviors, multiple redirection attempts, resident denies she is having hallucinations, however she is actively looking at the ceiling and having a conversation with someone. Resident is intrusive and having manic moods with behavioral issues. Will continue to monitor
02/26/23 at 06:05 a.m. read in part, Resident #6 slapped Resident #3 in the face in the dining room and she was combative during a.m. rounds, resident refused to change clothing. Resident was removed from the dayroom room and was placed on 1:1. Performed head to toe on both residents.
Resident was not in the facility for the duration of the survey 04/24/23-04/25/23, and was not available for observation or interview.
Resident #3.
Review of Resident #3's record revealed he was admitted to the facility on [DATE] with diagnoses which included, Hereditary Deficiency of Clotting Factors, Peripheral Vascular Disease, Muscle Wasting, Lack of Coordination, Major Depressive Disorder, and Bipolar Disorder.
Resident #3's most recent MDS dated [DATE] revealed a BIMS score of 3 implicating severe cognitive impairment.
Review of the facilities incidents logged for the past 120 days revealed an incident on 02/26/23 at 05:55 a.m. in which, Resident #3 was slapped on cheek by Resident #6 unprovoked. Residents were separated immediately and Resident #6 was separated from all residents, her speech was not decipherable she was placed one on one until she was transferred to a behavioral health facility for treatment on the same day of the incident, 02/26/23.
Review of Resident #3's Body Audit Tool, dated 02/26/23 at 06:15 a.m., revealed RN re-assessed resident and no redness or new marks on face or body.
On 04/24/23 at 10:50 a.m., an interview and observation of Resident #3 was conducted as he was seated in a wheel chair in the memory unit dining room. Resident #3 stated his name, nodded his head as he spoke softly as he answered questions. He denied anyone ever hit him since he has lived in this facility. He repeatedly reached out to shake hands.
On 04/25/23 at 05:45 p.m., a telephone interview was conducted with S3CNA. She confirmed she witnessed the incident and said that she and a staff nurse, whom she did not know, immediately separated the residents when Resident #6 slapped Resident #3 for no known reason on 02/26/23. S3CNA stated Resident #6 was not behaving or talking normal.
On 04/25/23 at 02:40 p.m., during a telephone interview, Resident #3's representative stated when he talked to Resident #3 after the incident on 02/26/23, he didn't seem to remember being slapped but he reminded him and that may have triggered a little recollection. He said Resident #3 assured him that he was ok. He also said Resident #3 had no redness on his face or marks that were visible anywhere.
On 04/24/23 at 04:15 p.m., an interview was conducted with S2DON and S1ADM. S2DON confirmed that he was in the facility when Resident #6 had a behavior of a physical aggression and had slapped Resident #3 on 02/26/23. He further stated he spoke with Resident #6 right after the incident and he could not understand what she was saying. S2DON said he thought he saw a slight redness on Resident #3's cheek immediately after the incident but when he assessed him for the body audit shortly after the incident it was not red. S2DON confirmed he and S1ADM had substantiated resident to resident physical abuse.
Feb 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · 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 all residents received all care and treatment in accordance ...
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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 all residents received all care and treatment in accordance with professional standards of practice as evidenced by the nurse failing to perform a blood glucose checks for 1 (#3) out of 3 (#1, #3, #4) residents getting CBG (Capillary Blood Glucose) checks.
The deficient practice resulted in an actual harm for Resident #3, who has a diagnosis of diabetes, on 1/2/2023 at 6:00 a.m., when the facility's surveillance camera on the resident's hall revealed S2LPN (Licensed Practical Nurse) did not check the blood glucose level that AM and documented a level of 137. Resident #3 had a blood glucose level of 656 per lab work drawn on 1/2/2023 at 4:29 a.m. Resident #3 was transferred to the emergency room on 1/2/2023 at 10:00 a.m. after the resident's daughter voiced concerns about the resident not eating, complaints of sore throat and losing weight. The resident's blood work was drawn in the emergency room and the blood glucose result was 646. The resident's admitting diagnosis to the hospital included Hyperosmolar Hyperglycemic State (HHS). The resident did not return to the facility after being sent to the emergency room.
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:
Resident #3. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Alzheimer's Disease, Major Depressive Disorder, Aphasia, Dysphagia, Diabetes, Chronic Kidney Disease, and Unspecified Protein Calorie Malnutrition.
Review of the resident's physician's orders with start date 1/19/2022 revealed an order for Novolin R solution (Insulin Regular Human) inject as per sliding scale subcutaneously one time a day related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease before breakfast. If 0-60 = 0 give 4 oz (ounce) of OJ (orange juice) recheck CBG in 15 minutes; 61-150 = 0 do nothing; 151-200 = 2 Units; 201-250 = 3 Units; 251-300 = 5 Units; 301-350 = 7 Units; 351-400 = 10 Units; Call MD/NP (Medical Doctor/Nurse Practitioner) if over 400 for further directions, subcutaneously one time a day related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease before breakfast.
Review of the resident's MAR (Medication Administration Record) for December 2022 revealed that S2LPN checked the resident's blood glucose level on 12/26/2022 at 6:00 a.m. to 1/2/2023 at 6:00 a.m. and documented the resident's results as 137 for all 8 days.
Review of the resident's nurse note dated 1/2/2023 at 10:00 a.m. revealed, Resident being sent to (hospital emergency room) at this time per family request . Resident transported to hospital per stretcher via ambulance . Further review of the nurse's note revealed that there was no documentation of the resident's condition at the time of transfer to the hospital.
Review of the resident's emergency room notes dated 1/2/2023 at 10:53 a.m. revealed, [AGE] year old female past medical history of Alzheimer's, Diabetes, Hypertension, Hypothyroidism presents for encephalopathy and somnolence. Per daughter the patient is normally very interactive, apparently she had COVID 2 to 3 weeks ago, returned back to the nursing home and over the past 2 to 3 days has had progressively more generalized weakness and today she is not speaking or interacting which is very abnormal for the patient . Per EMS (Emergency Medical Services) . Patient was Hyperglycemic with CBG (Capillary Blood Glucose) 560 and heart rate was slightly elevated 105 . Patient is minimally interactive on exam unable to obtain a history from the patient. Patient presents from nursing home with somnolence . found to be mildly acidotic . primary diagnosis is HHS (Hyperosmolar Hyperglycemic State) . Patient was given fluids and insulin in the emergency department .Medically appropriate to be admitted to hospitalist team for further management.
Review of the facility's Incident/Accident log revealed that on 1/9/2023 a medication error occurred with the resident. The comments on the report read, Nurse documented that resident's blood glucose level was 137 x 6 days and resident had labs drawn on 1/2/2023 @ (at) 0429 (4:29 am) and blood glucose was 656. @ 0600 (6:00 am) on 1/2/2023, nurse charted that blood glucose was 137, resident's family member called and stated that her mother's blood glucose at the hospital was 780. Camera reviewed and nurse did not check the blood glucose level that AM and documented that she did. On 1/9/2023 family member notified nursing facility of the blood glucose and stated that she was not happy because this could have been prevented .
Review of the facility's Medication Deviation Report dated 1/9/2023 revealed that the resident was scheduled a blood glucose on 1/2/2023 at 6:00 am. Nurse charted blood glucose result of 137. The resident's physician's order was blood glucose every am before breakfast with sliding scale. The resident was sent out to emergency room and outcome of deviation was Hyperglycemia. The investigative findings revealed that the resident's family called the facility on 1/9/2023 to inform that lab work showed 656 at 4:29 a.m. and the blood glucose at 6:00 a.m. 137 and then at hospital had 780 blood glucose on 1/2/23.
On 2/20/2023 at 12:50 p.m, an interview was conducted with S2LPN. She stated that she worked the 6p-6a shift. S2LPN stated the resident appeared to be fine during the shift she worked on 1/2/2023. S2LPN stated that routine labs were drawn at 4:00 am, which included the blood glucose level. S2LPN stated that she was off duty when the resident's lab results came in. S2LPN stated she checked the resident's blood glucose level with the blood glucose machine between 4:45 a.m. and 5:45 a.m. in the morning and that the resident's blood glucose results was 137. S2LPN was asked about the blood glucose results on the dates 12/26/2022 to 1/2/2023 when she worked. She stated that she documented the results that she saw on the blood glucose machine and on those dates the results were 137. S2LPN stated that she did not know about the resident being admitted to the hospital until later. S2LPN stated that S1DON (Director of Nurses) spoke to her concerning the blood glucose results and she stated that she told him the same thing and that 137 was the result that she saw on the machine.
On 2/20/2023 at 2:40 p.m., an interview was conducted with S1DON. He stated that on 1/9/2023, the resident's daughter had brought to his attention that the resident's blood glucose that was drawn on 1/2/2023 at 4:49 a.m. was 656 and that the nurse at the facility told her the blood glucose was 137. S1DON stated that was when he checked to see what the nurse had documented. S1DON stated that S2LPN had documented 137 for the resident's blood glucose results for 8 days from 12/26/2022 to 1/2/2023. He stated that it did not look right, so he went and checked video footage to see if the nurse had actually went in the room and performed the blood glucose check. S1DON stated he viewed camera footage from 4:45 a.m. to 6:30 a.m. on 1/2/2023 and S2LPN was by the resident's room door. He did not see the nurse go in the resident's room with the blood glucose machine. Instead, she walked away with the blood glucose machine. S1DON stated that he spoke to S2LPN and she told him that she did check the resident's blood glucose levels on those dates. S1DON stated that the nurse later called him back and told him that on the morning of 1/2/2023 that she had not checked the resident's blood glucose levels that morning.
On 2/20/2023 at 4:11 p.m., the nurse was observed conducting blood glucose testing on resident #4. The nurse was observed to conduct the test appropriately and document the result accurately on the MAR (Medication Administration Record).
On 2/20/2023 at 3:20 p.m., S1DON provided documentation of in-service training for the nursing staff. The training included instructions on blood glucose checks and that blood glucose results must be completed and charted appropriately. S1DON stated that he physically observed the nursing staff perform the resident's blood glucose weekly to ensure the blood glucose were being done and documented accurately.
On 2/20/2023 at 4:20 pm, an interview was conducted with S4LPN. She stated that the staff was in-serviced on performing blood glucose checks and documenting the blood glucose results.
On 2/22/2023 at 8:50 am, an interview was conducted with S5LPN. S5LPN stated that she was in-serviced on blood glucose checks a month ago and that S1DON and Assistant Director of Nurses (ADON) observed her perform the blood glucose checks.
The facility has implemented the following actions to correct the deficient practice:
Quality Assurance Action Plan:
POC (plan of correction)- CBGs
In order to ensure that the deficient practice does not reoccur for any and all other residents in the facility, the Director of Nursing and or facility designee will in-service the nursing staff on following the policy and procedure on blood glucose monitoring to ensure that all residents who are on scheduled blood glucose checks are consistent and are accurately transcribed with the physician order. A review will be conducted to ensure that monitoring of blood glucose levels are occurring in the facility.
The blood glucose monitoring in-service was conducted on 1/10/2023. Reviewed the weekly monitoring logs that were provided by S1DON.
A review was conducted on all residents with scheduled blood glucose checks to ensure no discrepancies re-occurred within the facility. The resident was transferred to a higher level of care for hyperglycemia monitoring but did not have an adverse event. No other residents were affected.
The Director of Nursing and or Facility Designee will perform weekly random quality measure checks on residents who have scheduled blood glucose checks to ensure consistency with blood glucose are present and documented accurately in the residents' EMR (Electronic Medical Record). The Director of Nursing or Facility Designee will monitor for 90 days and will re-evaluate POC to determine if the compliance is met or revision needs to be conducted. Date of compliance is 2/1/2023.
The policy and procedure has been updated for blood glucose to reflect changes to prevent adverse events from re-occurring. The nurse in question was agency and was terminated/Do not return to facility and removed from schedule permanently. Blood glucose control log was updated to reflect hi and low numbers for control test.
Any staff member observed to not be in compliance with the practice is subject to further disciplinary action including possible termination.
S2LPN was an agency nurse and was terminated from the facility. The staffing agency was informed that S2LPN was a DNR (Do Not Return).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the nurse informed the physician of a critical blood glucose...
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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 the nurse informed the physician of a critical blood glucose result for 1 (#3) resident out of 5 (#1-#5) residents diagnosed with Diabetes.
Findings:
Review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revealed, Policy Statement Our facility promptly notifies . his or her attending physician . of changes in the resident's medical/mental condition and/or status . Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(n): . d. significant change in the resident's physical/emotional/mental condition; . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition status .
Resident #3. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Alzheimer's Disease, Major Depressive Disorder, Aphasia, Dysphagia, Diabetes, Chronic Kidney Disease, and Unspecified Protein Calorie Malnutrition.
Review of the resident's care plan dated 10/18/2022 revealed the resident had Diabetes Mellitus. The interventions included obtain labs as ordered and notify MD/NP (Medical Doctor/Nurse Practitioner) of results.
Review of the resident's nurse's note dated 1/2/2023 at 10:00 am revealed, Resident being sent to (hospital emergency room) at this time per family request .
Review of the resident's lab report dated 1/2/2023 revealed that a blood specimen was collected for a comprehensive metabolic panel on 1/2/2023 at 4:29 am. The results of the panel dated 1/2/2023 at 9:56 am revealed the resident's blood glucose level was 656. The narrative note on the lab report revealed, Critical result called to S3LPN (Licensed Practical Nurse) 1/2/2023 at 0956. There was no evidence in the resident's electronic clinical record that S3LPN notified the physician or nurse practitioner of the resident's critical blood glucose result.
On 2/22/2023 at 10:55 am, an interview was conducted with S3LPN. She confirmed that she did receive a call from the lab on 1/2/2023 that Resident #3 had a critical blood glucose level. She stated that she could not remember what the critical blood glucose result was, but she remembered that it was really high. S3LPN stated that she did not remember if she documented the resident's critical blood glucose level in the resident's clinical record or documented that the physician was notified concerning the critical blood glucose level.
On 2/22/2023 at 11:05 am, an interview was conducted with S1DON (Director of Nurses). He stated that S3LPN did not report that the hospital had called in a critical blood glucose result the morning the resident was transferred to the hospital. S1DON confirmed that S3LPN did not document that she received a call from the lab concerning a critical blood glucose result or that it was reported to the physician.
Sept 2022
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to inform the resident or his or her legal representative in writing that Medicare services may not be covered and of the resident's or benefi...
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Based on interview and record review, the facility failed to inform the resident or his or her legal representative in writing that Medicare services may not be covered and of the resident's or beneficiary's potential liability for payment for the non-covered services for 1 (Resident #321) out of 3 (Resident #33, Resident #52, Resident #321 sampled residents for reviewed for Beneficiary Notice. The facility had a census of 69 residents.
Findings:
A review of the SNF Beneficiary Protection Notification Review form completed by the facility revealed that a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), Form CMS-10055 was not provided to the resident. A Notice of Medicare Non-Coverage (NOMNC) (CMS10123) was not provided to the resident.
An interview was conducted with S5SSD on 9/21/22 at 10:55 am. She stated a SNF ABN and NOMNC was not provided to the resident or legal representative. She stated the resident admitted to facility on 6/6/22 for Medicare Part A Skilled Services. The resident discharged from the facility on 7/6/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of the reason for the transfer/discharge to the hospital in a language they understand for 1 (#39) of 3 (#39, #52, #62) residents investigated for hospitalizations.
Findings:
Review of Resident #39's electronic medical record revealed she was admitted to the facility on [DATE] with diagnosis including Aphasia and Bipolar type Schizoaffective Disorder. The resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 01 indicating the resident's cognition was severely impaired.
Review of the resident's progress nursing notes June 2022- August 2022 revealed the resident was transferred to an inpatient mental health hospital for inpatient treatment for combative behavior towards nursing staff on 6/30/22. Further review revealed the resident was transferred again on 8/14/22 to receive inpatient treatment at a mental health hospital for slapping another resident on the forearm.
Review of the Ombudsman Notification of Transfer logs June 2022- August 2022 revealed Resident #39's transfer dates of 6/30/22 and 8/14/22. Review of the column titled written notification to resident date revealed the statement covid 19. There was no documentation that a written notification had been sent to the resident's RP (responsible party).
On 09/21/22 at 07:48 AM, an interview was conducted with S2DON who stated that Resident #39 was transferred to a behavioral health hospital on 6/30/22 and 8/14/22 to receive in-patient treatment for hitting staff and another resident.
On 09/21/22 at 07:55 AM, a phone interview was conducted with Resident #39's RP who confirmed the resident was transferred to the behavioral health hospital for in-patient treatment on 6/30/22 and 8/14/22. She further stated that she did not receive written notification regarding any of resident's transfers.
On 09/21/22 at 08:37 AM, an interview was conducted with S5SSD who stated that she completed the Ombudsman Notification Transfer logs. S5SSD stated that covid 19 was noted in the column marked written notification to resident date because the family was not able to come into the facility to sign and receive a copy of the transfer forms in person. She stated that S13WC was responsible for mailing transfer notifications to the families. S5SSD stated that S13WC was currently on vacation and not available for interview, but she would provide a binder containing records of mailed notifications S13WC maintained.
On 09/21/22 at 08:50 AM, a review of the transfer notification binder was conducted with S5SSD. S5SSD confirmed there was no documentation that written notifications were sent to Resident #39's RP on 6/30/22 and 8/14/22. When asked about the facility's policy regarding notification of transfers, S5SSD provided a copy of the facility's September newsletter sent out to families which read in part: You will be receiving a copy of our bed hold policy by mail each time your family member will be admitted to any other healthcare facility (ER, Hospital, Psych Facility, LTAC, etc.) S5SSD stated that a copy of the transfer form detailing reason and location of transfer should have been mailed to the resident's RP after each transfer.
On 09/21/22 at 09:07 AM, an interview and record review was conducted with S1ADM who stated that the facility did not have a policy regarding notifications of facility initiated transfers. S1ADM stated that a copy of the facility's bed hold policy and a copy of the transfer form should be sent out to the residents' RP each time the resident is transferred out to another facility as stated in the September newsletter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide to the resident and the resident representative written not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy for 1 (#39) of 3 (#39, #52, #62) residents investigated for hospitalizations.
Findings:
Review of Resident #39's electronic medical record revealed she was admitted to the facility on [DATE] with diagnosis including Aphasia and Bipolar type Schizoaffective Disorder. The resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 01 indicating the resident's cognition was severely impaired.
Review of the resident's progress nursing notes June 2022- August 2022 revealed the resident was transferred to an inpatient mental health hospital for inpatient treatment for combative behavior towards nursing staff on 6/30/22. Further review revealed the resident was transferred again on 8/14/22 to receive inpatient treatment at a mental health hospital for slapping another resident on the forearm.
Review of the Ombudsman Notification of Transfer logs June 2022- August 2022 revealed Resident #39's transfer dates of 6/30/22 and 8/14/22. Review of the column titled written notification to resident date revealed the statement covid 19. There was no documentation that a written notification had been sent to the resident's RP (responsible party).
On 09/21/22 at 07:48 AM, an interview was conducted with S2DON who stated that Resident #39 was transferred to a behavioral health hospital on 6/30/22 and 8/14/22 to receive in-patient treatment for hitting staff and another resident.
On 09/21/22 at 07:55 AM, a phone interview was conducted with Resident #39's RP who confirmed the resident was transferred to the behavioral health hospital for in-patient treatment on 6/30/22 and 8/14/22. She further stated that she did not receive a copy of the facility's bed hold policy after any of resident's transfers.
On 09/21/22 at 08:37 AM, an interview was conducted with S5SSD who stated that she completed the Ombudsman Notification Transfer logs. S5SSD stated that covid 19 was noted in the column marked written notification to resident date because the family was not able to come into the facility to sign and receive a copy of the bed hold and transfer forms in person. She stated that S13WC was responsible for mailing a copy of the bed hold policy to the families. S5SSD stated that S13WC was currently on vacation and not available for interview, but she would provide a binder containing records of mailed notifications S13WC maintained.
On 09/21/22 at 08:50 AM, a review of the transfer notification binder was conducted with S5SSD. S5SSD confirmed there was no documentation that a copy of the facility's bed hold policy was sent to Resident #39's RP on 6/30/22 and 8/14/22. When asked about the facility's policy regarding notification of transfers, S5SSD provided a copy of the facility's September newsletter sent out to families which read in part: You will be receiving a copy of our bed hold policy by mail each time your family member will be admitted to any other healthcare facility (ER, Hospital, Psych Facility, LTAC, etc.) S5SSD stated that a copy of the facility's bed hold policy should have been mailed to the resident's RP after each transfer.
On 09/21/22 at 09:07 AM, an interview and record review was conducted with S1ADM who stated that the facility did not have a policy regarding notifications of facility initiated transfers. S1ADM stated that a copy of the facility's bed hold policy and transfer form should be sent out to the residents' RP each time the resident is transferred out to another facility as stated in the September newsletter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8
A review of the incident report notes dated [DATE] revealed that the resident was sent to ______ for evaluation of l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8
A review of the incident report notes dated [DATE] revealed that the resident was sent to ______ for evaluation of left hand/wrist. The X-ray results revealed fracture of distal end of left radius.
A review of resident # 8's significant change MDS revealed an ARD of [DATE]. The resident's significant change was completed greater than 14 days after the significant change was identified.
On [DATE] at 11:15 a.m., S4MDS reviewed resident #8's significant change MDS assessments and confirmed the assessments were not completed timely.
Based on record reviews and interviews, the facility failed to ensure residents' comprehensive minimum data set (MDS) assessments were completed timely by failing to complete an annual assessment for 2 residents ( #1,#4), failing to complete a signifcant change assessment timely for 1 resident (#8) and failing to complete a death in facility assessment for 1 resident (#6) out of 42 sampled residents.
Findings:
A review of resident #1's annual MDS revealed an assessment reference date (ARD) of [DATE]. The status of the MDS was in progress indicating the assessment was incomplete.
A review of resident # 4's annual MDS revealed an ARD of [DATE]. The status of the MDS was in progress indicating the assessment was incomplete.
A review of resident #6's clinical record revealed he expired in the facility on [DATE]. A review of resident #6's MDS record revealed no death in facility assessment had been initiated.
On [DATE] at 10:51 a.m., S4MDS reviewed resident #1 and #4's annual comprehensive MDS assessments and confirmed the assessments were not completed timely. S4MDS also confirmed resident #6 has expired in the facility and a death in facility assessment had not been done.
On [DATE] at 10:55 a.m., an interview was conducted with S2DON (Director of Nursing). He confirmed he was the Registered Nurse that reviewed and signed for completion of the MDS assessments. He confirmed the assessments for resident #1, #4 and #6 were not completed timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to complete a quarterly minimum data set (MDS) assessment within the required timeframe for 3 (#2, # 3, #5) out of 41 sampled residents.
Fin...
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Based on record reviews and interviews, the facility failed to complete a quarterly minimum data set (MDS) assessment within the required timeframe for 3 (#2, # 3, #5) out of 41 sampled residents.
Findings:
A review of resident #2's quarterly MDS assessment revealed an assessment reference date (ARD) of 08/16/2022. The status of the MDS was in progress indicating the assessment was incomplete.
A review of resident #3's quarterly MDS assessment revealed an ARD of 08/16/2022. The status of the MDS was in progress indicating the assessment was incomplete.
A review of resident #5's quarterly MDS assessment revealed an ARD of 08/16/2022. The status of the MDS was in progress indicating the assessment was incomplete.
On 9/20/2022 at 10:51 a.m., S4MDS reviewed resident #2, #3, and #5's quarterly MDS assessments and confirmed the assessments were not completed timely.
On 9/20/2022 at 10:55 a.m., an interview was conducted with S2DON (Director of Nursing). He confirmed he was the Registered Nurse that reviewed and signed for completion of the MDS assessments. He confirmed the assessments for resident #2, #3, and #5 were not completed timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurate...
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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 the resident's Minimum Data Set (MDS) was completed accurately for 1 (#8) resident out of a finalized sample of 42 residents.
Findings:
Review of the facility's Wandering and Elopement Policy stated in part: The MDS nurse will conduct a wandering and elopement risk assessment quarterly and/or when significant change occurs triggering the assessment.
A review of Resident #8's chart revealed an admit date of 03/31/2022 with diagnoses that included Aphasia, Unsteady on feet, Alzheimer's, Depression and Psychosis.
A review of Resident #8's care plan revealed the resident was at risk for elopement.
A review of Resident #8's chart revealed the most recent elopement assessment was dated 3/31/22 with a category of High risk.
A review of Resident #8's significant change MDS dated [DATE] revealed a BIMS (Brief interview for mental status) score of 03. Section E, E0900 Wandering - Presence and Frequency 0 was enter, behavior did not occur.
On 9/20/22 at 11:15 AM an interview was conducted with S4MDS (Minimum Data Set), she review the resident EMR (Electronic Medical Record) and found the last Elopement risk assessment was completed on 3/31/22. She reported the Elopement Risk should be completed with each quarterly MDS for assessment to be documented accurately. She confirmed the most recent MDS completed was dated 5/23/22 and an elopement risk was not completed prior to completion of the MDS.
,
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0741
(Tag F0741)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure that all facility staff received annual dementia, abuse/neglect and violence in the work place training for 3 (#S6LPN, #S7LPN, S8CNA...
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Based on record review and interview, the facility failed to ensure that all facility staff received annual dementia, abuse/neglect and violence in the work place training for 3 (#S6LPN, #S7LPN, S8CNA) staff out of 5 (S6LPN, S7LPN, S8CNA, S9LPN, S12CNA) personnel records reviewed. This had the potential to effect all 52 employees.
Findings:
Review of the facility's personnel records for S6LPN, S7LPN, S8CNA revealed no current dementia, abuse/neglect and violence in the work place training.
Review of S6LPN's (Licensed Practical Nurse) personnel records revealed dementia training, abuse/neglect and violence in the work place last completion date was 3/16/21.
Review of S7LPN's personnel records revealed most current documented education was dated 10/16/2008.
Review of S8CNA's (Certified Nursing Assistant) personnel records revealed she had no annual training since 4/19/2018.
On 9/20/22 at 12:10 PM, an interview was conducted with S6LPN, she stated she did not completed any type of training since she had been hired in 2021.
On 09/21/22 at 11:46 AM, an interview was conducted with S3BOM (Business office manage). She confirmed the training provided in the personnel records was the most current training for the specific training reviewed, Dementia, Abuse/Neglect and Violence in the Work Place. She confirmed she reviewed the in-service binder and there were no additional education for S6LPN, S7LPN and S8CNA.
On 09/21/22 at 12:05 PM, an interview was conducted with S2DON. He reported, if the in-service for Dementia, HIPPA, Abuse/Neglect and Violence in the work place was not in the in-service binder, then there was no current education for the specified training.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #66
Resident #66 admitted to the facility on [DATE] with the following diagnoses: status post syncope and subsequent fr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #66
Resident #66 admitted to the facility on [DATE] with the following diagnoses: status post syncope and subsequent fracture of right toes 2nd, 3rd, 4th, Diabetes Mellitus, Alzheimer's disease. Other diagnoses included, in part: Major depressive disorder without psychotic features, dementia with behavioral disturbances.
A review of Resident #66's Physician Orders included the following, in part:
1)
Aricept 10 milligram (mg) by mouth at bedtime
2)
Neurontin 100mg by mouth at bedtime
3)
Victoza Solution Pen-Injector 18mg/3 milliliter (ML) Inject 1.8mg subcutaneously at bedtime
4)
Antidepressive Medication-Monitor for worsening of depression, suicidal thoughts, anxiety, agitation, insomnia, irritability, hostility, severe restlessness, and mania every shift
5)
Antipsychotic medication-Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, Extrapyramidal symptoms (EPS)(tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift
6)
Assess for pain every shift and as needed
7)
Behaviors-Monitor for the following: itching, picking at skin, restlessness, agitation, hitting,, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care every shift
8)
Census check every hour every shift
9)
Coreg 25mg by mouth two times a day
10)
Detrol 2mg by mouth two times a day
11)
Ferrousul 325mg by mouth two times a day
12)
Monitor bowel movement every shift
13)
Monitor side effects for all medications every shift
14)
Namenda 10mg by mouth two times a day
15)
Nasonex 50microgram (mcg) alternating nostrils two times a day
16)
Non-skid socks. Monitor every shift for fall intervention
17)
Oxygen saturation and temp every shift
18)
Padded side rails to bed daily every shift
19)
Pressure relief reduction mattress every shift
20)
Snack three times a day between meals every day and night shift
21)
Tresiba FlexTouch 100 unit/ml-Inject 20 unit subcutaneously two times a day
22)
Bed Alarm to bed; monitor every shift for proper functioning every shift
23)
Insulin Aspart -Inject as per sliding scale: if 0-64 give 4 ounces orange juice or glucose gel (24 gram) and repeat Capillary blood glucose (CBG) in 15 minutes; 65-200= do nothing; 201- 250=3 units; 251-300=6 units; 301-350=9 units; 351-400=12 units; 401+ =or greater give 15 units subcutaneously three times a day
24)
Offer resident to get up in wheelchair when restless as tolerated every shift for intervention for fall
25)
Give 8 ounces water/fluids four times a day
26)
House supplement four times a day for weight loss/protein calorie malnutrition (PCM) give 8 ounces sugar free/NSA
27)
Tramadol 50mg by mouth every 6 hours
A review of Resident #66's Medication Administration Record (MAR) for September 2022 revealed missing medication administration documentation. On 9/4/2022 and 9/17/22, the following medications and orders were not documented as administered: Aricept, Neurontin, Victoza, Antidepressive Medication-Monitor, Antipsychotic Medication-Monitor, Assess for pain, Behaviors-Monitor, Census check every hour every shift, Coreg, Detrol, Monitor bowel movement (BM) every shift, Monitor side effects for all medications, Namenda, Nasonex, non-skid socks, Oxygen (O2) saturation and temperature every shift, padded side rails to bed, pressure relief reduction mattress every shift, Snacks three times a day(TID) between meals, Tresiba, Bed Alarm, Insulin Aspart per sliding scale/ Capillary Blood Glucose (CBG) test , Offer resident to get up in wheelchair when restless, Give 8 ounces water/fluids, and House supplement. On 9/5/22, the following medications were not documented as administered: Tresiba, Insulin Aspart per sliding scale/ Capillary Blood Glucose (CBG) test, and Tramadol. On 9/7/22, the following were not documented: Monitor bowel movement every shift, Tresiba, Insulin Aspart per sliding scale/ Capillary Blood Glucose (CBG) test, and Tramadol. On 9/9/22, the following were not documented: Monitor bowel movement every shift, Oxygen saturation and temperature. On 9/17/22, the following medications were also not documented: FerroSul and Tramadol. On 9/18/22, the following were not documented: Tramadol, FerroSul, Monitor bowel movement every shift, Tresiba, Insulin Aspart per sliding scale/ Capillary Blood Glucose (CBG) test , Give 8 ounces water/fluids, and House supplement. On 9/19/22, the following were not documented: Aricept, Neurontin, Victoza, Coreg, Detrol, Namenda, Nasonex, Tresiba, and Insulin Aspart per sliding scale/ Capillary Blood Glucose (CBG) test CBG, Give 8 ounces water/fluids, and House supplement.
An interview was conducted on 9/21/22 at 12:20 p.m. with S2DON. He confirmed the lack of documentation on the MAR for September 2022. He stated the medication was administered, but the documentation in MAR was not completed.
Based on record review and interview, the facility failed to ensure accurate documentation of medication administration on the Medication Administration Record (MAR) for 2 residents (Resident #47, Resident #66) out of a sample of 41 residents. This deficient practice had the potential to affect a census of 69 residents.
Findings include:
A review of the Documentation of Medication Administration policy revealed the following: The facility shall maintain a medication administration record to document all medications administered to each resident on the resident's medication administration record (MAR). Implementation: 1) A nurse or certified medication aide shall document all medications administered to each resident on the resident's medication administration record (MAR). 2) Administration of medication must be documented immediately after (never before) it is given. 3)Documentation must include, as a minimum (name and strength of drug, dosage, method of administration, date and time of administration, reasons why a medication was withheld, not administered, or refused, signature and title of the person administering the medication, resident response to the medication, if applicable.
Resident #47: Resident #47 admitted to the facility on [DATE] with diagnoses that included protein calorie malnutrition, hypothyroidism, major depressive disorder, diabetes, hypertension, peripheral vascular disease, Alzheimer's disease, muscle wasting, aphasia, and dysphagia
A review of Resident #47's physician monitoring order for July 2022 included the following, in part:
(1)
Blood pressure and pulse checks every 3 days every night shift.
(2)
Assess for pain every shift and as needed.
(3)
Behaviors- monitor for the following, in part: restlessness, agitation, hitting, increase in complaints, aggression, refusing care. Monitor every shift.
(4)
Monitor side effects for all medication every shift.
(5)
O2 (oxygen saturation level) and temperature every day and night shift
(6)
Quarter Rails for bed support and repositioning every shift.
(7)
Census check every 2 hours every shift
(8)
Heel protectors on bilateral heels while in bed as tolerated every shift
(9)
Maintain pommel cushion when up in WC (wheelchair). Check proper placement of cushion and positioning of resident every shift.
(10)
Monitor BM (bowel movement) every shift.
(11)
Turn and reposition every 2 hours as tolerated every shift.
Further review of Resident #47's Medication Administration Record (MAR) for dates 07/01/2022 to 07/31/2022 revealed there was no documented initials that orders were monitored and/or rendered for the night shift on dates 7/6/2022, 7/8/2022, 7/16/2022, 7/20/2022, 7/23/2022, and 7/27/2022 for the following:
(1)
Blood pressure, pulse, pain assessment, oxygen saturation, temperature checks
(2)
Assessment for pain
(3)
Behavior monitoring
(4)
Monitoring for side effects for all medications
(5)
Monitoring for bowel movements
There was no documented initials for the night shift on dates 7/8/2022, 7/16/2022, 7/23/2022 and 7/27/2022 for monitoring of:
(1)
Quarter rails
(2)
Census checks
(3)
Heel protectors on bilateral heels while in bed
(4)
Pommel cushion while up in wheelchair, checking proper placement and positioning
(5)
Turn and reposition as tolerated.
An interview on 9/21/2022 at 2:15 p.m. was conducted with S2DON during which he reviewed the MAR for July 2022 and confirmed that there was missing documentation for several days. He stated he has agency nursing staff that does not always document.
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
- "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
- • 29 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $24,065 in fines. Higher than 94% of Louisiana facilities, suggesting repeated compliance issues.
- • Grade D (48/100). Below average facility with significant concerns.
- • 63% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Courtyard Manor Nurse & Assisted Liv's CMS Rating?
CMS assigns COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV an overall rating of 3 out of 5 stars, which is considered average nationally. Within Louisiana, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Courtyard Manor Nurse & Assisted Liv Staffed?
CMS rates COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 63%, which is 17 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 Courtyard Manor Nurse & Assisted Liv?
State health inspectors documented 29 deficiencies at COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV during 2022 to 2024. These included: 1 that caused actual resident harm and 28 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Courtyard Manor Nurse & Assisted Liv?
COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 92 certified beds and approximately 74 residents (about 80% occupancy), it is a smaller facility located in LAFAYETTE, Louisiana.
How Does Courtyard Manor Nurse & Assisted Liv Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV's overall rating (3 stars) is above the state average of 2.4, staff turnover (63%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Courtyard Manor Nurse & Assisted Liv?
Based on this facility's data, families visiting should ask: "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?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Courtyard Manor Nurse & Assisted Liv Safe?
Based on CMS inspection data, COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Courtyard Manor Nurse & Assisted Liv Stick Around?
Staff turnover at COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV is high. At 63%, the facility is 17 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 Courtyard Manor Nurse & Assisted Liv Ever Fined?
COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV has been fined $24,065 across 3 penalty actions. This is below the Louisiana average of $33,320. 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 Courtyard Manor Nurse & Assisted Liv on Any Federal Watch List?
COURTYARD MANOR NURSE CARE CENTER & ASSISTED LIV 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.