Twin Oaks Nursing Home
For profit - Corporation
148 Beds
INSPIRED HEALTHCARE MANAGEMENT
Data: November 2025
Trust Grade
23/100
#259 of 264 in LA
Photo by Twin Oaks Nursing Home
Photo by Twin Oaks Nursing Home
Photo by Twin Oaks Nursing Home
1 / 5 photos
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Twin Oaks Nursing Home has a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #259 out of 264 facilities in Louisiana, placing it in the bottom half of all nursing homes in the state and is the second lowest option in St. John the Baptist County. Although the facility is showing improvement, with issues decreasing from 17 in 2024 to 9 in 2025, it still has a concerning number of deficiencies, totaling 45, with no critical or serious harm reported but all being potential harm concerns. Staffing is average with a rating of 3/5 stars and a turnover rate of 54%, which is close to the state average. While the RN coverage is good, exceeding that of 91% of Louisiana facilities, specific incidents such as failing to notify the State Ombudsman of discharges and neglecting the behavioral health needs of residents raise red flags about the overall care provided.
- Trust Score
- F
- In Louisiana
- #259/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $15,000 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 45 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 2%
Review needed
17 → 9 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 54%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $15,000
Below median ($33,413)
Minor penalties assessed
Chain: INSPIRED HEALTHCARE MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 45 deficiencies on record
Aug 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure a resident's room was maintained free of odors, soiled linens, a spill, and debris for 1 (Resident #56) of 7 (Resident #1, Resident ...
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Based on observations and interviews, the facility failed to ensure a resident's room was maintained free of odors, soiled linens, a spill, and debris for 1 (Resident #56) of 7 (Resident #1, Resident #12, Resident #45, Resident #49, Resident #56, Resident #83, Resident #89) sampled residents investigated for environment. Findings: Observation on 08/11/2025 at 9:26AM, revealed Resident #56's room had a strong unpleasant odor. Observation further revealed linens with an odor were piled on Resident #56's roommate's bed. Further observation of Resident #56's room revealed a small puddle of an unknown liquid by the door, small pieces of paper, a straw, and other small white colored debris scattered on the floor. In an interview on 08/11/2025 at 9:31AM, S7Certified Nursing Assistant (CNA) confirmed the presence of a strong urine odor, soiled linen on Resident #56's roommate's bed, trash and debris on the floor, and a spill by the door. In an interview on 08/13/2025 at 1:42PM, S2Director of Nursing stated S7CNA confirmed the above findings in Resident #56's room. S2DON acknowledged Resident #56's room should not have been in that state.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure respiratory nebulizer tubing was changed and dated 1 (Resident #22) of 8(Resident #1, Resident #12, Resident #13, Resi...
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Based on observation, interview, and record review, the facility failed to ensure respiratory nebulizer tubing was changed and dated 1 (Resident #22) of 8(Resident #1, Resident #12, Resident #13, Resident #15, Resident #22, Resident #49, Resident #56 and Resident #89) sampled residents investigated for respiratory care. Findings:Review of Resident #22's July 2025 and August 2025 physician's orders revealed, in part, the nurse was to change and date all respiratory tubing/supplies/storage bag every Sunday on the 11:00PM to 7:00AM shift. Observation on 08/11/2025 at 9:58AM revealed Resident #22's nebulizer tubing was dated 07/07/2025. Observation on 08/12/2025 at 2:45PM revealed Resident #22's nebulizer tubing was dated 07/07/2025.In an interview on 08/13/2025 at 1:09PM, S18Licensed Practical Nurse (LPN) indicated nebulizer tubing should be changed every week on Sunday. In an interview on 08/13/2025 at 1:11PM, S17LPN indicated nebulizer tubing should be changed every week on Sunday night. Observation on 08/13/2025 at 1:17PM Resident #22's nebulizer tubing was dated 07/07/2025. In an interview on 08/13/2025 at 1:19PM, S2Director of Nursing (DON) indicated nebulizer tubing was to be changed and dated, with the date tubing was changed, weekly. Observation completed with S2DON on 08/13/2025 at 2:05PM revealed Resident #22's nebulizer tubing was dated 07/07/2025. In an interview on 08/13/2025 at 2:05PM, S2DON confirmed Resident #22's nebulizer tubing had not been changed since 07/07/2025 and should be changed weekly.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, the facility failed to ensure menu substitutions were approved by the facility's dietician. Findings:Review of the facility's approved lunch menu for ...
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Based on observations, interviews, record review, the facility failed to ensure menu substitutions were approved by the facility's dietician. Findings:Review of the facility's approved lunch menu for 08/11/2025 revealed, in part, the facility was to serve white beans, ham, steamed rice, and brussel sprouts.Observation on 08/11/2025 at 12:05PM revealed the lunch menu served was white beans, rice, and beets.In an interview on 08/12/2025 at 10:45AM, S12Dietary Manager (DM) indicated she did not document the substitution of beets for the 08/11/2025, nor had she notified S19RD for approval of the substitution. In an interview on 08/12/2025 at 2:47PM, S1Administrator indicated the before menu revision should have been documented, and S19Registered Dietician (RD) should have been notified of the above mentioned menu change.In an interview on 08/12/2025 at 3:47PM, S19RD indicated the facility had not notified him of the above mentioned substitution. There was no documented evidence, and the facility could not produce any documented evidence, S19RD was notified of the revision to the facility's lunch menu on 08/11/2025.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations and interviews the facility failed to:1. Ensure food items stored in the facility's three door refrigerator and the facility's freezer were dated once opened; 2. Ensure food item...
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Based on observations and interviews the facility failed to:1. Ensure food items stored in the facility's three door refrigerator and the facility's freezer were dated once opened; 2. Ensure food items stored in the facility's three door refrigerator were covered; 3. Ensure food items from an outside source which were stored in the facility's freezer were labeled; and, 4. Ensure the sanitization test strips used to test the amount of sanitization in the dishwasher were not expired. Findings: 1. Observation on 08/12/2025 at 8:20AM revealed three undated disposable bowls with round multi colored dry cereal, and one undated disposable bowl of dry corn cereal in the facility's three door refrigerator. In an interview on 08/12/2025 at 8:30AM, S12Dietary Manager (DM) indicated the above mentioned items in the facility's three door refrigerator should have been labeled with an opened date. Observation on 08/12/2025 at 9:10AM revealed an undated partially used container of frozen chicken liver in the facility's freezer. In an interview on 08/11/2025 at 9:10AM, S12DM indicated the above mentioned item should have been labeled with an opened date once in the facility's freezer. In an interview on 8/12/2025 at 2:47PM, S1Administrator indicated above mentioned item should have been labeled with an opened date once in the facility's freezer. Observation on 08/12/2025 at 8:20AM revealed three disposable cups of a pudding like substance with no opened date in the facility's three door refrigerator. In an interview on 08/12/2025 at 8:21AM, S12DM indicated the above mentioned items in the facility's three door refrigerator should have have been labeled with an opened date. In an interview on 8/12/2025 at 2:47PM, S1Administrator indicated the above-mentioned items should have had an open date once opened. 2.Observation on 08/12/2025 at 8:20AM revealed three disposable cups of a pudding like substance not covered and in the facility's three door refrigerator. In an interview on 08/12/2025 at 8:21AM, S12DM indicated the above mentioned items in the facility's three door refrigerator should have been covered. In an interview on 8/12/2025 at 2:47PM, S1Administrator indicated the above-mentioned items should have been covered. 3. Review of the facility's Preventing Foodborne Illness policy and procedure, revised July 2014, revealed the facility only accepted prepared foods from suppliers subject to federal, state or local food service inspections and who remain in good standing with such agencies. Observation on 08/11/2025 at 9:10AM revealed a bottle of frozen hydrate alkaline water and a frozen bottle of an electrolyte drink were stored in the facility's freezer and not labeled to indicate they were from an outside food source and not from an approved supplier. In an interview on 08/11/2025 at 9:11AM, S12DM indicated the above-mentioned bottle of electrolyte drink was for a resident was from an outside source. S12DM further indicated the above-mentioned frozen bottle of hydrate alkaline water was from an outside source. In an interview on 08/12/2025 at 2:47PM, S1Administrator indicated the above mentioned items should not have been in the facility's freezer. 4. Observation on 08/13/2025 at 12:06PM revealed the sanitization test strips for the facility's low temperature dishwasher had an expiration date of 07/2025. In an interview on 08/13/2025 at 12:06PM, confirmed the sanitization test strips with an expiration date of 07/2025 were expired and should not have been used.
Apr 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #4) of 4 (Resident #1, Resident #2, Reside...
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Based on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents reviewed for resident rights.
Findings:
Review of the facility's undated Abuse, Neglect and Misappropriation of Funds Program policy revealed, in part, abuse was defined as the willful infliction of injury which resulted in physical harm or pain. Further review revealed physical abuse way defined as hitting, slapping, pinching, kicking and any other means used to cause physical injury to a resident.
Review of Resident #4's Electronic Medical Record (EMR) revealed, in part, a note by S4Registered Nurse (RN) dated 11/07/2024 at 10:42AM indicating Resident #4 was complaining of pain to his right upper lip after he was hit by another resident. Further review revealed when S4RN assessed Resident #4 and noted that Resident #4's right upper lip was swollen.
Review of the facility's investigative documents for the above mentioned revealed a written statement signed by S5Certified Nursing Assistant which revealed S5CNA witnessed Resident #2 repeatedly hit Resident #4 in the face.
In an interview on 04/30/2025 at 1:38PM, S6Quality Assurance (QA) Nurse indicated she was one of the employees investigating the incident between Resident #2 and Resident #4. S6QA Nurse further indicated she would not consider the incident which occurred between Resident #2 and Resident #4 as physical abuse because Resident #2 hit Resident #4 because he was digging in his bag.
In an interview on 04/30/2025 at 2:25PM, S4RN indicated she assessed Resident #4 after he was hit in the face by Resident #2 and she noted that his lip was swollen.
In an interview on 04/30/2025 at 2:50PM, S1Administrator confirmed Resident #4 hit Resident #2, but she did not not consider it to be abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview record and reviews, the facility failed to report an incident of resident to resident abuse to the statewide incident management system (SIMS) as required for 2 (Resident #2, Reside...
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Based on interview record and reviews, the facility failed to report an incident of resident to resident abuse to the statewide incident management system (SIMS) as required for 2 (Resident #2, Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents.
Findings:
Review of the facility's undated Abuse, Neglect and Misappropriation of Funds Program policy revealed, in part, abuse was defined as the willful infliction of injury with resulting physical harm or pain. Further review revealed physical abuse is defined as hitting, slapping, pinching, kicking and any other means used to cause physical injury to a resident. Further review revealed if the determination was that abuse occurred or was unable to determine with reasonable certainty, or the injury was unknown and cannot be determine, the incident will be reported by the administrator to the state surveying agency.
Review of Resident #4's Electronic Medical Record (EMR) revealed, in part, a nurse's note by S4Registered Nurse (RN) dated 11/07/2024 at 10:42AM indicating Resident #4 was complaining of pain to his right upper lip after he was hit by another resident. Further review revealed when S4RN assessed Resident #4 she noted that his right upper lip was swollen.
Review of the facility's investigative documents for the above mentioned incident revealed a written statement signed by S5Certified Nursing Assistant (CNA) which revealed S5CNA witnessed Resident #4 repeatedly hit Resident #2 in the face.
In an interview on 04/30/2025 at 2:50PM, S1Administrator confirmed Resident #2 hit Resident #4 but, she did not consider it to be abuse. S1Administrator further confirmed the above mentioned findings were not reported to the SIMS.
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
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure a resident with a new diagnosis of bipolar disorder (a mood...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure a resident with a new diagnosis of bipolar disorder (a mood disorder that can cause intense mood swings) was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #3) of 2 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for PASARR.
Findings:
Review of Resident #3's electronic medical record (EMR) revealed, in part, Resident #3 was admitted to the facility on [DATE] with a Level I PASARR which was approved for a temporary period from 01/22/2024 through 04/20/2024 for skilled therapies. Further review revealed Resident #3 received another Level I PASARR screening dated 04/21/2024 indicating Level II services were not required.
Review of Resident #3's psychiatric assessment completed on 02/07/2025 revealed, in part, Resident #3 received a new diagnosis of bipolar disorder.
Review of Resident #3's EMR revealed no documented evidence, and the facility did not present any documented evidence, that a Level II PASARR screening was completed for Resident #3 after his new diagnosis of bipolar disorder.
In an interview on 04/29/2025 at 3:10PM, S3Social Worker indicated she had never completed a new referral to the Office of Behavioral Health for a PASARR Level II screening for Resident #3 after his new diagnosis of bipolar disorder, as required.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 2 (Resident #3, Resident R1) of 3 (Resident #1, Resident #3, Res...
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Based on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of discharges in writing for 2 (Resident #3, Resident R1) of 3 (Resident #1, Resident #3, Resident R1) sampled residents reviewed for discharge requirements.
Findings:
Resident #3
Review of Resident #3's electronic medical record (EMR), in part, revealed he was discharged from the facility on 03/05/2025.
Resident R1
Review of Resident R1's EMR, in part, revealed she was discharged from the facility on 01/11/2025.
The facility did not present any documented evidence the State's Long-Term Care Ombudsman was notified of Resident #3 or Resident R1's discharge in writing as required.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on record reviews and interview, the facility failed to ensure its facility-wide assessment addressed the behavioral health needs of its resident population as required .
This deficient practic...
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Based on record reviews and interview, the facility failed to ensure its facility-wide assessment addressed the behavioral health needs of its resident population as required .
This deficient practice was identified for 3 (Resident #2, Resident #3, Resident #4) of 2 (Resident #2, Resident #3, Resident #4) sampled residents reviewed for behavioral health needs.
Findings :
Review of the facility's matrix revealed 42 residents were identified as having behavioral health needs
Review of the facility's September 2024 facility-wide assessment last revised September 2024 revealed no documented evidence and the facility did not present any documented evidence its facility wide assessment addressed the behavioral health needs of its resident population, staff competencies related to the behavioral health needs of its resident population, or facility resources necessary to care for the behavioral health needs of its resident population.
In an interview on 04/30/2025 at 4:15PM, S1Administrator confirmed the above mentioned findings.
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Reside...
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Based on record reviews and interviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for neglect.
Findings:
Review of the facility's Policy for Prohibition of Abuse, Neglect and Misappropriation of Property revised on 08/05/2024 revealed, in part, the facility will have evidence of a thorough investigation of all alleged violations.
Review of the facility's records revealed a report dated 08/21/2024 revealed, in part, in which the allegation of neglect was reported and investigated for Resident #1. Further review revealed Resident #1 was sent to the hospital due to a drop in blood pressure on 08/21/2024. In the emergency room Resident #1 was found to have gauze and an empty ketchup packet lodged in the back of his throat. Further review of the report revealed the lunch meal on 08/21/2024 included French fries served with ketchup. Further review revealed the camera footage was reviewed by the facility and the footage showed multiple staff members were present in the dining room, Resident #1 had fed himself, and Resident #1 had not placed a ketchup packet in his mouth. The facility's report further revealed Resident #1 did not require wound care and speculated Resident #1 obtained the gauze during the emergency transport to the hospital or when he arrived to the hospital.
Review of Resident #1's August 2024 Physician Orders revealed, in part, Resident #1 had a physician's order implemented on 08/15/2024 to Apply a Bordered Gauze Pad (Gauze Pads & Dressings) to the right knee topically one time a day related to an unspecified open wound to the right knee.
Review of Resident #1's August 2024 Electronic Treatment Administration Record (ETAR) revealed, in part, Resident #1 received the above mentioned application of a gauze pad and/or dressings to his right knee on 08/15/2024 through 08/21/2024.
Review of the facility's camera footage on 09/04/2024 at 12:18 p.m. with S1Administrator and S3CNA Supervisor present revealed, in part, on 08/21/2024 Resident #1 was seated at a table with Random Resident #4 for the lunch meal service. Further review revealed S4Dietary Aide placed Resident #1's lunch tray in front of him on the table. Further review revealed Resident #1 was seen bringing his hands to his face and/or mouth multiple times; however, the footage was out of focus and you could not identify what items Resident #1 brought to his face and/or mouth. Further review revealed S5Housekeeper was observed walking near and/or around Resident #1 while he sat at the table in the dining room.
In an interview on 09/04/2024 at 12:27 p.m., S5Housekeeper indicated the facility administrative staff had not questioned her or asked her to provide a statement of any observations S5Housekeeper made of Resident #1 in the dining room during lunch meal service on 08/21/2024.
In an interview on 09/04/2024 at 12:33 p.m., S4Dietary Aide confirmed she often assisted residents in the dining room during meals services. S4Dietary Aide further indicated the facility administrative staff had not questioned her or asked her to provide a statement of any observations S4Dietary Aide made of Resident #1 in the dining room during lunch meal service on 08/21/2024.
Review of Random Resident #4 revealed, in part, Random Resident #4 had a Brief Interview of Mental Status score of 15 which indicated her cognition was intact.
In an interview on 09/05/2024 at 12:18 p.m., Random Resident #4 indicated the facility staff had not questioned her or asked Random Resident #4 to provide a statement of any observations Random Resident #4 made of Resident #1 while she sat at the table with Resident #1 during the lunch meal service on 08/21/2024.
Review of the facility's investigative documents for Resident #1's facility report on 08/21/2024 revealed, in part, no documented evidence and the facility did not present any documented evidence S5Housekeeper, S4Dietary Aid, or Random Resident #4 was interviewed by administrative staff and/or that a statement was obtained.
In an interview on 09/05/2024 at 2:38 p.m., S1Administrator confirmed Resident #1 had an active wound care order to apply a gauze dressing to Resident #1's right knee which was completed as ordered on August 8/15/2024 through 08/21/2024. S1Administrator indicated she was not aware of the above mentioned wound care orders for Resident #1. S1Administrator confirmed the facility's report for Resident #1 on 08/21/2024 indicated Resident #1 did not have orders for wound care and the information was inaccurate. S1Administrator confirmed Random Resident #4 was not interviewed by the facility's administrative staff of her observation of Resident #1 during the lunch meal service on 08/21/2024. S1Administrator confirmed the facility did not obtain interviews and/or statements from all staff who observed Resident #1 during the lunch meal service on 08/21/2014. S1Administrator further indicated the facility could have done a better job formalizing the information gathered during Resident #1's investigation.
Aug 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to protect client confidentiality for 1 resident (Resident #8) of 32 sampled residents (Resident #1, Resident #3, Resident #8, Resident #11, Res...
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Based on observation and interview, the facility failed to protect client confidentiality for 1 resident (Resident #8) of 32 sampled residents (Resident #1, Resident #3, Resident #8, Resident #11, Resident #15, Resident #25, Resident #21, Resident #24, Resident #28, Resident #29, Resident #40, Resident #43, Resident #47, Resident #53, Resident #54, Resident #56, Resident #57, Resident #60, Resident #6, Resident #67, Resident #68, Resident #70, Resident #73, Resident #78, Resident #80, Resident #88, Resident #86, Resident #87, Resident #89, Resident #340, Resident #34, and Resident #342).
Findings:
Observation on 08/06/2024 at 11:02 a.m. revealed Resident #8's closed exterior side of the door facing the hallway revealed written sign titled, Appointment Sheet. Further observation revealed, in part, Resident #8's written name with Tuesday, Thursday and Saturday goes to dialysis with a pick up time of 5:30 a.m.
In an interview on 08/06/2024 at 12:15 p.m., S10Licensed Practical Nurse (LPN), after reading Resident #8's sign on exterior side of the door that was facing the hallway, indicated it would be a HIPPA violation, Health Insurance Portability and Accountability Act which protected the medical information in patients records and allowed for confidential communication between patients and medical professionals. S10 LPN further indicated people could figure out Resident #8 has end stage renal disease.
In an interview on 08/06/2024 at 3:23 p.m., S4Director of Nursing indicated the sign on Resident #8's exterior door should not be posted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PAS...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR) was completed correctly for 1 (Resident #56) of 1 (Resident #56) residents reviewed for PASARR.
Findings:
Resident #56 was admitted to the facility on [DATE] with diagnoses, in part, of Major Depressive Disorder, Anxiety, and Schizophrenia.
Review of Resident #56's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/23/2024, revealed, in part, diagnosis of Major Depressive Disorder, Anxiety, and Schizophrenia. Further review revealed Resident #56 received antipsychotics on a daily basis.
Review of Resident #56's record revealed a Level- 1 PASARR completed on 10/21/2021. Further review revealed Section 3: Mental Illness was marked yes. Further review revealed a referral was not made to appropriate state designated authority for Level II PASARR evaluation and determination.
In an interview on 08/07/2024 at 2:05 p.m., S3Social Services indicated Resident #56's Level- 1 PASARR was completed incorrectly and a Level II PASARR should have been requested for Resident #56 due to her diagnosis of Major Depressive Disorder, Anxiety, and Schizophrenia.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure a resident was referred for dental services f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure a resident was referred for dental services for 1 (Resident #25) of 3 (Resident #25, Resident #68, and Resident #21) sampled residents reviewed for dental services.
Findings:
Review of Resident #25's medical record revealed, in part, Resident #25 was admitted on [DATE].
Review of Resident #25's care plan with a goal date of 08/21/2024 revealed, in part, the potential for dental issues. Further review revealed care plan approaches to include arranging for dental appointments and periodic dental visits.
Review of Resident #25's records revealed, in part, no documented evidence, and the provider could not provide any documented evidence, Resident #25 was evaluated for dental services.
Review of Facility's resident dental treatment schedule dated 08/19/2024 revealed, in part, Resident #25 was not listed on the schedule for dental services.
Observation on 08/05/2024 at 9:57 a.m. revealed Resident #25 did not have any upper teeth. Further observation revealed Resident #25 only had the front bottom teeth. Further observation revealed Resident #25's remaining bottom teeth were grey colored in the middle.
In an interview on 08/05/2024 at 10:00 a.m., Resident #25 indicated she needed to see the dentist. Resident #25 further indicated she only had 6 teeth left and did not want to lose anymore. Resident #25 further indicated food was sometimes hard to chew.
In an interview on 08/07/2024 at 12:17 p.m., S3SocialServices (SS) indicated she could not find any documentation Resident #25 was evaluated by dental services. S3SS further indicated Resident #25 was not on the dental services patient list. S3SS further indicated Resident #25 should have been evaluated for dental services.
In an interview on 08/07/2024 at 12:32 p.m., S1Administrator confirmed Resident #25 should have been evaluated for dental services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews the facility failed to ensure:
1. Ensure clean items in the facility's laundry room were not kept in the contaminated laundry area, and
2. Ensure...
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Based on observations, interviews, and record reviews the facility failed to ensure:
1. Ensure clean items in the facility's laundry room were not kept in the contaminated laundry area, and
2. Ensure staff wore proper protective equipment and performed hand hygiene during incontinence care for 1 (Resident #24) of 6 (Resident #24, Resident #28, Resident #40, Resident #47, Resident #61, and Resident #78) residents investigated for activities of daily living.
Findings:
1.
Observation on 08/05/2024 at 9:15 a.m. revealed the facility's clean mop heads were hung on wall hooks directly over soiled linen barrels in the facility's contaminated laundry area.
Observation on 08/06/2024 at 10:52 a.m. revealed 15 of the facility's clean mop heads were hung on wall hooks in the facility's contaminated laundry area.
In an interview on 08/06/2024 at 10:52 a.m., S2Laundry Supervisor confirmed the facility's clean mop heads were stored on the wall of the contaminated area of the facility's laundry room.
In an interview on 08/06/2024 at 10:53 a.m., S1Administrator confirmed the facility's clean mop heads were stored on the wall of the contaminated linen area of the facility's laundry room and should not have been.
2.
Review of Facility's Handwashing/Hand Hygiene Policy and Procedure last revised August 2015 revealed, in part, hand hygiene was performed before and after removing gloves. Further review revealed staff should follow the handwashing/hand hygiene procedure to prevent the spread of infection.
Review of Resident #24's Care Plan with a goal date of 09/03/2024 revealed, in part, Resident #24 was on Enhanced Barrier Precaution (EBP) for a right ankle diabetic ulcer. Further review revealed staff were to wear proper EBP and perform hand hygiene before and after providing incontinence care.
Observation on 08/06/2024 at 8:27 a.m. revealed an EBP sign above Resident #24's bed indicating staff must wear PPE during incontinence care.
Observation on 08/06/2024 at 1:50 p.m. revealed S7Certified Nursing Assistant (CNA) entered Resident #24's room to perform incontinence care without a gown on. Further observation revealed S7CNA had on gloves and cleansed Resident #24's vaginal area, removed her gloves, and did not perform hand hygiene. S7CNA then put new gloves on. Further observation revealed S7CNA cleansed Resident #24's buttocks, removed her gloves, and did not perform hand hygiene. S7CNA then put new gloves on, positioned Resident #24, put a new adult brief on, removed gloves, and then performed hand hygiene.
In an interview on 08/06/2024 at 1:49 p.m., S7CNA indicated she should have performed hand hygiene in between glove changes and should have worn a gown when performing incontinence care to Resident #24.
In an interview on 08/07/2024 at 11:00 a.m., S5Assistant Director of Nursing indicated S7CNA should have performed hand hygiene in between glove changes and should have worn a gown when performing incontinence care for Resident #24.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nail care for 2 (Resident #28 and Resident #4...
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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 provide nail care for 2 (Resident #28 and Resident #40) of 6 (Resident #24, Resident #28, Resident #40, Resident #47, Resident #61, and Resident #78) sampled residents investigated for activities of daily living (ADLs).
Findings:
Resident #28
Resident #28 was admitted to the facility on [DATE] with diagnoses of hemiplegia affecting the right side.
Review of Resident #28's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/16/2024 revealed she had impairment on one side of her upper and lower extremities.
Review of Resident #28's Care Plan revealed Resident #28 required assistance with ADLs with a goal to be kept clean, dry and well-groomed.
Observation on 08/06/2024 at 2:20 p.m. revealed Resident #28's toe nails extended past the tips of her toes.
Observation on 08/07/2024 at 9:40 a.m. with S13Certified Nursing Assistant (CNA) and S6MedRecords/CNA Supervisor revealed Resident #28's bilateral toe nails and bilateral fingernails extended past the tips of the nailbeds.
In an interview on 08/07/2024 at 9:42 a.m., S6MedRecords/CNA Supervisor indicated Resident #28's finger nails and toe nails needed to be trimmed.
In an interview on 08/07/2024 at 9:50 a.m., S12Wound Care Nurse confirmed Resident #28's finger nails and toe nails needed to be trimmed.
Resident #40
Resident #40 was admitted to the facility on [DATE] with diagnoses of right side hemiplegia (paralysis on one side of the body).
Review of Resident #40's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/02/2024 revealed Resident #40 had impairment on one side of his upper and lower extremities.
Review of Resident #40's Care Plan revealed Resident #40 had a self-care deficit related right side hemiplegia with goal to be kept clean, dry and well-groomed.
Review of Resident #40's ADL record from 07/23/2024 through 08/06/2024 revealed no documented evidence Resident #40's nails were trimmed.
Observation on 08/06/2024 at 2:25 p.m. revealed Resident #40's nails extended past the tips of his fingers.
Observation on 08/07/2024 at 12:27 p.m. revealed Resident #40's nails extended past the tips of his fingers.
In an interview on 08/07/2024 at 12:30 p.m., S4Director of Nursing indicated Resident #40's nails needed to be trimmed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observations, record reviews, and interviews, the facility failed to develop a plan of care for 1 (Resident #3) of 1 resident (Resident #3) receiving respiratory care by nasal cannula.
Findi...
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Based on observations, record reviews, and interviews, the facility failed to develop a plan of care for 1 (Resident #3) of 1 resident (Resident #3) receiving respiratory care by nasal cannula.
Findings:
Observation on 08/05/2024 at 9:40 a.m. revealed Resident #3 received oxygen at 2 liters per minute (LPM) by nasal cannula.
Review of Resident #3's Minimum Data Set (MDS) with an assessment reference date of 04/29/2024 revealed, in part, a brief interview mental status of 13 which indicated cognitively intact.
Review of Resident #3's Physician Orders dated August 2024 revealed, in part, no orders for oxygen per nasal cannula.
Review of Resident #3's Care Plan revealed, in part, most current target date listed for problems identified was dated 10/01/2024. Further review of the care plan revealed no plan of care was developed for oxygen care by nasal cannula.
Observation on 08/06/2024 at 11:40 a.m. revealed Resident #3's received oxygen at 4 LPM per NC.
In an interview on 08/06/2024 at 11:58 a.m., S10Licensed Practical Nurse (LPN) indicated Resident #3 received oxygen at 2 LPM by NC. S10LPN further indicated no physician's order for respiratory care for Resident #3.
In an interview on 08/06/2024 at 12:30 p.m., S5Assistant Director of Nursing indicated they could not find a physician's order for Resident #3' oxygen care per NC.
In an interview on 08/06/2024 at 3:49 p.m., S4Director of Nursing indicated there was no plan of care developed for Resident #3's oxygen care per NC.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure the nursing staff signed a verification of an accurate medication count at the beginning and end of each shift for 2 [Medication C...
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Based on record reviews and interviews, the facility failed to ensure the nursing staff signed a verification of an accurate medication count at the beginning and end of each shift for 2 [Medication Cart (a) and Medication Cart (b)] of 2 [Medication Cart (a) and Medication Cart (b)] Medication Carts (Med Cart) observed and reviewed for accurate dispensation of controlled medications.
Findings:
Review of the facility's undated Controlled Substances Policy revealed, in part, the nursing staff must count controlled drugs at the end of the shift with the nurse coming on duty and the nurse going off duty. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Further review revealed the nursing staff must document and report any discrepancies to the Director of Nursing (DON) or designee immediately.
Review of Med Cart (a)'s controlled substance binder dated 05/31/2024 to 08/07/2024 revealed, in part, no documentation of signatures of the nurse coming on duty and the nurse going off duty on the following dates and shifts:
06/03/2024 the 3:00 p.m. to 11:00 p.m. shift;
06/06/2024 the 7:00 a.m. to 3:00 p.m. shift;
06/11/2024 the 11:00 p.m. to 7:00 a.m. shift;
06/14/2024 the 11:00 p.m. to 7:00 a.m. shift;
06/23/2024 the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shift;
06/30/2024 the 3:00 p.m. to 11:00 p.m. shift;
07/06/2024 the 11:00 p.m. to 7:00 a.m. shift;
07/11/2024 the 11:00 p.m. to 7:00 a.m. shift;
07/12/2024 the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts;
07/14/2024 the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts;
07/17/2024 the 3:00 p.m. to 11:00 p.m. shift;
07/18/2024 the 3:00 p.m. to 11:00 p.m. shift;
07/19/2024 the 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts;
07/22/2024 the 11:00 p.m. to 7:00 a.m. shift;
07/24/2024 the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift;
07/25/2024 the 11:00 p.m. to 7:00 a.m. shift;
07/27/2024 the 3:00 p.m. to 11:00 p.m. shift;
07/29/2024 the 11:00 p.m. to 7:00 a.m. shift;
08/03/2024 the 7:00 a.m. to 3:00 p.m. shift;
08/06/2024 the 3:00 p.m. to 11:00 p.m. shift; and
08/07/2024 the 7:00 a.m. to 3:00 p.m. shift.
In an interview on 08/07/2024 at 12:41 p.m., S8Licensed Practical Nurse (LPN) indicated she did not sign the narcotics book after the narcotics count on 08/07/2024 at 7:00 a.m. S8LPN further indicated she should have signed the narcotic book after she completed the narcotic count with the nurse going off duty.
Review of Med Cart (b) 's controlled substance binder dated 05/22/2024 to 08/07/2024 revealed, in part, no documentation of signatures of the nurse coming on duty and the nurse going off duty on the following dates and shifts:
05/23/2024 the 7:00 a.m. to 3:00 p.m. shift;
05/27/2024 the 3:00 p.m. to 11:00 p.m. shift;
05/31/2024 3:00 p.m. to 11:00 p.m. shift;
07/05/2024 the 3:00 p.m. to 11:00 p.m. shift;
07/10/2024 11:00 p.m. to 7:00 a.m. shift;
07/14/2024 the 7:00 a.m. to 3:00 p.m. shift;
07/24/2024 the 7:00 a.m. to 3:00 p.m. shift; and
08/07/2024 the 7:00 a.m. to 3:00 p.m. shift.
In an interview on 08/07/2024 at 1:08 p.m., S9LPN indicated she did not sign the narcotics book after the narcotics count on 08/07/2024 at 7:00 a.m. S9LPN further indicated she should have signed the narcotic book after she completed the narcotic count with the nurse going off duty.
In an interview on 08/07/2024 at 1:15 p.m., S4Director of Nursing (DON) indicated all narcotic counts should be performed and documented in the narcotics book at the beginning and ending of each shift by the nurse coming on duty and the nurse going off duty. S4DON further indicated on the above mentioned dates narcotic counts were not documented as they should have been.
Jun 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to implement a training program for 1 (S1Administrator) of 6 (S1Administrator, S6Sunshine Aide, S7Social Services, S8Cerified Nursing Assistan...
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Based on record review and interview, the facility failed to implement a training program for 1 (S1Administrator) of 6 (S1Administrator, S6Sunshine Aide, S7Social Services, S8Cerified Nursing Assistant [CNA], S9CNA, and S10CNA) sampled personnel files reviewed for training.
Findings:
Review of S1Administrator's Personnel File revealed a date of hire of 07/22/2015. Further review revealed, no documented evidence and the facility presented no documented evidence, S1Administrator received training on Quality Assurance and Performance Improvement (QAPI) program, behavioral health training, ethics training, and resident rights.
In an interview on 06/27/2024 at 3:05 p.m., S2Regional Administrator indicated the facility did not have documented evidence S1Administrator had received trainings for QAPI, behavioral health, ethics, abuse, and resident rights.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an allegation of verbal and physical abuse was reported to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an allegation of verbal and physical abuse was reported to the required state survey agency for 1 (Resident #1) of the 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse.
Findings:
Review of the facility's policy and procedure titled Policy for Prohibition of Abuse, Neglect and Misappropriation of Property with a revision date of 09/26/2017 revealed, in part, all alleged violations and all substantiated incidents should be reported to the required state agency, and any employee who becomes aware of an allegation of abuse should report the incident to a supervisor, Director of Nursing, or Administrator immediately. Further review of the policy revealed the facility will report all allegations of abuse to the state agency.
Review of Resident #1's closed medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses, in part, Alzheimer's disease, schizophrenia, depressive disorder, dementia, and anxiety.
Review of Resident #1's Physician's Emergency Certificate (PEC) dated 06/03/2024 revealed, in part, Resident # assaulted the nursing home administrator. Further review of the PEC revealed Resident #1 alleged the nursing home administrator pushed her.
Review of the police report document with a disposition/completion date and time of 06/03/2024 at 1:41 p.m. revealed, in part, Resident #1 stated S1Administrator pushed her on 06/03/2024.
In a telephone interview on 06/25/2024 at 10:50 a.m., Resident #1's Responsible Party (RP) stated Resident #1 reported she was pushed by S1Administrator on 06/03/2024.
In a telephone interview on 6/25/2024 at 11:34 a.m., the facility's Ombudsmen stated Resident #1's RP informed her Resident #1 was pushed by S1Administrator during an incident on 06/03/2024.
In a telephone interview on 06/25/2024 at 11:53 a.m., Resident #1 stated S1Administrator pushed her on 06/03/2024 and Resident #1 informed the police deputy and facility staff of the incident.
In an interview on 06/25/2024 at 1:42 p.m., S1Administrator stated Resident #1's RP called S2Regional Administrator 06/04/2024 and reported S1Administrator yelled at and pushed Resident #1. S1Administrator further stated Resident #1's allegation of abuse was not reported to the state agency.
In an interview on 06/25/2024 at 2:28 p.m., S1Administrator denied the previously documented interview and indicated she was inconsistent in reporting her source of information. S1Administrator further indicated she must have obtained Resident #1's allegation of abuse from the police report.
In an interview on 06/25/2024 at 2:30 p.m., S2Regional Administrator verified Resident#1 alleged she was abused by S1Administrator the after reviewing the police report and the PEC report. S2Regional Administrator indicated he was not made aware of Resident #1's allegation until today (06/25/2024) and further confirmed the incident was not reported to the state agency as required.
In an interview on 06/26/2024 at 9:53 a.m., S3Director of Nursing (DON) stated she reviewed Resident #1's PEC and was aware Resident #1 alleged S1Administrator pushed her on 06/03/2024. S3DON further stated she was not aware if the incident was reported to the state agency and confirmed she did not report the alleged abuse of Resident #1 by S2Administrator to corporate management as required.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of physical abuse for 1(Resident #1) of the 3 (Resident #1, Resident #2, and Res...
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Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of physical abuse for 1(Resident #1) of the 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse.
Findings:
Review of the facility's policy and procedure titled Policy for Prohibition of Abuse, Neglect and Misappropriation of Property with a revision date of 09/26/2017 revealed, in part, the facility will thoroughly investigate all alleged violations of abuse and take appropriate actions.
Review of Resident #1's Physician's Emergency Certificate (PEC) dated 06/03/2024 revealed Resident #1 alleged claimed S1Administrator pushed her.
Review of the police report document case with a disposition/completion date and time of 06/04/2024 at 1:41 p.m. revealed, in part, Resident #1 stated S1Administrator pushed her.
There was no documented evidence, and the facility did not present any documented evidence Resident #1's allegation of abuse by S2Administrator was investigated.
In an interview on 06/25/2024 at 1:42 p.m., S1Administrator stated Resident #1's allegation of abuse by S1Administrator was not investigated.
In an interview on 06/25/2024 at 2:30 p.m., S2Regional Administrator confirmed the allegation of abuse of Resident #1 by S1Administrator was not investigated.
May 2024
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to protect the residents' right to be free from verbal and physical abuse by other residents. This deficient practice was identified for 6 (...
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Based on interviews and record reviews, the facility failed to protect the residents' right to be free from verbal and physical abuse by other residents. This deficient practice was identified for 6 (Resident #4, Resident #5, Resident #6, Resident #8, Resident #9, and Resident #10) of 10 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) reviewed for abuse.
Findings:
Resident #4
Review of facility documents related to an incident dated 03/17/2024 revealed, in part, Resident #3 struck Resident #4 in the face in the facility dining room.
In an interview on 05/01/2024 at 10:30 a.m., S4Food and Nutrition Manager stated she witnessed Resident #3 approach Resident #4, who had his eyeglasses on and was sitting in his wheelchair. Resident #3 then stated that was her glasses. Resident #3 removed Resident #4's eyeglasses and pulled her hand back and struck Resident #4 in the face.
In an interview on 05/02/2024 at 11:26 a.m., S1Administrator stated she reviewed the facility video tape of the incident which occurred on 03/17/2024 between Resident #3 and Resident #4 and confirmed Resident #3 did strike Resident #4 in the face.
Resident #5 and Resident #6
Review of Resident #5's progress note dated 04/05/2024 at 4:31 p.m. revealed, in part, S5Laundry Supervisor reported to the nurse she was talking to Resident #6, and Resident #5 walked up to them and got into Resident #6's face and shouted at Resident #6 to go to his room. Record review further revealed Resident #6 then shoved Resident #5.
In an interview on 05/01/2024 at 11:37 a.m., S5Laundry Supervisor indicated she was in the hallway on Hall Z and Resident #5 was in his wheelchair next to her clothing cart. S5Laundry Supervisor indicated Resident #6 became aggressive toward Resident #5. S5Laundry Supervisor indicated she witnessed Resident #6 lean down close to Resident #5, point her finger in Resident #5's face, and yelled at him to go to his room. Resident #5 then pushed Resident #6 backwards into the clothing cart.
Review of the facility's documents related to the incident on 04/05/2024 revealed, in part, Resident #6 was verbally abusive to Resident #5, and Resident #5 then shoved Resident #6. The documentation further revealed both Resident #5 and Resident #6 were at fault; however, the incident was unsubstantiated by the facility.
In an interview on 05/02/2024 at 2:59 p.m., S1Administrator confirmed Resident #6 acted aggressively towards Resident #5 when she leaned down into his personal space and yelled at him to go to his room. S1Administrator confirmed Resident #5 then pushed Resident #6 into the clothing cart. S1Administrator confirmed Resident #5 should not have pushed Resident #6.
Resident #8
Review of facility documents related to an incident dated 04/06/2024 revealed, in part, Resident #7 hit Resident #8 in the head. Further reviewed that Random Resident R1 witnessed the incident which occurred in the dining room.
In an interview on 05/02/2024 at 9:30 a.m., Random Resident R1 with a Brief Interview for Mental Status of 14 (cognitive), stated on 04/06/2024 Resident #8 was sitting in the dining room next to her when Resident #7 walk up to them and hit Resident #8 on the forehead.
In an interview on 05/02/2024 at 10:15 a.m., S1Administrator indicated she reviewed the video footage for 04/06/2024 related to the above mentioned incident and observed Resident #7 hit Resident #8 on the front forehead.
Resident #9
Review of facility documents related to an incident dated 04/11/2024 revealed, in part, Resident #2 slapped Resident #9 in the dining room. Further review revealed, in part, this incident was witnessed.
In an interview on 05/01/2024 at 1:40 p.m., S3Treatment (Tx) Nurse indicated she witnessed Resident #2 intentionally slap Resident #9 in the dining room right after S3Tx Nurse had pushed Resident #9 to the front table and seated Resident #2 next to Resident #9. S3Tx Nurse indicated Resident #9 told her that was a good spot because she knew him. S3Tx Nurse indicated she witnessed Resident #2 look at Resident #9 and then Resident #2 intentionally swung with his left hand and hit Resident #9. S3Tx Nurse also indicated Resident #2 was cognitive enough to know what he was doing when he swung and hit Resident #9.
In an interview on 05/01/2024 at 2:05 p.m., Resident #2 indicated he remembered the day when he hit Resident #9. When asked if Resident #2 knew it was wrong to hit someone at the facility, he nodded his head yes.
In an interview on 05/02/2024 at 12:00 p.m., S1Administrator indicated she had no doubt Resident #2 slapped Resident #9.
Resident #10
Review of Resident #1's medical record reveal a nurse's note dated 04/01/2024 which revealed Resident #1 verbally abused resident #10, quoting I'm gonna kill you if you don't shut up! shouted at Resident #10.
In an interview on 05/01/2024 2:51 p.m., S1Administrator confirmed this would be considered resident-to-resident verbal abuse.
In an interview on 05/02/2024 at 2:10 p.m., S8Licensed Practical Nurse (LPN) confirmed Resident #1 stood over Resident #10 and stated he would F-ing kill him if he didn't shut up.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure an allegation of resident-to-resident abuse was:
1.
Reported to the State Survey Agency for 1 (Resident #10) of 10 (Resident #1, R...
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Based on record review and interviews, the facility failed to ensure an allegation of resident-to-resident abuse was:
1.
Reported to the State Survey Agency for 1 (Resident #10) of 10 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) sampled residents reviewed for abuse; and,
2.
Reported timely to the State Survey Agency for 2 (Resident #6 and Resident #9) of 9 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) sampled residents reviewed for timeliness of reporting of abuse allegations.
Findings:
#1
Review of Resident #1's medical record reveal, in part, a nurse's note dated 04/01/2024 documenting Resident #1 verbally threatened Resident #10 by shouting I'm gonna kill you if you don't shut up!
Review of Morning Leadership Meeting minutes dated 04/01/2024 revealed an incident of Resident #1 yelling at Resident #10 and had been discussed by the leadership team.
In an interview on 05/01/2024 2:51 p.m., S1Administrator indicated a State Incident Management Systems (SIMS) report should have been filed and it was not.
In an interview on 05/02/2024 at 2:10 p.m., S8 Licensed Practical Nurse (LPN), indicated she was caring for Resident #1 and Resident #10 on the night of 03/31/2024-04/01/2024. S8LPN further indicated during the shift a certified nursing assistant informed her that Resident #1 threatened Resident #10 by shouting he would F-ing kill him if he didn't shut up. S8LPN stated she should have written an incident report and she did not.
There was no evidence, and the facility failed to provide evidence, that verbal abuse had been reported to the state agency as required.
#2
Resident #6
Review of facility documents related to an incident dated 04/05/2024 revealed, in part, an incident of physical abuse was discovered on 04/05/2024 at 2:20 p.m. Further review revealed the incident was reported to the State Incident Management System (SIMS) at 04/05/2024 at 5:46 p.m.
In an interview on 05/02/2024 at 12:00 p.m., S1Administrator confirmed the entry times of the SIMS were pass the 2 hour mark of required reporting. S1Admnistrator also stated she was the only one who had access to SIMS and responsible for reporting.
Resident #9
Review of facility documents related to an incident dated 04/11/2024 revealed, in part, an incident of physical abuse was discovered on 04/11/2024 at 2:00 p.m. Further review revealed the incident was reported to the SIMS at 04/11/2024 at 5:05 p.m.
In an interview on 05/02/2024 at 12:00 p.m., S1Administrator confirmed the entry times of the SIMS were past the 2 hour mark of required reporting. S1Admnistrator also indicated she was the only one who had access to SIMS and responsible for reporting.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of verba...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of verbal abuse between 2 (Resident #1 and Resident #10) of 10 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) sampled residents investigated for abuse.
Findings:
Resident #1 was admitted on [DATE] with diagnoses which included fractured left femur, pressure ulcer of right heel, hyperlipidemia, hypertension, chronic kidney disease, type 2 diabetes, cerebral infarction, depression, left BKA, lack of coordination/muscle weakness, repeated falls.
Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 04/17/2024 revealed, in part, Resident #1's cognition was moderately impaired. Further review revealed Resident #1 did not have physical or verbal symptoms directed toward others.
Resident #10 was admitted on [DATE] with diagnoses which included closed skull fracture, difficulty in walking/lack of coordination, cognitive communication deficit, altered mental status, epilepsy, progressive spinal muscle atrophy, and pain.
Review of Resident #10's Quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 04/05/2024 revealed, in part, Resident #10's cognition was moderately impaired. Further review revealed Resident #10 exhibited frequent physical and verbal behavioral symptoms directed toward others.
Review of Resident #1's nurses notes reveal a note dated 04/01/2024 documenting Resident #1's irate behavior towards staff and resident #10, quoting I'm gonna kill you if you don't shut up! shouted at Resident #10.
Review of Morning Leadership Meeting minutes dated 04/01/2024 revealed the incident between Resident #1 and Resident #10 had been discussed by the leadership team, but there was nothing indicating that an investigation had been conducted.
In an interview on 05/01/2024 2:51 p.m., S1Administrator confirmed the incident was resident-to-resident abuse, S1Administrator indicated an investigation should have been conducted for the above, and it was not.
There was no evidence, and the facility failed to provide evidence, that an investigation for resident-to-resident verbal abuse had been conducted.
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interviews, and record review, the facility failed to administer medications per a physician's order for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) resid...
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Based on interviews, and record review, the facility failed to administer medications per a physician's order for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) resident's records reviewed.
Findings:
Resident #2
Review of Resident #2's December 2023's physician's orders revealed, in part, an order dated 12/11/2023 to administer Levofloxacin (a medication used to treat infections) 750 milligrams (mgs) daily for 14 days, was discontinued on 12/20/2023. Further reviewed revealed an order dated 12/21/2023 to administer Levofloxacin 750 mgs daily for 14 days, was discontinued on 12/22/2023. Further review revealed, an order dated 12/27/2023 to administer Clonidine (a medication used to treat high blood pressure) 0.1 mg as needed for blood pressure reading greater than 170/90.
Review of Resident #2's December 2023 electronic medication administration record (eMAR) revealed, in part, Resident #2 was administered Levofloxacin 750 mg daily from 12/12/2023 to 12/22/2023 for a total of 11 days. Further review revealed Resident #2 had a blood pressure (B/P) of 236/100 on 12/27/2023 at 11:00 a.m., a B/P of 176/60 on 12/27/2023 at 4:00 p.m., a B/P of 175/82 on 12/28/2023 at 4:00 p.m., and a B/P of 178/87 on 12/29/2023 at 4:00 p.m. Further review revealed, no documentation that Clonidine 0.1 mg was given as ordered.
In an interview on 01/04/2024 at 10:45 a.m., S3Registered Nurse (RN) confirmed Resident #2 had orders to administer Levofloxacin 750 mg daily for 14 days, but had only received 11 days of the medication. S3RN acknowledged Resident #2's blood pressures were elevated greater than 170/90 on 12/27/2023, 12/28/2023, and 12/29/2023, and Resident #2 should have been administered Clonidine 0.1 mg for blood pressures greater than 170/90.
In a telephone interview on 01/04/2024 at 10:55 a.m., S9Licensed Practical Nurse (LPN) stated she notified S6Nurse Practitioner (NP) of Resident #2's elevated blood pressure on 12/27/2023 and was ordered to give Clonidine 0.1 mg as needed for a blood pressure greater than 170/90.
In a telephone interview on 01/04/2024 at 11:07 a.m., S5LPN stated Resident #2 should have been administered a total of 14 doses of the Levofloxacin 750 mg.
In an interview on 01/04/2024 at 11:35 a.m., S3RN stated Resident #2 should have been given Clonidine 0.1 mg as ordered for his blood pressures greater than 170/90.
In an interview on 01/04/2024 12:20 p.m., at S6Nurse Practitioner (NP) stated she had ordered the Clonidine 0.1 mg as needed for a blood pressure greater than 170/90 on 12/27/2023 for Resident #2, and the nurse should have given the medication as ordered. S6NP further stated Resident #2 should have gotten all 14 doses of his Levofloxacin 750 mg daily.
In an interview on 01/04/2024 at 12:40 p.m., S2Assistant Director of Nursing (ADON) stated when Resident #2 did not receive his full course of antibiotics. S2ADON further stated Resident #2 should have been given the as needed Clonidine 0.1 mg if his blood pressures were elevated over 170/90.
In an interview on 01/04/2024 at 1:49 p.m., S1Administrator stated the nurses should have given Resident #2 his full course of antibiotics. S1Administrator further stated if S9LPN had called S6NP for an order for Clonidine 0.1 mg due to Resident #2's high blood pressure, the nurses should have administered the Clonidine 0.1 mg when Resident #2's blood pressure was elevated.
Resident #3
Review of Resident #3's January 2024's physician's orders revealed, in part, an order dated 01/02/2024 to administer Ciprofloxacin (a medication to treat infections) 500 milligrams (mgs) every 12 hours, with a start date of 01/03/2024 and stop date of 01/04/2024 for treatment of a urinary tract infection.
Review of Resident #3's electronic medication administration record (eMAR) on 01/03/2024 at 2:30 p.m. revealed, in part, Resident #3's Ciprofloxacin 500 mg was to be administered twice a day at 6:00 a.m. and 6:00 p.m. starting on 01/03/2024.
Review of Resident #3's Ciprofloxacin 500 mg medication card on 01/03/2024 at 2:38 p.m., revealed none of the tablets had been administered.
Review of Resident #3's Ciprofloxacin 500 mg medication card on 01/04/2024 at 11:00 a.m., revealed one of the tablets had been administered.
In an interview on 01/03/2024 at 4:01 p.m., S10LPN stated she remembered being on shift last night when Resident #3's Ciprofloxacin 500 mg medication card was delivered. S10LPN further stated that she remembered handing Resident #3's Ciprofloxacin 500 mg medication card off to Resident #3's nurse the morning of 01/03/2024.
In an interview on 01/04/2024 at 11:25 a.m., S8LPN stated if Resident #3's Ciprofloxacin 500 mg was available on 01/03/2024 at 6 a.m., it should have been administered.
In an interview on 01/04/2024 at 12:22 p.m., S6NP stated Resident #3 should have been administered his Ciprofloxacin 500 mg the morning on 01/03/2024.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to have accurate orders and nursing notes for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) resident's records reviewed fo...
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Based on interviews and record review, the facility failed to have accurate orders and nursing notes for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) resident's records reviewed for accuracy.
Findings:
Review of Resident #3's January 2024 physician's orders revealed, in part, an order dated 01/03/2024 for Glucerna 1.5 calorie 10 milliliters (ml) per hour with goal of 55ml per hour. Further review revealed an order dated 01/03/2024 for Glucerna 1.5 calorie 20 milliliters ml per hour. Further review revealed an order dated 01/03/2024 for Glucerna 1.5 calorie 30 milliliters ml per hour. Further review revealed an order dated 01/03/2024 for Glucerna 1.5 calories 40 ml per hour.
Review of Resident #3's progress notes dated 01/04/2024 at 5:31 a.m. for a late entry on 01/03/2023 at 7:00 a.m. revealed, in part, S3RN (Registered Nurse) received a clarification order from S6Nurse Practitioner (NP) to increase Resident #3's enteral feedings every 1-2 hours by 10 ml increments, or as tolerated, up to a goal of 55 ml per hour. Further review revealed S3RN increased the enteral feedings to 20 ml an hour at 7:30 a.m., 30 ml an hour at 9:30 a.m., and 40 ml per hour at 11:30 a.m.
In an interview on 01/04/2024 at 9:19 a.m., S3RN stated she called S6NP on 01/03/2024 at 7:30 a.m. to clarify if Resident #3's enteral feeding needed to be titrated (slowly increasing the amount up). S3RN further stated that she was given an order by S6NP to start Resident #3's enteral feeding at 10 ml per hour and to increase Resident #3's enteral feeding to a goal of 55 ml per hour. S3RN further stated she made late entries for her nursing notes because she'd left her charting incomplete at the end of the previous day.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify a resident's physician of a significant change of condition f...
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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 a resident's physician of a significant change of condition for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents.
Findings:
Review of the policy: Change in a Resident's Condition or Status, revealed in part, the following
Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.
Review of Resident #1's record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, in part, Gastro-Esophageal Reflux with Esophagitis with Bleed and Gastrointestinal Hemorrhage unspecified.
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. Further review revealed Resident #1 needed extensive assistance by two persons with toileting.
Review of Resident #1's Care Plan revealed a problem of in part: Resident #1 had the potential for stomach discomfort related to Gastroesophageal Reflux (GERD) with interventions to include observe for any complaints of nausea.
Review of Resident #1's completed care documentation dated 11/23/2023 at 9:38 p.m., revealed, in part, Resident #1 had a watery liquid consistency extra-large bowel movement, nurse notified.
In an interview on 01/03/2023 at 3:43 p.m., S7Certified Nursing Assistant (S7CNA) stated on 11/23/2023 during the evening shift (3 p.m.-11 p.m.) Resident #1 had a large diarrhea bowel movement. S7CNA further stated Resident #1 had a diarrhea stool around supper and another diarrhea stool a few hours before her shift ended at 11 p.m. S7CNA stated she notified Resident #1's nurse that she had one extra-large diarrhea stool.
In an interview on 01/03/2024 at 4:20p.m., S4Licensed Practical Nurse (S4LPN) stated on 11/23/2023 evening shift (3 p.m. - 11 p.m.) Resident #1 had a diarrhea stool one time. S4LPN further stated she was informed in report on 11/23/2023 by the day shift (7a.m.-3 p.m.) nurse that Resident #1 had a diarrhea stool for a total of two diarrhea stools she was aware of. S4LPN further stated she just monitored Resident #1 and pushed fluids by mouth after she had one diarrhea stool on her shift. S4LPN stated S7CNA did not inform her that Resident #1 had an additional diarrhea stool on 11/23/2023 evening shift. S4LPN stated she should have notified Resident #1's physician that Resident #1 had two diarrhea stools that day.
Review of Resident #1's Nurses Note written by S5Licensed Practical Nurse dated 11/24/2023 at 2:38 p.m., revealed, in part, Resident #1 requested to stay in bed related to nausea. Further review revealed Resident #1 refused breakfast and lunch.
In an interview on 01/03/2024 at 2:12 p.m., S5Licensed Practical Nurse (S5LPN) stated she did not recall Resident #1 having diarrhea, nausea or vomiting but refer to her notes because what was in her notes was what happened.
Review of Nurses Note written by S10Licensed Practical Nurse (S10LPN) dated 11/25/2023 at 1:52 a.m., revealed, in part, look back charting 11 a.m.-7 p.m. shift, Resident #1 requested to stay in bed related to nausea.
On 01/04/2024 at 3:54 p.m., S10Licensed Practical Nurse stated on 11/24/2023 night shift (11p.m. -7 a.m.) Resident #1 had nausea. S10LPN stated she was informed Resident #1 had one diarrhea stool by the 11/24/2023 evening shift (3 p.m. -11 p.m.) nurse.
Review of Nurse Note dated 11/25/20223 at 9:33 a.m., revealed, in part, Resident #1 had a complaint of dizziness x 2 days and a blood pressure of 77/60 mmHg.
There was no documented evidence and the facility did not present any documented evidence that Resident #1's physician was notified of the above changes in condition.
In an interview on 01/04/2024 at 12:08 p.m., S6Nurse Practitioner (S6NP) stated the first time she was notified that Resident #1 had any gastrointestinal symptoms was on the day she gave orders to send resident #1 out to the hospital 11/25/2023. S6NP further stated she was not aware that Resident #1 had nausea on 11/24/2023 day shift and evening shift. S6NP stated she was not informed by the evening shift nurse on 11/23/2023 that Resident #1 had an extra-large diarrhea stool. S6NP stated Resident #1 had a history of an Upper Gastrointestinal bleed so she would be concerned with any gastrointestinal symptoms. S6NP stated the nurses should have called her when Resident #1 began experiencing the above mentioned symptoms.
Nov 2023
13 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
Based on record reviews, observations, and interviews, the facility failed to ensure a resident had access to the air conditioner thermostat controls in order to set the temperature in her room per he...
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Based on record reviews, observations, and interviews, the facility failed to ensure a resident had access to the air conditioner thermostat controls in order to set the temperature in her room per her preference for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for environment.
Findings:
Review of Resident #13's face sheet revealed, in part, Resident #13 had diagnoses including end stage renal disease and anemia.
Review of Resident #13's Minimum Data Set with an Assessment Reference Date of 09/29/2023 revealed, in part, Resident #13 had a Brief Interview for Mental Status score of 10, which indicated Resident #13 was moderately, cognitively intact. Further review revealed Resident #13 weighed 85 pounds.
Review of Resident #13's Resident [NAME] of Rights revealed, in part, each resident has the right to reside and receive services in the facility with reasonable accommodations of an individual's needs and preferences, except when the health or safety of the individual or other residents would be endangered.
Observation on 10/30/2023 at 10:10 a.m. revealed Resident #13's air conditioner unit had a locked padlock on the control panel cover.
In an interview on 10/30/2023 10:10 a.m., Resident #13 stated the facility placed a lock on her air conditioner because Resident #13 preferred the heater on. Resident #13 stated she was always cold because she was anemic. Resident #13 further stated the staff did not like Resident #13 using the heater in her room, so they locked the air conditioner.
Observation on 10/31/2023 at 1:47 p.m. revealed Resident #13's air conditioner unit had a locked padlock on the control panel cover.
In an interview on 11/01/2023 at 9:35 a.m., Resident #13 stated she was freezing to death.
Observation on 11/01/2023 at 9:36 a.m. revealed Resident #13 was curled up in the fetal position in her bed covered with blankets. Observation further revealed Resident #13's air conditioner unit had a locked padlock on the control panel cover.
In an interview on 11/01/2023 at 9:52 a.m., S10Certified Nursing Assistant (CNA) confirmed Resident #13's air conditioner had a padlock. S10CNA stated she knew Resident #13 was cold natured, but that was because Resident #13 was a dialysis resident.
In an interview on 11/01/2023 at 10:02 a.m., S8Licensed Practical Nurse (LPN) stated Resident #13 and her roommate, Resident #56, had an argument about the climate in the room so a padlock was put on Resident #13's air conditioner unit so the temperature could not be manipulated.
In an interview on 11/01/2023 at 12:12 p.m., S1Administrator stated she was unaware there was a padlock on Resident #13's air conditioner.
In an interview on 11/02/2023 at 9:56 a.m., S2Director of Nursing (DON) stated a concern was brought to a morning meeting that Resident #56 was sweating because Resident #13 had the thermostat set too high on the air conditioner. S2DON stated Resident #13 did not want to move to a different room, so the facility put a padlock on Resident #13's air conditioner. S2DON confirmed she would not like a padlock on her air conditioner at her home.
Review of Resident #56's record revealed no documented evidence any heat related illness from August 2023 to October 2023.
Review of Resident #56's documented temperatures from August 2023 to October 2023 revealed, in part, no documented evidence of temperatures outside normal limits.
Observation on 11/02/2023 at 10:05 a.m. revealed the lock on Resident #13's air conditioner was unlatched and placed on top of the air conditioner unit.
Review of Resident #13's Record of Concern or Compliment dated 09/28/2023 revealed, in part, Resident #13 was spoken to by S22Social Worker regarding the room temperature being too hot and Resident #56 was found sweating. Further review revealed documentation that Resident #13 refused to move to another room where the roommate also preferred the room warm. Review also revealed documentation that S1Administrator and S2Director of Nursing (DON) spoke with Resident #13 on 09/28/2023 in regards to putting a padlock on Resident #13's air conditioner.
In an interview on 11/02/2023 at 10:10 a.m., S22Social Worker stated during a morning meeting, S2DON asked S22Social Worker to speak with Resident #13 regarding the temperature in Resident #13's room. S22Social Worker stated Resident #13 told her she was always cold, which was why she kept the temperature high. S22Social Worker stated she informed S2DON that Resident #13 did not want to change rooms, so S2DON stated she had to put a padlock on Resident #13's air conditioner unit. S22Social Worker confirmed it was against a resident's rights to put a padlock on a resident's air conditioner unit if the resident was not in agreement with the padlock.
In an interview on 11/02/2023 at 10:18 a.m., S23Maintenance stated he placed the padlock on Resident #13's air conditioner because he was told Resident #13 had the room too hot. S23Maintenance confirmed he would not like someone to place a padlock on his air condition in his home.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed ensure necessary supervision was provided to ensure a resident did not verbally and physically abuse another resident for 1 (Resident #19) o...
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Based on record reviews and interviews, the facility failed ensure necessary supervision was provided to ensure a resident did not verbally and physically abuse another resident for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for abuse.
Findings:
Review of the facility's policy for Abuse, Neglect, and Misappropriation of Property revealed, in part, residents had the right to be free from abuse.
Review of the facility's Incident Report dated 09/05/2023 at 11:00 a.m. revealed, in part, Resident #19 hit another resident.
Review of Resident #19's care plan for Resident #19 exhibiting behaviors and hit another resident with a target date of 12/14/2023 revealed, in part, Resident #19 was told to keep hands to self.
In an interview on 11/01/2023 at 2:32 p.m., S11Dietary Manager stated on 09/05/2023 Resident #15 ambulated in her wheelchair next to Resident #19, who was sitting in her gerichair in the dining room. Resident #19 attempted to hit Resident #15 in the back, missed, then swung again and hit Resident #15 in the back.S11Dietary Manager further stated Resident #19 was cursing at Resident #15 when she yelled out after being hit. S11Dietary Manager stated Resident #19 continued to curse at Resident #15, while she sent S12Dietary staff to alert the nurse.
In an interview on 11/02/23 09:42 a.m., S12Dietary Staff stated after Resident #19 hit Resident #15 on her back she heard Resident #19 say she would hit that mother f****** again.
In an interview on 11/02/2023 at 9:50 a.m., S16Licensed Practical Nurse (LPN) stated S12DietaryStaff notified her Resident #19 hit Resident #15.
In an interview on 11/02/2023 at 10:00 a.m., S15LPN stated Resident #19 had aggressive tendencies and she often cursed at staff.
In an interview on 11/02/2023 at 10:14 a.m., S2Director of Nursing stated Resident #19 often cursed staff.
In an interview on 11/02/2023 at 11:05 a.m. S1Administrator stated she was not aware Resident #19 stated he/she would hit that mother f***** again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interviews, the facility failed to ensure an allegation of physical abuse and verbal abuse was reported to the state survey agency within 2 hours of the allegation for 1 (Re...
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Based on record review and interviews, the facility failed to ensure an allegation of physical abuse and verbal abuse was reported to the state survey agency within 2 hours of the allegation for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for abuse.
Findings:
Review of the facility's policy for Abuse, Neglect, and Misappropriation of Property revealed, in part, all alleged violations involving abuse should be reported immediately to the administrator of the facility and to other officials in accordance with state law.
Review of the facility Incident Report dated 09/05/2023 revealed, in part, Resident #19 hit another resident in the back.
Review of Resident #19's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/01/2023 revealed, in part, Resident #19 had a Brief Interview for Mental Status score of 10, which indicated Resident #19 had moderate cognitive impairment.
In an interview on 11/01/2023 at 2:32 p.m., S11Dietary Manager stated on 09/05/2023 Resident #15 ambulated in her wheelchair next to Resident #19, who was sitting in her gerichair in the dining room. Resident #19 attempted to hit Resident #15 in the back, missed, then swung again and hit Resident #15 in the back.S11Dietary Manager further stated Resident #19 was cursing at Resident #15 when she yelled out after being hit. S11Dietary Manager stated Resident #19 continued to curse at Resident #15, while she sent S12Dietary staff to alert the nurse.
In an interview on 11/02/23 09:42 a.m., S12Dietary Staff stated after Resident #19 hit Resident #15 on her back she heard Resident #19 say she would hit that mother f****** again.
In an interview on 11/02/2023 at 11:05 a.m. S1Administrator stated she was aware of the incident of physical abuse on 09/05/2023; however, she was not aware Resident #19 stated I'd hit that mother f***** again.
Review of the facility's list of Statewide Incident Management System (SIMS) report for the last six months revealed no documented evidence and the facility presented no documented evidence that the facility had completed a SIMS report for the incident involving Resident #15 and Resident #19 on 09/05/2023.
In an interview on 11/02/2023 at 11:05 a.m., S1Administrator confirmed she had not initiated a SIMS report for the incident involving Resident #15 and Resident #19 which occurred on 09/05/2023. S1Administrator stated she thought she did not need to complete a SIMS report because Resident #19 was cognitively impaired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview, failed to ensure an allegation of resident to resident physical abuse was thoroughly investigated for 1 (Resident #19) of 1 (Resident #19) sampled residents revie...
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Based on record review and interview, failed to ensure an allegation of resident to resident physical abuse was thoroughly investigated for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for abuse.
Findings:
Review of the facility's policy for Abuse, Neglect, and Misappropriation of Property revealed, in part, the facility should have had evidence of thoroughly investigating an incident of alleged physical abuse.
Review of the facility's Incident Report dated 09/05/2023 at 11:00 a.m. revealed, in part, Resident #19 hit another resident.
Review of Resident #19's care plan for Resident #19 exhibiting behaviors and hit another resident with a target date of 12/14/2023 revealed, in part, Resident #19 was told to keep hands to self.
There was no documented evidence and the facility did not present any documented evidence that an investigation was conducted after the above mentioned incident.
In an interview on 11/01/2023 at 2:32 p.m., S11Dietary Manager stated on 09/05/2023 Resident #15 ambulating in her wheelchair next to Resident #19, who was sitting in her gerichair in the dining room. Resident #19 attempted to hit Resident #15 in the back and missed, and therefore attempted again and hit Resident #15 in the back. S11Dietary Manager further stated Resident #19 was cursing at Resident #15 when she yelled out after being hit. S11Dietary Manager stated Resident #19 continued to curse at Resident #15, while she sent S12 Dietary staff to alert the nurse.
In an interview on 11/02/23 09:42 a.m., S12 Dietary Staff stated after Resident #19 hit Resident #15 on her back she heard Resident #19 say she would hit that mother f****** again.
In an interview on 11/02/2023 at 9:50 a.m., S16Licensed Practical Nurse (LPN) stated S12DietaryStaff notified her Resident #19 hit Resident #15.
In an interview on 11/02/2023 at 10:00 a.m., S15LPN stated Resident #19 had aggressive tendencies and she often cursed at staff.
In an interview on 11/02/2023 at 10:14 a.m., S2Director of Nursing stated Resident #19 often cursed staff.
In an interview on 11/02/2023 at 11:05 a.m. S1Administrator stated she was aware of the incident of physical abuse on 09/05/2023; however, she was not aware that Resident #19 stated he/she would hit Resident #15 again. S1Administrator did not offer any explanation as to why a thorough investigation was not completed related to the above incident, and indicated she would have dug a little deeper if she was made aware of the previously mentioned statement from Resident #19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure only licensed personnel administered medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure only licensed personnel administered medications for 1 (Resident #43) of 1 (Resident #43) sampled residents observed for medicated cream administration in a total sample of 18.
Findings:
Review of Resident #43's medical record revealed, in part, Resident #43 was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer of the buttock.
In an interview on 10/31/2023 at 9:27 a.m., S9Certified Nursing Assistant (CNA) stated she used cream on Resident #43's buttocks as needed. S9CNA presented the surveyor with two tubes of creams she used on Resident #43 buttocks. Observation revealed a tube of Miconazole Nitrate 2% cream (an antifungal ointment) and a tube of silicone cream (a moisture barrier). S9CNA further stated she used both creams and asked the wound care nurse which cream should be used.
In an interview on 11/02/2023 at 9:37 a.m., S5Treatment Nurse stated the CNAs were allowed to apply silicone cream as a moisture barrier for residents. S5Treatment Nurse further stated CNAs should not apply any medication creams. S5Treatment Nurse confirmed Miconazole Nitrate 2% ointment was an over the counter medicated ointment.
In an interview on 11/02/2023 at 9:47 a.m., S2Director of Nursing (DON) stated CNA staff should not apply medicated creams to residents. S2DON confirmed the Miconazole Nitrate 2% ointment was a medicated over the counter ointment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on observation and interviews, the facility failed to allow residents access to their personal funds for 1 (Resident #29) of 4 (Resident #4, Resident #29, Resident #44, and Resident #69) sampled...
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Based on observation and interviews, the facility failed to allow residents access to their personal funds for 1 (Resident #29) of 4 (Resident #4, Resident #29, Resident #44, and Resident #69) sampled residents investigated for personal funds.
Findings:
In an interview on 10/30/2023 at 10:34 a.m., Resident #29 stated she had money held in an account by the facility; however, she can only get her money at a certain time on Mondays through Fridays.
Observation on 11/01/2023 at 10:45 a.m. of S3Business Office Manager's (BOM) office door revealed signage which revealed, Banking hours Monday - Friday 8:30 a.m. to 9:30 a.m. and 12:30 p.m. to 1:30 p.m.
In an interview on 11/01/2023 at 10:50 a.m., S3BOM confirmed Resident #29 participated in the facility's resident trust fund. S3BOM stated approximately a month ago, S1Administrator implemented banking hours from 8:30 a.m. to 9:30 a.m. and 12:30 p.m. to 1:30 p.m. S1BOM further stated when she was not in the facility and on the weekends there was no system to ensure the residents could access money from their trust fund.
In an interview on 11/01/2023 at 10:57 a.m., S1Administrator stated she implemented banking hours to allow S3BOM time to get her work done without resident interruptions. S1Administrator stated she did not have a system in place to allow residents to get their money outside of the posted hours and on weekends.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident's code status matched and was maint...
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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 a resident's code status matched and was maintained throughout the clinical record for 1 (Resident #44) of 16 (Resident #4, Resident #5, Resident #6, Resident #13, Resident #18, Resident #19, Resident #25, Resident #29, Resident #38, Resident #44, Resident #53, Resident #57, Resident #58, Resident #59, Resident #69, and Resident #81) residents reviewed for code status.
Findings:
Review of Resident #44's medical record revealed, in part, Resident #44 was admitted to the facility on [DATE].
Review of Resident #44's [DATE] physician orders revealed, in part an order dated [DATE] the read Resident #44's code status was full code.
Review of Resident #44's Louisiana Physician Orders for Scope of Treatment (LaPOST) dated [DATE] revealed, in part, Resident #44 desired to have a code status of do not resuscitate (DNR).
Review of Resident #44's comprehensive care plan revealed, in part, Resident #44's code status was full code.
Observation on [DATE] at 12:02 p.m. revealed a bright orange sticker with the letters DNR (do not resuscitate) present on Resident #44's medical chart.
In an interview on [DATE] at 8:53 a.m., Resident #44 stated he desired to receive cardiopulmonary resuscitation (CPR) in an emergency event.
In an interview on [DATE] at 2:10 p.m., S8Licensed Practical Nurse stated Resident #44's code status was DNR.
In an interview on [DATE] at 2:11 p.m., S7Registered Nurse stated Resident #44's code status was DNR.
Observation on [DATE] at 2:18 p.m. revealed a bright orange sticker with the letters DNR (do not resuscitate) present on Resident #44's medical chart.
In an interview on [DATE] at 2:20 p.m., S2Director of Nursing (DON) stated Resident #44's current physician orders were incorrect. S2Don further stated Resident #44's physician order should have been updated on [DATE] upon Resident #44's LaPOST being acknowledged by the physician and it was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to implement a resident's care plan and administer a resident's insulin per physician's order for 1 (Resident #11) of 5 (Resident #11, Reside...
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Based on record review and interviews, the facility failed to implement a resident's care plan and administer a resident's insulin per physician's order for 1 (Resident #11) of 5 (Resident #11, Resident #13, Resident #53, Resident #57, and Resident #58) sampled residents reviewed for unnecessary medications.
Findings:
Review of Resident #11's Comprehensive Care Plan revealed, in part, Resident #11 was care planned for the potential of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) related to Diabetes with an intervention to have insulin administered as ordered.
Review of Resident #11's October 2023 Physician's Orders revealed, in part, an order dated 06/29/2023 for Novolog (a medication used to lower blood sugar levels) 100 units per milliliters (units/mL) subcutaneously (injection under the skin) sliding scale for a blood glucose of 0-60 milligrams/deciliter (mg/dL) administer 0 units and give orange juice or milk; for a blood glucose of 61-200 mg/dL administer 0 units; for a blood glucose of 201-250 mg/dL administer 2 units; for a blood glucose of 251-300 mg/dL administer 4 units; for a blood glucose of 301-350 mg/dL administer 6 units; and for a blood glucose of 351-400 mg/dL administer 8 units.
Review of Resident #11's October 2023 electronic Medication Administration Record (eMAR) revealed, in part, Resident #11 was administered Novolog insulin subcutaneously on the following dates as a result of Resident #11's capillary blood glucose reading:
-On 10/01/2023 at 11:30 a.m., Resident #11's capillary blood glucose was 203 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/07/2023 at 11:30 a.m., Resident #11's capillary blood glucose was 210 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/12/2023 at 11:30 a.m., Resident #11's capillary blood glucose was 432 mg/dL, and Resident #11 was administered 10 units of Novolog insulin;
-On 10/13/2023 at 11:30 a.m., Resident #11's capillary blood glucose was 165 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/13/2023 at 8:00 p.m., Resident #11's capillary blood glucose was 207 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/15/2023 at 11:30 a.m., Resident #11's capillary blood glucose was 174 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/16/2023 at 8:00 p.m., Resident #11's capillary blood glucose was 189 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/19/2023 at 4:30 p.m., Resident #11's capillary blood glucose was 212 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/20/2023 at 11:30 a.m., Resident #11's capillary blood glucose was 164 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/21/2023 at 8:00 p.m., Resident #11's capillary blood glucose was 178 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/24/2023 at 4:30 p.m., Resident #11's capillary blood glucose was 393 mg/dL, and Resident #11 was administered 8 units of Novolog insulin;
-On 10/24/2023 at 8:00 p.m., Resident #11's capillary blood glucose was 273 mg/dL, and Resident #11 was administered 6 units of Novolog insulin;
-On 10/25/2023 at 8:00 p.m., Resident #11's capillary blood glucose was 167 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/26/2023 at 8:00 p.m., Resident #11's capillary blood glucose was 177 mg/dL, and Resident #11 was administered 4 units of Novolog insulin;
-On 10/27/2023 at 8:00 p.m., Resident #11's capillary blood glucose was 259 mg/dL, and Resident #11 was administered 6 units of Novolog insulin; and,
-On 10/30/2023 at 4:30 p.m. Resident #11's capillary blood glucose was 206 mg/dL, and Resident #11 was administered 4 units of Novolog insulin.
In an interview on 10/31/2023 at 1:50 p.m., S2Director of Nursing (DON) stated Resident #13's Novolog insulin was not administered per signed the physician's orders. S2DON confirmed the nurses should be administering insulin per the physician's sliding scale order for Novolog.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1. Ensure a resident with a history of falls received...
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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:
1. Ensure a resident with a history of falls received increased supervision to prevent further falls for 1 (Resident #59) of 2 (Resident #18 and Resident #59) sampled residents reviewed for falls; and
2. Ensure a resident with a known history of unsafe smoking in his room did not have smoking materials in his possession for 1 (Resident #25) of 6 (Resident #6 and Resident #25) sampled residents reviewed for safe smoking.
Findings:
1.
Review of Resident #59's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/2023 revealed, in part, Resident #59 had a Brief Interview for Mental Status score of 0, which indicated Resident #59 had a severe cognitive impairment. Review also revealed Resident #59 required maximal assist for transfers.
Review of Resident #59's Fall Risk assessment dated [DATE] revealed, in part, Resident #59 was assessed as being at high risk for falls. Further review revealed Resident #59 had intermittent confusion, and a history of three or more falls in the past three months.
Review of Resident #59's October 2023 physician's orders revealed, in part, revealed an order with a start date of 05/15/2023 of hourly rounding of Resident #59 due to frequent falls.
Review of Resident #59's August 2023 - October 2023 progress notes revealed, in part, Resident# 59 fell on [DATE], twice on 8/11/2023, 8/26/2023, 09/09/2023, 09/11/2023 and 10/08/2023.
Review of Resident #59's care plan with target date of 11/11/2023 revealed, in part, the following interventions were placed after Resident #59's continued falls:
-On 08/03/2023, continue with frequent rounding;
-On 08/11/2023, reiterate all previous interventions and continue to round on Resident #59 for assistance with using the restroom;
-On 08/26/2023, Resident #59 is non-compliant;
-On 09/02/2023, continue to round on Resident #59 to assess for needs in order to help reduce falls and injuries;
-On 09/09/2023, reiterate call light usage;
-On 09/11/2023, keep fall mat at beside to help reduce fall related injuries; and,
-On 10/08/2023, reiterate all previous interventions to reduce fall/injuries.
There was no documented evidence and the facility did not present any documented evidence that there was an increase in supervision after Resident #59 kept falling with hourly rounding in place.
In an interview on 11/01/2023 at 10:02 a.m., S15Licensed Practical Nurse (LPN) stated Resident #59 required continual redirection on requiring assistance with getting up.
In an interview on 11/02/2023 at 12:10 p.m., S20Physical Therapist (PT) stated Resident #59 had decreased safety awareness. S20PT further stated Resident #59 wanted to be independent. S20PT stated supervision would help reduce Resident #59's falls.
In an interview on 11/02/2023 at 12:21 p.m., S4MDS Coordinator stated every 1 hour rounds was the most supervision that was increased for Resident #59.
In an interview on 11/02/2023 at 12:22 p.m., S21Quality Assurance Nurse stated rounding more often than every 1 hour was too excessive for staff, so supervision was never made more frequently than every hour.
In an interview on 11/02/2023 at 12:31 p.m., S2Director of Nursing (DON) stated they had not increased supervision to more frequently than every hour. She stated increased supervision would not decrease Resident #59's falls because he wanted to be independent.
In an interview on 11/02/2023 at 12:58 p.m., S15LPN stated increased supervision or one on one supervision would decrease falls.
In an interview on 11/02/2023 at 1:10 p.m., S19Certified Nursing Assistant (CNA) stated Resident #59 falls frequently and that one on one supervision may help.
2.
Review of Resident #25's Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 10/11/2023 revealed, in part, had a Brief Interview for Mental Status score of 6, which indicated he had moderate cognitive impairment.
Review of Resident #25's Nurse's Note dated 08/18/2023 revealed Resident #25 was found smoking in bed.
Review of Resident #23's Safe Smoking assessment dated [DATE] revealed he was a safe smoker but smoking materials were to remain at the front desk and his lighter with the Administrator.
In an interview on 11/01/2023 at 9:00 a.m., Resident #25 stated his cigarettes are kept with him.
In an interview on 11/01/2023 at 2:39 p.m., Resident #25 stated he had his cigarettes with him.
Observation on 11/01/2023 at 2:39 p.m. revealed Resident #25 sitting in the dining room. Observation further revealed Resident #25 took a pack of cigarettes from his front right shirt pocket. Observation further revealed he had 5 cigarettes in the pack.
Observation on 11/02/2023 at 9:20 a.m. revealed Resident #25 had a lighter on his person while he was in his room in his bed.
In an interview on 11/02/2023 at 12:27 p.m., S22Social Services stated Resident #25 should not have his lighter or his cigarettes and his smoking materials should be located at the front desk.
In an interview on 11/02/2023 at 12:30 p.m., S2Director of Nursing confirmed Resident #25 should not have smoking materials.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to:
1. Ensure a resident's physician's order for dialysis was accurate for 1 (Resident #13) of 1 (Resident #13) sampled residents investigat...
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Based on record reviews and interviews, the facility failed to:
1. Ensure a resident's physician's order for dialysis was accurate for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for dialysis services; and,
2. Maintain ongoing communication regarding a resident's condition with the dialysis facility for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for dialysis services.
Findings:
1.
Review of Resident #13's Dialysis Care Plan revealed, in part, an intervention for Resident #13 to attend dialysis per the physician's order.
Review of Resident #13's October 2023 Physician's Order's revealed, in part, an order with a start date of 03/27/2023 for Resident #13 to attend dialysis on Tuesdays, Thursdays, and Saturdays at Dialysis Center A.
In an interview on 11/02/2023 at 11:30 a.m., S8Licensed Practical Nurse (LPN) stated Resident #13 attended Dialysis Center B. S8LPN confirmed Resident #13's dialysis location in the October 2023 Physician's Order with a start date of 03/27/2023 was incorrect.
In an interview on 11/02/2023 at 12:35 p.m., S2Director of Nursing confirmed Resident #13's dialysis location on the October 2023 Physician's Orders was incorrect. S2DON stated Resident #13 attended dialysis at Dialysis Center B.
2.
Review of the facility's Care of a Resident with End-Stage Renal Disease policy and procedure revealed, in part, agreements between the facility and the contracted dialysis facility must include all aspects of how the resident's care will be managed, including how information will be exchanged between the facility and the dialysis facility.
Review of Resident #13's October 2023 Physician's Order's revealed, in part, an order with a start date of 03/27/2023 for Resident #13 to attend dialysis on Tuesdays, Thursdays, and Saturdays.
In an interview on 10/31/2023 at 10:15 a.m., S1Administrator stated the facility did not have an agreement with the dialysis facility on how communication would be shared regarding a dialysis resident's condition, but the facility and the dialysis center communicated via a dialysis communication form.
In an interview on 11/01/2023 at 10:02 a.m., S8LPN stated the facility used a dialysis communication form to communicate back and forth with dialysis regarding a dialysis resident's condition.
In an interview on 11/01/2023 at 2:22 p.m., S14Ward Clerk, started Resident #13's dialysis communication form binder was left at dialysis and it was not present at this time.
There was no documented evidence and the facility was unable to provide any documented evidence of communication between the facility and the dialysis facility regarding Resident #13's condition before and after dialysis.
In an interview on 11/01/2023 at 2:25 p.m., S2DON stated communication with dialysis centers was completed by use of the dialysis communication form. S2DON stated the form should be filled out before a resident goes to dialysis, and the facility should ensure the form was before the resident returned from dialysis. S2DON confirmed Resident #13's dialysis communication binder with the dialysis communication forms was not present in the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure side effect monitoring for the use of anticoagulant medication was completed for 1 (Resident #53) of 5 (Resident #11, Resident #13, ...
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Based on record review and interview, the facility failed to ensure side effect monitoring for the use of anticoagulant medication was completed for 1 (Resident #53) of 5 (Resident #11, Resident #13, Resident #53, Resident #57, and Resident #58) sampled residents reviewed for unnecessary medications.
Findings:
Review of Resident #53's Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/29/2023 revealed, in part, Resident #53 received anticoagulant medication (a medication to prevent blood clots) 7 days of the 7 day look back period.
Review of Resident #53's physician's orders dated August 2023, September 2023, and October 2023 revealed, in part, an order with a start date of 06/28/2023 for Eliquis (an anticoagulant medication) 5 milligrams by mouth twice daily.
There was no documented evidence and the facility did not present any documented evidence of a side effect monitoring for Resident #53's anticoagulant use.
Review of Resident #53's Medication Administration Record (MAR) dated August 2023, September 2023, and October 2023 revealed, in part, no documented evidence Resident #53 was monitored for side effects of anticoagulant medication.
In an interview on 10/31/2023 at 10:57 a.m., S8Licensed Practical Nurse stated she was unsure as to why Resident #53 was receiving Eliquis.
In an interview on 11/02/2023 at 9:50 a.m., S4MDS Coordinator stated Resident #53 was on an anticoagulant medication. S4MDS Coordinator further stated the comprehensive care plan should have addressed Resident #53 receiving an anticoagulant medication and side effect monitoring for an anticoagulant medication and it did not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to:
1. Ensure the nurse performed hand hygiene during insulin (a medication used to lower blood sugar) administration for 3 (Resi...
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Based on observation, interview, and record review the facility failed to:
1. Ensure the nurse performed hand hygiene during insulin (a medication used to lower blood sugar) administration for 3 (Resident #9, Resident #53, and Resident #286) of 3 (Resident #9, Resident #53, and Resident #286) residents observed for glucose monitoring and insulin administration; and
2. Ensure a Certified Nursing Assistant (CNA) performed hand hygiene while passing ice to 7 residents (Resident #1, Resident #8, Resident #26, Resident #50, Resident #66, Resident #67, and Resident #286) of 7 residents (Resident #1, Resident #8, Resident #26, Resident #50, Resident #66, Resident #67, and Resident #286) observed for hand hygiene while passing ice.
Findings:
1.
Review of the facility's Hand Hygiene Policy revealed, in part, hand hygiene should be performed before and after preparing or handling medications. Further review revealed staff were to perform hand hygiene before applying non-sterile gloves.
Observation on 10/31/2023 at 11:55 a.m. revealed S5Treatment Nurse entered Resident #286's room, applied gloves without performing hand hygiene, then performed Resident #286's capillary blood glucose check.
Observation on 10/31/2023 at 12:06 p.m. revealed S5Treatment Nurse entered Resident #53's room and placed the insulin needle and alcohol wipe on the nightstand. S5Treatment Nurse applied gloves without performing hand hygiene, repositioned Resident #53's wheelchair, and closed the privacy curtain. Further observation revealed S5Treatment nurse failed to change gloves and perform hand hygiene prior to having administered Resident #53's insulin injection.
Observation on 10/31/2023 at 12:14 p.m. revealed S5Treatment Nurse entered Resident #9's room, applied gloves without performing hand hygiene, then performed Resident #9's capillary blood glucose monitoring.
Observation on 10/31/2023 at 12:19 p.m. revealed S5Treatment Nurse entered Resident #9's room, applied gloves without performing hand hygiene then administered Resident #9's insulin injection.
Observation on 10/31/2023 at 12:44 p.m. revealed S5Treatment Nurse entered Resident #286's room, moved the wheelchair, then applied gloves without performing hand hygiene, then administered Resident #286's insulin injection.
In an interview on 11/01/2023 at 11:40 a.m., S5Treatment Nurse stated hand hygiene should be performed after touching items, prior to applying gloves, and after removing gloves. S5Treatment Nurse confirmed she did not perform hand hygiene prior to performing glucose monitoring for the above mentioned residents on 10/31/2023. S5Treatment Nurse further confirmed she did not perform hand hygiene prior to applying gloves and prior to administering insulin for above mentioned residents on 10/31/2023.
In an interview on 11/02/2023 at 11:40 a.m., S2Director of Nursing (DON) stated hand hygiene should be performed before touching residents to provide care and after providing care to residents.
2.
Observation on 10/31/2023 at 8:48 a.m. revealed S17CNA exited Resident #66's room with an ice pitcher, S17 CNA filled the ice pitcher with ice, then returned the ice pitcher to Resident #66's room. S17 CNA then exited Resident #66's room without performing hand hygiene.
Observation on 10/31/2023 at 8:49 a.m. revealed S17CNA entered Resident #8's and Resident #286's room without performing hand hygiene. Observation further revealed S17CNA grabbed Resident #8's ice pitcher then touched the bathroom door handle, entered the bathroom to empty to ice pitcher, did not perform hand hygiene, and then exited the bathroom and room. Further observation revealed S17CNA then filled Resident #8's ice pitcher and delivered the ice pitcher back to Resident #8's room and exited Resident #8's room without performing hand hygiene.
Observation on 10/31/2023 at 8:50 a.m. revealed S17CNA entered Resident #1's and Resident #26's room and grabbed Resident #1's ice pitcher. Observation revealed S17CNA then exited the room, filled Resident #1's ice pitcher, then delivered the ice pitcher back to Resident #1's room. Further observation revealed S17CNA then exited Resident #1's and Resident #26's room without performing hand hygiene.
Observation on 10/31/2023 at 8:51 a.m. revealed S17CNA entered Resident #67's and Resident #50's room, S17CNA grabbed Resident #67's ice pitcher, filled the ice pitcher, and then went into Resident #67's room. Further observation revealed S17CNA then obtained Resident #50's ice pitcher, opened the bathroom door, entered the bathroom, emptied water out of the pitcher, didn't perform hand hygiene, and then exited the bathroom and the room. S17CNA then filled Resident #50's ice pitcher, and delivered the ice pitcher back to Resident #50's room without performing hand hygiene.
In an interview on 11/01/2023 at 11:55 a.m., S17CNA confirmed she did not perform hand hygiene while she was passing ice. S17CNA further stated she should have performed hand hygiene between resident rooms while she was passing ice.
In an interview on 11/01/2023 at 11:57 a.m., S1Administrator confirmed S17CNA should have used hand sanitizer between resident rooms.
In an interview on 11/01/2023 at 12:00 p.m., S2Director of Nursing confirmed S17CNA should have performed hand hygiene when entering and exiting resident rooms.
Aug 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
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to ensure:
1. Resident's medications were not left unattended on top of the medication cart for 1 (Medication Cart a) of 3 (Medication Cart a, Me...
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Based on observation and interview the facility failed to ensure:
1. Resident's medications were not left unattended on top of the medication cart for 1 (Medication Cart a) of 3 (Medication Cart a, Medication Cart b, and Medication Cart c) medication carts observed, and
2. Medication Carts were locked when unattended for 1 (Medication Cart b) of 3 (Medication Cart a, Medication Cart b, and Medication Cart c) medication carts observed.
Findings:
1.
Observation on 08/22/2023 at 8:50 a.m. revealed Fluoxetine (medication to treat depression) 20 milligram (mg) capsule card, Divaloproex Sodium (medication used to treat seizures) 250 mg tablet card, Potassium Chloride Extended Release (medication used to replace potassium) 10 milliequivalent (meq) tablet card, Furosemide (medication used to treat edema) 40 mg tablet card, and Cyproheptadine (medication used to treat allergy symptoms) 4 mg tablet card was left on the top Medication Cart a unattended.
In an interview on 08/22/2023 at 8:55 a.m., S8Licensed Practical Nurse (LPN) acknowledged she left Fluoxetine 20 mg capsule card, Divaloproex Sodium 250 mg tablet card, Potassium Chloride Extended Release 10 meq tablet card, Furosemide 40 mg tablet card, and Cyproheptadine 4mg tablet card on the top of Medication Cart a unattended.
2.
Observation on 08/22/2023 at 1:20 p.m. revealed S3Registered Nurse (RN) prepared Hydromorphone (medication used to treat pain) 8 mg 1.5 tablets for Resident #4, then placed the medicine cup in the top drawer of Medication Cart b. Further observation revealed, S3RN left Medication Cart b unlocked and unattended.
In an interview on 08/22/2023 at 1:22 p.m., S3RN acknowledged she left Medication Cart b unlocked and unattended. S3RN stated she should have locked Medication Cart b prior to stepping away from the cart.
In an interview on 08/24/2023 at 1:05 p.m., S2Director of Nursing (DON) stated medications should be locked in the medication cart at all times when unattended. S2DON further stated medication cards should not be left on top of the cart unattended.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review, observations, and interviews the facility failed to ensure:
1. Maintain accurate reconciliation records of controlled medication for 2 (Medication Cart b and Medication Cart c...
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Based on record review, observations, and interviews the facility failed to ensure:
1. Maintain accurate reconciliation records of controlled medication for 2 (Medication Cart b and Medication Cart c) of 3 (Medication Cart a, Medication Cart b, and Medication Cart c) medication carts observed;
2. Maintain accurate reconciliation records of controlled medication for 5 (Resident #3, Resident #5, Resident #R6, Resident #R7, and Resident #R8) residents who received controlled medication; and
3. Medication records were accurately documented for 3 (Resident #3, Resident #4, and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.
Findings:
1.
Observation on 08/22/2023 at 1:05 p.m. revealed Medication Cart c did not have two signatures for the Schedule Drug Count on 08/01/2023 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, and 11:00 to 7:00 p.m. shift; on 08/02/2023 7:00 a.m. to 3:00 p.m. shift; 08/03/2023 7:00 a.m. to 3:00 p.m. shift and 3:00 p.m. to 11:00 p.m. shift; on 08/05/2023 11:00 p.m. to 7:00 a.m. shift; on 08/06/2023 7:00 a.m. to 3:00 p.m. shift and 11:00 p.m. to 7:00 a.m. shift; on 08/07/2023 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, and 11:00 p.m. to 7:00 a.m. shift; on 08/08/2023 11:00 p.m. to 7:00 a.m. shift; on 08/12/2023 3:00 p.m. to 11:00 p.m. shift and 11:00 p.m. to 7:00 a.m. shift; on 08/13/2023 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, and 11:00 p.m. to 7:00 a.m. shift; on 08/17/2023 7:00 a.m. to 3:00 p.m. shift; on 08/21/2023 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, and 11:00 p.m. to 7:00 a.m. shift.
In an interview on 08/22/2023 at 1:10 p.m., S6Licensed Practical Nurse (LPN) stated the Schedule Drug Count should have been counted by the off going nurse and on coming nurse. S6LPN further stated each nurse should have signed the schedule drug count log. S6LPN stated there should have been two signatures on each shift on the daily schedule drug count log. S6LPN confirmed there are several missing signatures on the August 2023 schedule drug count log.
Observation on 08/22/2023 at 1:30 p.m. revealed Medication Cart b did not have two signatures for the Schedule Drug Count on 08/01/2023 3:00 p.m. to 11:00 p.m. shift, on 08/05/2023 3:00 p.m. to 11:00 p.m. shift, on 08/08/2023 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, 11:00 p.m. to 7:00 a.m. shift, on 08/09/2023 3:00 p.m. to 11:00 p.m. shift, 11:00 p.m. to 7:00 a.m. shift, on 08/11/2023 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, on 08/12/2023 3:00 p.m. to 11:00 p.m. shift, 11:00 p.m. to 7:00 a.m. shift, on 08/14/2023 7:00 a.m. to 3:00 p.m. shift, 08/18/2023 3:00 p.m. to 11:00 p.m. shift, 11:00 p.m. to 7:00 a.m. shift, 08/19/2023 3:00 p.m. to 11:00 p.m. shift, 11:00 p.m. to 7:00 a.m. shift, on 08/20/2023 3:00 p.m. to 11:00 p.m. shift, and 11:00 p.m. to 7:00 a.m. shift
In an interview on 08/23/2023 at 2:20 p.m., S2Director of Nursing (DON) stated controlled medications should be counted by the off going nurse and the oncoming nurse every shift 7:00 a.m., 3:00 p.m. to 11:00 p.m., 11:00 p.m. to 7:00 a.m. S2DON further stated the schedule drug count log should be signed by two nurses. S2DON confirmed the schedule drug count log was not signed by the off going nurse and the oncoming nurse.
2.
Observation on 08/22/2023 at 1:31 p.m. revealed Resident #R6's medication card for Pregabalin (medication used to treat pain) 100 milligrams (mg) had 17 capsules and the individual narcotic count was 18 capsules. Further review revealed Resident #R6's medication card for Alprazolam (medication used to treat anxiety) 0.5 mg had 26 tablets and the individual narcotic count was 27.
In an interview on 08/22/2023 at 1:32 p.m., S3Registered Nurse (RN) stated she should have signed the medication out at the time of administration.
Observation on 08/22/2023 at 1:33 p.m. revealed Resident #5's individual narcotic count for Norco (medication used to treat pain) 10 mg-325 mg was 1 and there was no medication card for Resident #5's Norco 10mg-325mg medication.
In an interview on 08/22/2023 at 1:33 p.m., S3RN stated she should have signed the medication out at the time of administration.
Observation on 08/22/2023 at 1:34 p.m. revealed Resident #R7's medication card for Pregabalin 50 mg had 27 capsules and the individual narcotic count was 28 capsules.
In an interview on 08/22/2023 at 1:34 p.m., S3RN stated she should have signed the medication out at the time of administration.
Observation on 08/22/2023 at 1:35 p.m. revealed Resident #R8's medication card for Pregabalin 50 mg had 77 capsules and the individual narcotic count was 78 capsules.
In an interview on 08/22/2023 at 1:35 p.m., S3RN stated she should have signed the medication out at the time of administration.
Observation on 08/22/2023 at 1:36 p.m. revealed Resident #3's medication card for Oxycodone-APAP (acetaminophen) (medication used to treat pain) 5 mg-325 mg had 19 capsules and the individual narcotic count was 20 capsules.
In an interview on 08/22/2023 at 1:36 p.m., S3RN stated she should have signed the medication out at the time of administration.
In an interview on 08/23/2023 at 2:20 p.m., S2DON stated controlled medications should be counted by the off going nurse and the oncoming nurse and the schedule drug count log should be signed. S2DON confirmed the schedule drug count log was not signed by the off going and oncoming nurse. S2DON stated controlled medications should be signed out at the time of administration.
3.
Resident #3
Review of Resident #3's oxycodone 5mg-325mg revealed, in part, oxycodone 5mg-325mg was signed out on 08/21/2023 at 9:40 p.m.
Review of Resident #3's Medication Administration Record (MAR) dated August 2023 revealed, in part, no documentation oxycodone 5mg-325mg was administered on 08/21/2023 at 9:40 p.m.
Resident #4
Review of Resident #4's individual narcotic record dated 06/28/2023 of Hydromorphone 8 mg tablet 1 tablet by mouth every 4 hours as needed revealed, in part, Hydromorphone was signed out on 07/02/2023 at 12:30 a.m. and 07/02/2023 at 5:30 a.m.
Review of Resident #4's MAR dated July 2023 revealed, in part, no documentation Hydromorphone was administered on 07/02/2023 at 12:30 a.m. and 07/02/2023 at 5:30 a.m.
Review of Resident #4's individual narcotic record dated 07/10/2023 of Hydromorphone 1.5 tablets by mouth every 4 hours as needed revealed, in part, Hydromorphone was signed out on 07/21/2023 at 11:00 p.m.
Review of Resident #4's MAR dated July 2023 revealed, in part, no documentation Hydromorphone 8 mg (1.5 tablets 12 mg total) was administered on 07/21/2023 at 11:00 p.m.
Review of Resident #4's individual narcotic record dated 08/01/2023 of Hydromorphone 8 mg 1 tablet by mouth every 4 hours as needed revealed, in part, Hydromorphone was signed out on 08/14/2023 at 2:30 p.m.
Review of Resident #4's MAR dated August 2023 revealed, in part, no documentation of Hydromorphone 8 mg 1 tablet by mouth every 4 hours as needed on 08/14/2023 at 2:30 p.m.
Review of Resident #4's individual narcotic record dated 08/01/2023 of Hydromorphone 8 mg (1.5 tablets) by mouth every 4 hours as needed revealed, in part, Hydromorphone was signed out on 08/14/2023 at 9:18 p.m. and 08/15/2023 at 5:00 p.m.
Review of Resident #4's MAR dated August 2023 revealed, in part, no documentation of Hydromorphone 8 mg tablet (1.5 tablets 12 mg total) was administered on 08/14/2023 at 9:18 p.m. and 08/15/2023 at 5:00 p.m.
Review of Resident #4's MAR dated June 2023 revealed, in part, Hydromorphone 8 mg was administered on 06/29/2023 at 2:20 p.m. and 06/30/2023 at 2:14 p.m.
Review of Resident #4's individual narcotic record dated 06/28/2023 of Hydromorphone 8 mg tablet 1 tablet by mouth every 4 hours as needed revealed, in part, Hydromorphone 8 mg was not signed out on 06/29/2023 at 2:20 p.m. and 06/30/2023 at 2:14 p.m.
Resident #5
Review of Resident #5's individual narcotic record #2047919 for Hydrocodone-APAP (Acetaminophen) (medication used to treat pain) 10 mg-325 mg revealed, in part, Hydrocodone-APAP was signed out on 06/01/2023 at 6:00 p.m. and 06/21/2023 at 11:00 a.m. Further review revealed on 06/07/2023 and 06/10/2023 1 tablet signed out on each day with no documented time.
Review of Resident #5's individual narcotic record #2047996 for Norco (medication used to treat pain) 10 mg-325 mg revealed, in part, Norco 10mg-325 mg was signed out on 06/04/2023 at 7:00 a.m., 06/07/2023 at 10:00 a.m., 06/09/2023 at 3:20 a.m., 06/11/2023 at 8:00 p.m., 06/23/2023 at 9:00 p.m., and 06/24/2023 at 9:45 a.m.
Review of Resident #5's MAR dated June 2023 revealed, in part, no documentation that Norco 10 mg-325 mg or Hydrocodone-APAP 10 mg-325 mg was administered on 06/04/2023, 06/09/2023, 06/11/2023, and 06/23/2023. Further review revealed documentation of Norco 10mg-325 mg administered on 06/01/2023 at 8:27 p.m., 06/07/2023 at 1:25 p.m., 06/21/2023 at 8:31 a.m., and 06/24/2023 at 6:33 a.m.
Review of Resident #5's individual narcotic record #2047919 for Hydrocodone-APAP 10 mg-325 mg revealed, in part, documentation of Hydrocodone-APAP 10 mg-325 mg signed out on 07/02/2023 at 3:00 p.m. and 9:00 p.m., 07/10/2023 at 7:40 a.m., and 07/31/2023 at no documented accurate time.
Review of Resident #5's July 2023 MAR revealed, in part, no documentation of Hydrocodone-APAP 10 mg-325 mg administered on 07/02/2023 at 3:00 p.m. or 9:00 p.m., 07/10/2023 at 7:40 a.m., and 07/31/2023 at any time after the 1:54 p.m. dose.
Review of Resident #5's individual narcotic record #204754 for Norco 10 mg-325 mg tablet revealed, in part, documentation of Norco10 mg-325 mg signed out on 08/02/2023 at 8:00 p.m., 08/04/2023 at 5:15 p.m., 08/05/2023 at 8:45 a.m., 08/06/2023 at 7:30 p.m., 08/09/2023 at 6:00 p.m., and 08/16/2023 at 7:00 p.m.
Review of Resident #5's August 2023 MAR revealed, in part, no documentation of Norco 10 mg-325 mg tablet administered on 08/02/2023 at 8:00 p.m., 08/04/2023 at 5:15 p.m., 08/06/2023 at 7:30 p.m., and 08/16/2023 at 7:00 p.m. Further review revealed, in part, Norco 10 mg-325 mg tablet administered on 08/05/2023 at 10:42 a.m., 08/09/2023 at 10:22 p.m., and 08/16/2023 at 9:04 a.m.
In an interview on 08/24/2023 at 11:24 p.m., S2DON stated Resident #4's MAR documentation of administration of Hydromorphone 8 mg on 06/29/2023 at 2:20 p.m. and 06/30/2023 at 2:14 p.m. was inaccurate and did not reflect the medication was administered because the individual narcotic count was not inaccurate. S2DON also stated all controlled medications should have been signed out on the individual controlled medication log at the time of administration and administration of controlled medication should have been documented on the MAR. S2DON acknowledged Resident #3's MAR had no documentation oxycodone 5mg-325mg was administered on 08/21/2023 at 9:40 p.m. S2DON also acknowledged Resident #4's MAR had no documentation Hydromorphone 8 mg was administered on 07/02/2023 at 12:30 a.m., 07/02/2023 at 5:30 a.m., 07/21/2023 at 11:00 p.m., 08/14/2023 at 2:30 p.m.; and Hydromorphone 8 mg tablet (1.5 tablets 12 mg total) was administered on 08/14/2023 at 9:18 p.m. and 08/15/2023 at 5:00 p.m. S2DON acknowledged Resident #5's MAR also had no documentation Norco 10 mg-325 mg or Hydrocodone-APAP 10 mg-325 mg was administered on 06/04/2023, 06/09/2023, 06/11/2023, and 06/23/2023.
May 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
Based on observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) immediately reported an injury of unknown origin when a bruise was observed on a resident's forehe...
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Based on observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) immediately reported an injury of unknown origin when a bruise was observed on a resident's forehead. This deficient practice was identified for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents.
Findings:
Observation on 05/17/2023 at 11:32 a.m. revealed pictures from S1Administrator's cell phone of a dark purple colored bruise to Resident #1's right forehead, redness to Resident #1's left knee cap area, and a small quarter sized red area to left chest in what appeared to be above Resident #1's left breast. S1Adminitrator proceeded to explain Resident #1's daughter/RP (Responsible Party) sent the above mentioned photos from her cell phone on 04/23/2023.
In an interview on 05/15/2023 at 3:10 p.m., S3CNA stated she observed a dark bruise to Resident #1's right forehead while assisting her to bed on the evening of 04/22/2023. S3CNA also stated she did not report these findings to the nurse and was unaware of how the bruising occurred. The facility did not present any documented evidence that S3CNA reported the bruise to Resident #1's right forehead.
In an interview on 05/16/2023 at 11:15 a.m., S4Registered Nurse (RN) stated S5CNA informed her of a bruise noted to Resident #1's right forehead at approximately 1:00 a.m. on 04/22/2023. S4RN further stated upon assessing Resident #1, a quarter sized bruise was also observed to Resident #1's left chest above her left breast.
In an interview on 05/17/2023 at 1:17 p.m., S1Administrator acknowledged S3CNA should have reported the discovery of a bruise to Resident #1's right forehead immediately.
In an interview on 05/18/2023 at 8:14 a.m. S2Weekend Supervisor stated on 04/23/2023 prior to breakfast being served, she observed a dark purple crescent shaped bruise to Resident #1's right forehead.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure a resident dependent on staff for personal hygiene received personal care per their plan of care. This deficient practi...
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Based on observation, record review and interview, the facility failed to ensure a resident dependent on staff for personal hygiene received personal care per their plan of care. This deficient practice was identified for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents reviewed for assistance with ADL's (activities of daily living.
Findings:
Record review of Resident #1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/14/2023 revealed, in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 3 which indicated Resident #1 severely cognitively impaired and required extensive one person assistance with dressing and personal hygiene. Further record review revealed Resident #1 was unable to communicate when in pain and was always incontinent of bladder and frequently incontinent of bowel.
Record review revealed Resident #1 was care planned for requiring assistance with ADL's and personal hygiene.
Review of S1Administrator's investigation documentation revealed, in part, observation of camera footage dated stated while reviewing camera footage dated 4/22/2023 which revealed Resident #1 was not in her room and did not receive personal care from 5:42 a.m. to 5:56 p.m.
In an interview on 05/17/2023 at 1:17 p.m., S1Administrator stated, S6CNA (Certified Nurse Assistant) acknowledged she did not perform personal hygiene to Resident #1 during her shift on 04/22/2023.
Dec 2022
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observations, interview, and record reviews, the facility failed to ensure physician's orders for medication and supplements were coordinated with a resident's dialysis schedule to ensure adm...
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Based on observations, interview, and record reviews, the facility failed to ensure physician's orders for medication and supplements were coordinated with a resident's dialysis schedule to ensure administration.
This deficient practice was identified for 1 of 1 sampled residents reviewed for dialysis services (Resident #26) in a total sample of 14 residents.
Findings:
Review of Resident #26's October and November 2022 Physician Orders revealed, in part, the following: attend dialysis every Tuesday, Thursday, and Saturday; Promod liquid protein (used for nutritional supplement) 30 milliliters(mL) every day; Metoprolol tartrate (used for high blood pressure) 100mg twice daily; Losartan potassium (used for high blood pressure) 50mg daily; Isosorbide Mononite ER (extended release) (used for high blood pressure) 60mg daily; Nephro-vite (used for vitamin supplement) 1 tablet daily; Renvela (used for chronic kidney disease) 800mg tablet (tab), give 2 tablets (tabs) three times daily with meals; Lasix (diuretic) 80mg twice daily; Amlodipine besylate (used for high blood pressure) 5 mg twice daily; Vitamin D3 (used for vitamin supplement) 5,000 units daily; Famotidine (used for antacid) 20mg daily; Paroxetine HCL (used for depression) 10mg daily; Macrobid (used for infection) 100mg twice daily for 7 days, stop on 11/4/2022.
Review of Resident #26's care plan with goal date of 2/28/2023 revealed, in part: a problem related to attending dialysis with an intervention of Resident #26 will have his medication.
Review of Resident #26's October 2022 and November 2022 electronic Medication Administration Record (e-MAR) revealed, in part, the following medications were not administered as ordered:
Renvela 800mg tablet was not administered for the 7:30 a.m. dose on 10/20/2022, 10/22/2022, 10/25/2022, 10/27/2022, 10/29/2022, 11/03/2022, 11/05/2022, 11/10/2022, 11/12/2022, 11/15/2022, 11/17/2022, 11/19/2022, 11/21/2022, 11/23/2022, 11/26/2022, 11/29/2022, and the 12:00 p.m. dose on 11/04/2022 and 11/11/2022.
Promod Liquid Protein was not administered for the 7:30 a.m. dose on 10/25/2022, 10/27/2022, 10/29/2022, 11/03/2022, 11/05/2022, 11/10/2022, 11/12/2022, 11/15/2022, 11/17/2022, 11/19/2022, 11/21/2022, 11/23/2022, 11/26/2022, and 11/29/2022.
Metoprolol tartrate 50mg (2 tabs); Amlodipine besylate 5mg; Vitamin d3 5,000 units; Famotidine 20mg; Nephro-vite 1 tab; Isosorbide mononit ER 60 mg; Losartan potassium 50mg tab; Paroxetine HCL 10mg tablet; Lasix 80mg tablet were not administered for the 8:00 a.m. dose on 10/20/2022, 10/22/2022, 10/25/2022, 10/27/2022, 10/29/2022, 11/03/2022, 11/05/2022,
11/10/2022, 11/12/2022, 11/15/2022, 11/17/2022, 11/19/2022, 11/21/2022, 11/23/2022, 11/26/2022, 11/29/2022; and Macrobid 100 mg on 11/03/2022 at 8:00 a.m.
In an interview on 11/30/2022 at 10:54 a.m., S9License Practical Nurse stated the above medications and/or supplements were not administered as ordered due to his dialysis schedule and she had not contacted the physician about changing the schedule of Resident #26's morning medications due to his dialysis schedule.
In an interview on 11/30/2022, at 11:05 a.m. S2Director of Nursing stated the above medications and/or supplements were not administered as ordered due to his dialysis scheduled and the physician should have been contacted for new orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview the facility failed to maintain an infection prevention and control program by:
1.) Failing to ensure transmission based precautions for a resident (...
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Based on record review, observation, and interview the facility failed to maintain an infection prevention and control program by:
1.) Failing to ensure transmission based precautions for a resident (Resident #20) with Colostrum Difficile was properly maintained;
2.) Failing to ensure a certified nursing assistant (CNA) completed hand hygiene following incontinence care for 1 (Resident #20) of 1 residents observed for incontinence care; and,
3.) Failing to develop and implement a policy and procedure for the surveillance of legionella and other opportunistic water pathogens.
Findings:
#1
Review of the facility's Infection Prevention and Control Program revealed disease specific guidelines from the Centers for Disease Control and Prevention (CDC) should be established and followed.
Review of the facility's Clostridium Difficile (C-Diff) In-service dated 10/27/2022 revealed staff was in-serviced on CDC guidelines of a gown and gloves should be worn when entering a C-Diff resident's room and during their care. Further review revealed hand hygiene should always be performed after removing gloves.
Review of the facility's Clostridium Difficile (C-Diff) policy revealed, in part, the primary reservoirs for Colostrum Difficile are infected people and surfaces. Further review revealed spores can persist on resident care items and surfaces for several months. Review also revealed when caring for residents with a C- Diff infection, staff should maintain vigilant on hand hygiene.
Review of Resident #20's Minimum Data Set with an Assessment Reference Date of 11/04/2022 revealed, in part, Resident #20 had a diagnosis of Entercolitis due to Colostridium difficile and received antibiotics for the 7 days prior to the completion of the assessment.
Review of Resident #20's December 2022 Physician Orders revealed, in part, an order with a start date of 10/28/2022 for isolation and contact precautions for a diagnosis of C Diff. Further review revealed, in part, an additional order with a start date of 11/28/2022 for Vancomycin (an antibiotic used to treat C-Diff infections) 125mg (milligrams) capsule by mouth every 6 hours for 14 days related to Entercolitis due to Clostridium difficile.
Observation on 11/28/2022 at 9:41 a.m. revealed Resident #20's door to room aa was open. Observation revealed a red and white sign present on Resident #20's door that read all visitors please see nurse before entering. Observation further revealed no personal protective equipment was outside of the room.
Observation on 11/28/2022 at 11:48 a.m., revealed Resident #20's door to room aa was open. Observation further revealed during the time the door was open, two residents passed Resident #20's door and touched the doorway and handrail to assist as they ambulated down the hall way. Observation revealed two staff members passed the doorway of Resident #20's room without closing the door.
Observation on 11/28/2022 at 11:50 a.m. revealed Resident #20's door to room aa was open. Observation further revealed S6CNA (Certified Nursing Assistant) entered Resident #20's room without PPE to assess Resident #20 for needs. Observation then revealed S6CNA walked to the PPE caddy located inside Resident #20's room near the head of Resident #20's bed, and placed a gown and gloves on.
Observation on 11/28/2021 at 4:00 p.m. revealed Resident #20's door to room aa was open and with disposable gowns were hanging out of the PPE caddy located near the head of Resident #20's bed, touching the floor.
In an interview on 11/30/2022 at 10:00 a.m., S2Direcctor of Nursing (DON) stated the PPE for Resident #20 in room as was being kept inside the room and it should have been kept outside the room. S2DON further stated the staff had been putting it on in the room, and they should have been donning PPE on outside of the room to prevent transmission of C. Diff to other residents.
In an interview on 11/30/2022 at 11:30 a.m., S6CNA stated PPE should be placed outside the room and put on prior to entering Resident #20's room to help prevent the spread of C-Diff to other residents.
Observation on 11/30/2022 at 11:51 a.m. revealed the PPE caddy in room aa near Resident #20's bed with gowns hanging out of the drawers of the caddy and on top of the caddy touching the floor and the wall of Resident #20's room.
Observation on 12/01/2022 at 9:06 a.m. revealed the door to Resident #20's room was open. Further review revealed S3Activities Director was sitting in a chair inside Resident #20's room with no PPE applied.
In an interview on 11/30/2022 at 12:50 p.m., S3Infection Preventionist stated she used C. Diff training material from the CDC website to educate the staff on the proper precautions for C Diff.
#2
Review of the facility's Clostridium Difficile (C-Diff) In-service dated 10/27/2022 revealed staff was in-serviced on CDC guidelines of a gown and gloves should be worn when entering a C-Diff resident's room and during their care. Further review revealed hand hygiene should always be performed after removing gloves.
Review of the facility's Clostridium Difficile (C-Diff) policy revealed, in part, the primary reservoirs for Colostrum Difficile are infected people and surfaces. Further review revealed spores can persist on resident care items and surfaces for several months. Review also revealed when caring for residents with a C- Diff infection, staff should maintain vigilant on hand hygiene.
Observation on 11/30/2022 at 11:49 a.m. revealed S5CNA entered Resident #20's room without donning PPE. Observation further revealed S5CNA approached the PPE caddy placed near the head of Resident #20's bed and put on a gown and gloves. Observation revealed Resident #20 was visibly soiled with loose feces on bed pad and incontinence brief. Observation then revealed S5CNA initiated pericare and wiped the crease of Resident #20's inner groin on the right and left side with a wipe, folded the wipe and proceeded to wipe Resident #20's labia with the same wipe. Observation revealed S5CNA removed Resident #20's brief and bed pad, visibly soiled with feces, opened the red bin in the room with her soiled gloves, and placed the linens and brief in the red bin. Observation revealed S5CNA did not perform hand hygiene, removed a new pair of gloves from her left front scrub pocket, placed them on both hands and placed a clean brief and bed pad on Resident #20.
In an interview on 11/30/2022 at 11:55 a.m., S5CNA stated the PPE should have been kept outside of Resident #20's room. S5CNA further stated the PPE had been inside the room since Resident #20 went on transmission-based precautions or contact precautions so she just put the PPE on when she went inside the room. S5CNA stated she shouldn't have used the same wipe to wipe Resident #20's labia and the crease of the groin. S5CNA stated she should have washed her hands between removing the Resident #20's visibly soiled brief, touching the linen barrel, and placing the clean brief.
#3
Review of facility's policy and procedure manual revealed no documented evidence of a plan for the surveillance of legionella or other water pathogens.
In an interview on 11/30/2022 at 10:01 a.m., S2DON stated the facility did not have a legionella water policy, and the staff did not monitor for opportunistic water pathogens.
In an interview on 11/30/2022 at 10:23 a.m., S1Administrator stated the facility must have missed the memo regarding a water pathogen and legionella policy and surveillance plan. S1Adminstrator further stated the facility did not have a water pathogen plan, and the staff did not monitor the facility's water for pathogens.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding. Review inspection reports carefully.
- • 45 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $15,000 in fines. Above average for Louisiana. Some compliance problems on record.
- • Grade F (23/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Twin Oaks Nursing Home's CMS Rating?
CMS assigns Twin Oaks Nursing Home an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Twin Oaks Nursing Home Staffed?
CMS rates Twin Oaks Nursing Home's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 54%, compared to the Louisiana average of 46%.
What Have Inspectors Found at Twin Oaks Nursing Home?
State health inspectors documented 45 deficiencies at Twin Oaks Nursing Home during 2022 to 2025. These included: 45 with potential for harm.
Who Owns and Operates Twin Oaks Nursing Home?
Twin Oaks Nursing Home is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by INSPIRED HEALTHCARE MANAGEMENT, a chain that manages multiple nursing homes. With 148 certified beds and approximately 76 residents (about 51% occupancy), it is a mid-sized facility located in LAPLACE, Louisiana.
How Does Twin Oaks Nursing Home Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Twin Oaks Nursing Home's overall rating (1 stars) is below the state average of 2.4, staff turnover (54%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Twin Oaks Nursing Home?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Twin Oaks Nursing Home Safe?
Based on CMS inspection data, Twin Oaks Nursing Home has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Twin Oaks Nursing Home Stick Around?
Twin Oaks Nursing Home has a staff turnover rate of 54%, which is 8 percentage points above the Louisiana average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Twin Oaks Nursing Home Ever Fined?
Twin Oaks Nursing Home has been fined $15,000 across 1 penalty action. This is below the Louisiana average of $33,229. 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 Twin Oaks Nursing Home on Any Federal Watch List?
Twin Oaks Nursing Home is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.