THE BROADWAY NURSING AND REHABILITATION CTR
Non profit - Corporation
126 Beds
ELDER OUTREACH NURSING & REHABILITATION
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
11/100
#252 of 264 in LA
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
The Broadway Nursing and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #252 out of 264 facilities in Louisiana places it in the bottom half, and #4 out of 4 in Lafourche County suggests that there are no better local alternatives. The facility is worsening, with issues increasing from 9 in 2024 to 14 in 2025. Staffing is a relative strength, with a turnover rate of 38% that is below the state average, although the overall staffing rating is only 2 out of 5 stars. However, the facility has incurred $44,810 in fines, which is concerning and reflects ongoing compliance problems. Additionally, there are critical issues, such as staff not having the appropriate licenses to provide care, and instances of inadequate hand hygiene that could lead to infection risks. While there are some strengths, such as lower staff turnover, the overall picture indicates serious challenges in care quality.
- Trust Score
- F
- In Louisiana
- #252/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 38% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $44,810 in fines. Higher than 82% of Louisiana facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 11 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
11/100
Bottom 5%
Review needed
9 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 14 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Louisiana average of 48%
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: 38%
Near Louisiana avg (46%)
Typical for the industry
Federal Fines: $44,810
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: ELDER OUTREACH NURSING & REHABILITA
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 38 deficiencies on record
2 life-threatening
May 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure a resident's choice to eat breakfast in the dining room was supported for 1 (Resident #53) of 4 (Resident #51, Resident #53, Resid...
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Based on interviews and record reviews, the facility failed to ensure a resident's choice to eat breakfast in the dining room was supported for 1 (Resident #53) of 4 (Resident #51, Resident #53, Resident #66, Resident #77) sampled residents investigated for choices.
Findings:
Review of Resident #53's Minimum Data Set with an assessment reference date of 03/13/2025 revealed, in part, Resident #53's Brief Interview Mental Status score was 11, which indicated moderately impaired cognition. Further review revealed Resident #53 used a wheel chair for mobility and required set up or clean up assistance for eating.
Review of Resident #53's care plan with a target date of 06/27/2025 revealed, in part, Resident #53 required staff assistance for activities of daily living related to activity intolerance, poor endurance and shortness of breath on exertion and needed set up and/or clean up assistance with meals. Further review revealed Resident #53 required substantial/maximal assistance with transfers.
In an interview on 05/12/2025 at 9:23AM, Resident #53 indicated the staff did not help her up out of bed for breakfast this morning. Resident #53 further indicated because of this, Resident #53 had to eat breakfast in her room this morning.
In an interview on 05/13/2025 at 10:03AM, S6Certified Nursing Assistant (CNA) indicated Resident #53 sometimes liked to eat in the dining room. S6CNA indicated on 05/12/2025 she was working the hall and indicated by the time she went check in on Resident # 53 it was too late to get her out of bed for breakfast.
In an interview on 05/14/2025 at 8:05AM, S1Administrator confirmed he was informed about the incident where Resident # 53 complained about not being taken out of bed to go to the dining room to go eat breakfast, and S1Adminstrator acknowledged the surveyors findings that Resident #53's choice to brought to breakfast should have been supported.
In an interview on 05/14/2025 at 11:38AM, S2Director of Nursing confirmed Resident # 53 needs staff help to get her out of bed and into her wheel chair to go eat in the dining room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to follow a physician's order for oxygen administration for 1 (Resident #48) of 4 (Resident #27, Resident #34, Resident #48, ...
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Based on observations, interviews, and record reviews, the facility failed to follow a physician's order for oxygen administration for 1 (Resident #48) of 4 (Resident #27, Resident #34, Resident #48, Resident #77) sampled residents investigated for oxygen administration.
Findings:
Review of Resident #48's Minimum Data Set with an assessment reference date of 03/27/2025 revealed, in part, a Brief Interview Mental Status score of 12, which was indicative of moderate cognitive impairment. Further review revealed Resident #48 had a medical history of chronic obstructive pulmonary disease, respiratory failure, shortness of breath with exertion, and oxygen therapy.
Review of Resident #48's Care Plan with a target date of 07/11/2025 revealed, in part, Resident #48 had an intervention for staff to initiate Resident #48's oxygen as ordered.
Review of Resident #48's May 2025 Physician's Orders dated May 2025 revealed, in part, Resident #48 to receive oxygen at a rate of 3 liters per minute (LPM) via nasal cannula (NC) continuously. to prevent hypoxia every shift related to chronic respiratory failure with hypoxia.
Observation on 05/12/2025 at 9:25AM revealed Resident #48's oxygen flow meter was set to deliver oxygen to Resident #48 at a rate of 4.5 LPM per NC.
Observation on 05/12/2025 at 3:40PM revealed Resident # 48's oxygen flow meter was set to deliver oxygen to Resident #48 at a rate of 4.5 LPM per NC.
In an interview on 05/12/2025 at 3:43PM, S11Licensed Practical Nurse (LPN) confirmed Resident #48's oxygen rate was set at 4.5 LPM per the flow meter, but Resident #48's oxygen should have been set at 3 LPM as per the physician's orders.
In an interview on 05/13/2025 at 8:30AM, S2Director of Nursing confirmed Resident #48's oxygen rate should have been set at 3 LPM as ordered per the physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to:
1. Ensure staff performed hand hygiene when assis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to:
1. Ensure staff performed hand hygiene when assisting residents with meals (Resident #10, Resident #57, and Resident #63);
2. Ensure infection surveillance was performed after a resident tested positive for a communicable disease (Resident #104);
This deficient practice was identified for 5 (Resident #10, Resident #57, Resident #63, Resident #104) of 5 (Resident #10, Resident #57, Resident #63, Resident 91, Resident #104) sampled residents reviewed for infection control.
Findings:
1.
Review of the facility's Hand Hygiene policy and procedure, dated February 2025, revealed, in part, hand hygiene should be performed after direct contact with residents and before and after assisting residents with meals.
Observation on 05/13/2025 at 11:23AM revealed S5Certified Nursing Assistant (CNA) touched Resident #63's leg with ungloved hands then proceeded to touch Resident #63's dining utensils without performing hand hygiene. Further observation revealed S5CNA then proceeded to feed Resident #10, Resident #57, and Resident #63 without performing hand hygiene before and/or after assisting the above mentioned residents with their meal.
In an interview on 05/13/2025 at 11:3AM, S5CNA confirmed she did not perform hand hygiene between Resident #10, Resident #57 and Resident #63 and she should have.
In an interview on 05/13/2025 at 12:12PM, S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed hand hygiene should be performed before and after touching a resident and assisting another resident with meals.
2.
Review of the facility's undated COVID-19 Testing policy and procedure revealed, in part, after having had high-risk exposure to COVID-19, staff should have had a series of three viral tests for COVID-19. Further review revealed testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again in 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. Further review revealed the tests typically occur at day 1(where day of exposure is day 0), day 3, and day 5.
Review of Resident #104's electronic medical record (EMR) revealed, in part, Resident #104 as admitted to the facility on [DATE]. Further review of Resident #104's EMR revealed she tested positive for COVID-19 on 04/12/2025 at 2:55PM.
There was no documented evidence, and the provider did not present any documented evidence, the facility performed COVID-19 testing for staff members who were exposed to Resident #104 after she tested positive for COVID-19.
In an interview on 05/13/2025 at 4:25PM, S3ADON/IP indicated she had no documented evidence of outbreak testing was completed after Resident #104 tested positive for COVID-19 on 04/12/2025.
3.
Review of Resident #91's Minimum Data Set with an Assessment Reference Date of 04/21/2025 revealed, in part, Resident #91 had a urinary catheter.
Observation on 05/12/2025 at 9:15AM revealed Resident #91's urinary catheter tubing was on the floor of Resident #91's room.
Observation on 05/12/2025 at 2:44PM revealed Resident #91's urinary catheter tubing was on the floor in Resident #91's room.
Observation on 05/13/2025 at 3:56PM revealed Resident #91's urinary catheter tubing was on the floor in Resident #91's room.
In an interview on 05/13/2025 at 4:00PM, S2Director of Nursing indicated Resident #91's urinary catheter tubing should not be on the floor of Resident #91's room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to ensure the facility was free of pests.
Findings:
Room A
Observation on 05/13/2025 at 8:31AM revealed a brown colored flying insect in Room ...
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Based on observations and interviews the facility failed to ensure the facility was free of pests.
Findings:
Room A
Observation on 05/13/2025 at 8:31AM revealed a brown colored flying insect in Room A.
In an interview on 05/13/2025 at 9:23AM, Resident #36, Resident #71's roommate, indicated she had noticed brown colored flying insects in Room A.
Observation of Room A 05/14/2025 at 7:50AM revealed S1Administrator tapped Resident #71's live potted plant, and a brown colored flying insect came out of the live potted plant.
In an interview on 05/14/2025 at 7:51AM, S1Administrator indicated there was a fly that came out of the live potted plant in Room A.
In an interview on 05/14/2025 at 9:50AM, S8Certified Nursing Assistant (CNA) indicated in the past, Resident #36 stored food in Room A, which attracted flying insects.
Room B
Observation on 05/14/2025 at 8:40AM revealed a brown colored flying insect flew out of a cabinet when the cabinet door was opened in Room B.
In an interview on 05/14/2025 at 8:42AM, S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed there was a brown colored flying insect that flew out of a cabinet in Room B.
Room C
Observation on 05/14/2025 at 8:55AM, S3ADON/IP revealed a brown colored flying insect in Room C.
In an interview on 05/14/2025 at 8:56AM, S3ADON/IP confirmed there was a brown colored flying insect in Room C.
Room D
Observation on 05/13/25 at 8:45AM revealed a brown colored flying insect in Room D.
Room E
Observation on 05/14/2025 at 11:20AM revealed a brown colored flying insect in Room E.
Room F
Observation on 05/14/2025 at 7:55AM revealed a fly light (a device that used light bulbs to attract flying insects) was present in Room F, but the light bulbs were not functioning.
Observation on 05/14/2025 at 9:45AM revealed a fly light in Room F, the light bulbs were not functioning.
In a phone interview on 05/14/2025 at 8:14AM, S9Exterminator further indicated the light bulbs in the fly light in Room F were not working and needed to be replaced.
In an interview on 05/14/2025 at 11:20AM, S1Administrator indicated the light bulbs in the fly light in Room F were not working.
MINOR
(B)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure assessments of a resident's nonoperational dialysis access ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure assessments of a resident's nonoperational dialysis access site were accurately documented in the resident's electronic Medication Administration Record (eMAR) for 1 (Resident #370) of 1 (Resident #370) sampled resident investigated for dialysis.
Findings:
Review of Resident #370's May 2025 Physician's Orders revealed, in part, an order dated 05/06/2025 for staff to monitor Resident #370's right forearm dialysis AV fistula (a connection between an artery and an vein used for resident's to receive dialysis) for a thrill and a bruit (assessments to indicate if a dialysis fistula was patent and functioning)every shift.
Review of Resident #370's May 2025 eMAR revealed, in part, on 05/07/2025, 05/08/2025, 05/09/2025, 05/11/2025, 05/12/2025 on the day shift, 05/10/2025 on the evening shift, and 05/07/2025, 05/08/2025, 05/09/2205, and 05/11/2025 on the night shift, staff documented a Y, indicated that Resident #370's right forearm dialysis AV fistula had a thrill and bruit.
In an interview on 05/13/2025 at 10:36AM, S2Director of Nursing (DON) indicated Resident #370's right forearm dialysis AV fistula had not been functioning since Resident #370 returned to the facility on [DATE]. S2DON acknowledged the facility's nurses should have documented a N in Resident #370's eMAR when assessing Resident #370's right forearm dialysis AV fistula, to indicate Resident #370's AV fistula was not functioning.
Feb 2025
8 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on interviews, and record reviews the facility failed to ensure personnel had the appropriate state licensure to provide care and services to residents. This deficient practice was identified fo...
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Based on interviews, and record reviews the facility failed to ensure personnel had the appropriate state licensure to provide care and services to residents. This deficient practice was identified for 1 (S5Unlicensed Personnel) of 50 (S1Administrator, S2Director of Nursing [DON], S3Assistant Director of Nursing [ADON], S5Unlicensed Personnel, S14Agency Licensed Practical Nurse [LPN], S16LPN, S17LPN, S18Registered Nurse [RN], S19LPN, S20RN, S21Physician, S22Physician, S23Podiatrist, S24RN, S25RN, S26RN, S27RN, S28Treatment RN, S29LPN, S30LPN, S31LPN, S32LPN, S33LPN, S34LPN, S35LPN, S36Minimum Data Set [MDS]Coordinator/LPN, S37LPN, S38LPN, S39LPN, S40LPN, S41LPN, S42LPN, S43LPN, S44LPN, S45LPN, S46LPN, S47LPN, S48LPN, S49LPN, S50LPN, S51LPN, S52Quality Assurance [QA] LPN, S53Physician Assistant, S55Agency LPN, S56Agency LPN, S57LPN, S58LPN, S59LPN, S60Agency LPN, S61Agency LPN) personnel files reviewed for active and current licensure.
The deficient practice resulted in an immediate jeopardy situation on 11/20/2024 when S5Unlicensed Personnel worked in the capacity of a LPN and performed nursing tasks without a Louisiana nursing license. This deficient practice affected 87 residents who were identified by the facility as having received care and services from S5Unlicensed Personnel until S5Unlicensed Personnel was suspended on 01/24/2025 and terminated on 01/24/2025.
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation.
Findings:
Cross reference F839
Review of the facility's undated Professional Licensure Verification Policy revealed, in part, all employees with a professional license would be verified upon hire and as required through the appropriate licensure board.
Review of the facility's undated Administrator Job's Description revealed, in part, the Administrator reported to the Regional Director and was responsible for adopting and enforcing rules and for the healthcare and safety of patients and others.
Review of the facility's undated Director of Nursing's Job Description revealed, in part, the DON reported to the Administrator. Further review revealed the DON's responsibility was to assist with interviewing, evaluating and selecting new personnel.
Review of the facility's undated Human Resources/Payroll Manager Job Description revealed, in part, the Human Resources/Payroll Manager reported to the Administrator and was responsible for maintenance of all personnel files in compliance with local and federal laws.
Review of S5Unlicensed Personnel's Employee Status Change signed by S7Team Member Specialist (TMS) on 11/20/2024 revealed, in part, S5UnlicensedPersonnel had a title change from Certified Nurse Aide (CNA) to LPN.
Review of S5Unlicensed Personnel's personnel file revealed, in part, S5Unlicensed Personnel signed the Licensed Staff (Registered Nurse/Licensed Practical Nurse) Job Description on 11/22/2024.
Review of an email communication received by S7TMS dated 01/29/2025 at 12:15PM from the Louisiana State Board of Practical Nurse Examiners revealed, in part, S5Unlicensed Personnel did not have an active Practical Nurse License in the state of Louisiana.
In an interview on 02/10/2025 at 12:30PM, S7TMS indicated she was responsible for verifying licensure for newly hired staff at the time of hire, and when there was a position change. S7Team Member Specialist/Human Resources further indicated on 11/20/2024 she officially changed S5Unlicensed Personnel's status from a CNA to a LPN. S7TMS further indicated on 01/24/2025 she emailed the Louisiana State Board of Practical Nurse Examiners inquiring about S5Unlicensed Personnel's LPN status and received an answer that S5Unlicensed Personnel did not pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) with the Louisiana State Board of Practical Nurse Examiners.
In an interview on 02/10/2025 at 2:41PM, S2DON indicated S5Unlicensed Personnel started training as a LPN on 11/20/2024. S2DON further indicated a nurse in training would observe and provide nursing care under supervision of another licensed nurse. S2DON further indicated she should have called the Louisiana State Board of Practical Nurse Examiners to verify S5Unlicensed Personnel had a Louisiana nursing license before allowing S5Unlicensed Personnel to provide care and services to residents in the capacity of a LPN.
In an interview on 02/12/2025 at 3:15PM S1Administrator indicated he directed S7TMS to change S5Unlicensed Personnel's status from CNA to LPN. S1Administrator further indicated he directed S2DON to allow S5Unlicensed Personnel to perform duties as a LPN. S1Administrator further indicated he should have verified S5Unlicensed Personnel had a valid Louisiana Practical Nurse license before allowing her to perform care and services as a Louisiana Practical Nurse.
In an interview on 02/17/2025 at 10:15AM S1Administrator indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services.
In an interview on 02/17/2025 at 11:15AM S6Chief Operations Officer (COO) indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services. He further indicated he would be providing administrative on site supervision and remote oversite for 3 months as part of the correction plan.
The facility implemented the following actions to correct the deficient practice beginning on 01/24/2025 with a completion date of 01/31/2025:
1. S5Unlicensed Personnel was suspended on 01/24/2025, and terminated on 01/29/2025.
2. All 87 residents identified on the electronic medical record system audit trail report had the potential to be affected by the deficient practice.
3. To ensure the deficient practice would not reoccur the following measures had been implemented.
a. S1Administrator, S2DON, and S7TMS were in-serviced on licensure verification and reporting wrong doing. S1Administrator was in-serviced on 01/24/2025, S2DON was in-serviced on 01/29/2025 and S7TMS was in-serviced on 01/30/2025.
b. Cognitive resident interviews were completed by S51Regional RN regarding any medication administration concerns or other nursing concerns on 01/30/2025.
c. Full facility wide audit started on 01/24/2025 on all nurses to ensure active license in place.
d. In-service on reporting wrongdoing was completed by S1Administrator, S2DON, S7TMS, and staff by 01/31/2025.
e. Audits were completed on 01/31/2025 of resident's electronic medical records documentation who received care from S5Unlicensed Personnel while S5Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.
4. The facility would monitor its performance to ensure solutions were sustained by completing the following:
a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level.
b. S4Corporate Compliance Officer to audit weekly for compliance for three months and
annually.
5. Plan of Correction to be completed by 01/31/2025.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0839
(Tag F0839)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on interviews, and record reviews the facility failed to ensure personnel had the appropriate state licensure to provide care and services to residents. This deficient practice was identified fo...
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Based on interviews, and record reviews the facility failed to ensure personnel had the appropriate state licensure to provide care and services to residents. This deficient practice was identified for 1 (S5Unlicensed Personnel) of 50 (S1Administrator, S2Director of Nursing [DON], S3Assistant Director of Nursing [ADON], S5Unlicensed Personnel, S14Agency Licensed Practical Nurse [LPN], S16LPN, S17LPN, S18Registered Nurse [RN], S19LPN, S20RN, S21Physician, S22Physician, S23Podiatrist, S24RN, S25RN, S26RN, S27RN, S28Treatment RN, S29LPN, S30LPN, S31LPN, S32LPN, S33LPN, S34LPN, S35LPN, S36Minimum Data Set [MDS]Coordinator/LPN, S37LPN, S38LPN, S39LPN, S40LPN, S41LPN, S42LPN, S43LPN, S44LPN, S45LPN, S46LPN, S47LPN, S48LPN, S49LPN, S50LPN, S51LPN, S52Quality Assurance [QA] LPN, S53Physician Assistant, S55Agency LPN, S56Agency LPN, S57LPN, S58LPN, S59LPN, S60Agency LPN, S61Agency LPN) personnel files reviewed for active and current licensure.
The deficient practice resulted in an immediate jeopardy situation on 11/20/2024 when S5Unlicensed Personnel worked in the capacity of a LPN and performed nursing tasks without a Louisiana nursing license. This deficient practice affected 87 residents who were identified by the facility as having received care and services from S5Unlicensed Personnel until S5Unlicensed Personnel was suspended on 01/24/2025 and terminated on 01/29/2025.
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation.
Findings:
Review of the facility's undated Professional Licensure Verification Policy revealed, in part, all employees with a professional license would be verified upon hire and as required through the appropriate licensure board.
Review of the facility's undated Administrator Job's Description revealed, in part, the Administrator reported to the Regional Director and was responsible for adopting and enforcing rules and for the healthcare and safety of patients and others.
Review of the facility's undated Director of Nursing's Job Description revealed, in part, the DON reported to the Administrator. Further review revealed the DON's responsibility was to assist with interviewing, evaluating and selecting new personnel.
Review of the facility's undated Human Resources/Payroll Manager Job Description revealed, in part, the Human Resources/Payroll Manager reported to the Administrator and was responsible for maintenance of all personnel files in compliance with local and federal laws.
Review of S5Unlicensed Personnel's Employee Status Change signed by S7Team Member Specialist (TMS) on 11/20/2024 revealed, in part, S5UnlicensedPersonnel had a title change from Certified Nurse Aide (CNA) to LPN.
Review of S5Unlicensed Personnel's personnel file revealed, in part, S5Unlicensed Personnel signed the Licensed Staff (Registered Nurse/Licensed Practical Nurse) Job Description on 11/22/2024.
Review of facility documentation revealed, in part, the facility identified 87 residents had received care and services from S5Unliensed Personnel working in the capacity of an LPN from 11/20/2024 until 01/24/2025.
Review of an email communication received by S7TMS dated 01/29/2025 at 12:15PM from the Louisiana State Board of Practical Nurse Examiners revealed, in part, S5Unlicensed Personnel did not have an active Practical Nurse License in the state of Louisiana.
In an interview on 02/10/2025 at 12:30PM, S7TMS indicated she was responsible for verifying licensure for newly hired staff at the time of hire, and when there was a position change. S7Team Member Specialist/Human Resources further indicated on 11/20/2024 she officially changed S5Unlicensed Personnel's status from a CNA to a LPN. S7TMS further indicated on 01/24/2025 she emailed the Louisiana State Board of Practical Nurse Examiners inquiring about S5Unlicensed Personnel's LPN status and received an answer that S5Unlicensed Personnel did not pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) with the Louisiana State Board of Practical Nurse Examiners.
In an interview on 02/10/2025 at 2:41PM, S2DON indicated S5Unlicensed Personnel started training as a LPN on 11/20/2024. S2DON further indicated a nurse in training would observe and provide nursing care under supervision of another licensed nurse. S2DON further indicated she should have called the Louisiana State Board of Practical Nurse Examiners to verify S5Unlicensed Personnel had a Louisiana nursing license before allowing S5Unlicensed Personnel to provide care and services to residents in the capacity of a LPN.
In an interview on 02/12/2025 at 3:15PM S1Administrator indicated he directed S7TMS to change S5Unlicensed Personnel's status from CNA to LPN. S1Administrator further indicated he directed S2DON to allow S5Unlicensed Personnel to perform duties as a LPN. S1Administrator further indicated he should have verified S5Unlicensed Personnel had a valid Louisiana Practical Nurse license before allowing her to perform care and services as a Louisiana Practical Nurse.
In an interview on 02/17/2025 at 10:15AM S1Administrator indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having unlicensed personnel providing nursing services.
The facility implemented the following actions to correct the deficient practice beginning on 01/24/2025 with a completion date of 01/31/2025:
1. S5Unlicensed Personnel was suspended on 01/24/2025, and terminated on 01/29/2025.
2. All 87 residents identified on the electronic medical record system audit trail report had the potential to be affected by the deficient practice.
3. To ensure the deficient practice would not reoccur the following measures had been implemented.
a. S1Administrator, S2DON, and S7TMS were in-serviced on licensure verification and reporting wrong doing. S1Administrator was in-serviced on 01/24/2025, S2DON was in-serviced on 01/29/2025 and S7TMS was in-serviced on 01/30/2025.
b. Cognitive resident interviews were completed by S51Regional RN regarding any medication administration concerns or other nursing concerns on 01/30/2025.
c. Full facility wide audit started on 01/24/2025 on all nurses to ensure active license in place.
d. In-service on reporting wrongdoing was completed by S1Administrator, S2DON, S7TMS, and staff by 01/31/2025.
e. Audits were completed on 01/31/2025 of resident's electronic medical records documentation who received care from S5Unlicensed Personnel while S5Unlicensed Personnel worked in the capacity as a LPN to ensure no harm occurred.
4. The facility would monitor its performance to ensure solutions were sustained by completing the following:
a. S7TMS to verify licensure prior to nurse hired or role change if currently working. S2DON would be provided with a copy for double verification at the facility level.
b. S4Corporate Compliance Officer to audit weekly for compliance for three months and
annually.
5. Plan of Correction to be completed by 01/31/2025.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure the staff properly completed the grievance report form and failed to document a resolution of the grievance for 1 (Resident #13) of...
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Based on interviews and record review, the facility failed to ensure the staff properly completed the grievance report form and failed to document a resolution of the grievance for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for grievances.
Findings:
Review of the facility's undated Grievance policy and procedure revealed, in part, the facility administrator or designee will act as the grievance official, and all grievances made by a resident or resident's family would be documented on the grievance form by the grievance official. Further review revealed the grievance form would include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as whether the grievance was confirmed or not confirmed, corrective action taken by the facility as a result of the grievance, and the date the written decision was issued.
Review of the facility's Grievance Log from 11/2024 to 2/2025 revealed, in part, Resident #13 filed a nurse-related grievance on 01/05/2025, and the grievance was resolved on 01/06/2025.
In an interview on 02/11/2025 at 1:50PM, S4Coporate Compliance Officer indicated S8Social Service Director (SSD) was the facility's grievance official and S1Administrator was responsible for overseeing and signing all grievance reports.
Review of Resident #13's Grievance Report revealed, in part, Resident #13's above mentioned grievance was not signed by S1Administrator. Further review of Resident #13's grievance report revealed there was no documented statement as whether the grievance was confirmed or not confirmed, there was no documented evidence of a resolution of Resident #13's grievance, there was no documented evidence of action taken by the facility as the result of the grievance, and there was no documented evidence the facility notified Resident #13 and/or Resident #13's responsible party of a resolution to Resident #13's grievance.
In an interview on 02/11/2025 at 2:30PM, S8SSD indicated she was not aware of the resolution and had not received the investigation completed by S1Administrator for Resident #13's Grievance Report dated 01/06/2025. S8SSD further indicated Resident #13's grievance investigation and resolution were not properly documented on the Grievance Report form and they should have been.
There was no documented evidence, and the facility did not present any documented evidence, Resident #13's above mentioned Grievance Report was properly documented.
In an interview on 02/12/2025 at 1:10PM, S1Administrator indicated he did not submit the investigation of Resident #13's grievance dated 01/06/2025 to the grievance official. S1Administrator further indicated Resident #13's Grievance Report did not include a resolution on the Grievance Report form, did not include the notification of Resident #13 or Resident #13's responsible party of the resolution, and was not signed by the administrator. S1Administrator confirmed Resident #13's above mentioned written Grievance Report was not properly completed by the grievance official and it should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews the facility failed to ensure an incident of neglect was reported to the Louisiana Department of Health no later than 24 hours after the incident was discovered....
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Based on interviews and record reviews the facility failed to ensure an incident of neglect was reported to the Louisiana Department of Health no later than 24 hours after the incident was discovered.
Findings:
Review of the facility's undated Abuse and Neglect policy revealed, in part, a type of Abuse included Neglect. Further review revealed, neglect was defined the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. Further review revealed neglect occurred when the facility was aware of, or should have been aware of, goods or services that a resident (s) required but the facility failed to provide them to the resident(s), that had resulted in or may had resulted in physical harm, pain mental anguish, or emotional distress. Further review revealed the facility administrator or designee shall complete a report to the mandated state agency according to state guidelines upon notification of alleged abuse.
Review of a facility document titled Employee Status Change revealed, in part, S5Unlicensed Personnel had a status change from Certified Nursing Aide to Licensed Practical Nurse effective 11/20/24.
Review of S5Unlicsened Personnel's personnel record revealed, in part, no documented evidence S5Unlicesened Personnel had a current valid Louisiana Practical Nurse License.
Review of S5Unlicensed Personnel's time records from 11/20/2024 through 01/23/2025 revealed S5Unlicensed Personnel worked 37 shifts as a LPN.
Review the facility's investigative report for neglect dated 01/31/2025 at 11:33AM revealed, in part, on 01/24/2024, S7Team Member Specialist/Human Resources was informed by the Louisiana State Board of Nursing that S5Unlicensed Personnel had not passed the NCLEX-PN (a standardized test that a nurses must pass to become a LPN.) Further review revealed S5Unlicensed Personnel began her training as a facility LPN on 11/20/2024 and started working as a facility LPN without direct supervision on 12/12/2024. Further review revealed this incident had occurred on 01/24/2025 at 12:18PM and was reported to the Louisiana Department of Health through the Statewide Incident Management System (SIMS) on 01/31/2025 at 11:33AM.
In an interview on 02/17/2025 at 10:15AM, S1Administrator indicated on 01/24/2025 S7Team Member Specialist/Human Resources informed him S5Unlicensed Personnel did not have a valid Louisiana state nursing license. S1Administrator further indicated there was a likelihood of serious injury, serious harm, serious impairment or death due to having an unlicensed personnel providing nursing services. S1Administrator further indicated a report should have been entered into the SIMS within 24 hours of the discovery of the incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure physician's orders were followed for 1 (Resident#16) of 19...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure physician's orders were followed for 1 (Resident#16) of 19 (Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, Resident #13, Resident #15, Resident #16, Resident #17, Resident #19, Resident #21, Resident #22, Resident #26, Resident #29, Resident #40, Resident #41, Resident #43, Resident #50, Resident #57) residents reviewed for physician order compliance.
Findings:
Review of Resident #16's clinical record revealed, in part, Resident #16 was admitted to the facility on [DATE] a diagnosis of, in part, type 2 diabetes mellitus (a condition which causes uncontrolled blood sugars).
Review of Resident #16's January 2025 electronic Medication Administration Record (eMAR) revealed, in part, an order with a start date of 01/07/2025 for blood glucose (sugar) monitoring before meals and at bedtime related to type 2 diabetes mellitus. Further review revealed staff was to call the physician if Resident #16's blood sugar was less than 60 milligrams per deciliter or greater than 250 mg/dL.
Review of Resident #16's Weights and Vitals Summary- Blood Sugar for January 2025 revealed the following blood sugars were greater than 250 mg/dL:
- On 01/23/2025 at 10:21PM, Resident #16's blood sugar was 569 mg/dL;
- On 01/21/2025 at 8:35PM, Resident #16's blood sugar was 289 mg/dL;
- On 01/21/2025 at 4:09PM, Resident #16's blood sugar was 559 mg/dL;
- On 01/20/2025 at 7:03PM, Resident #16's blood sugar was 340 mg/dL;
- On 01/20/2025 at 12:22PM, Resident #16's blood sugar was 298 mg/dL;
- On 01/18/2025 at 9:45PM, Resident #16's blood sugar was 415 mg/dL;
- On 01/18/2025 at 5:23PM, Resident #16's blood sugar was 375 mg/dL;
- On 01/15/2025 at 10:53PM, Resident #16's blood sugar was 385 mg/dL;
- On 01/15/2025 at 5:39PM, Resident #16's blood sugar was 403 mg/dL;
- On 01/15/2025 at 5:56AM, Resident #16's blood sugar was 401 mg/dL;
- On 01/14/2025 at 6:57PM, Resident #16's blood sugar was 254 mg/dL;
- On 01/13/2025 at 10:02PM, Resident #16's blood sugar was 285 mg/dL;
- On 01/13/2025 at 4:23PM, Resident #16's blood sugar was 314 mg/dL;
- On 01/11/2025 at 6:17PM, Resident #16's blood sugar was 405 mg/dL;
- On 01/10/2025 at 5:48PM, Resident #16's blood sugar was 354 mg/dL; and,
- On 01/08/2025 at 9:31PM, Resident #16's blood sugar was 313 mg/dL.
Further review revealed no documented evidence, and the facility did not present any documented evidence, Resident #16's physician was notified when Resident #16's blood sugar was greater than 250 mg/dL on the above mentioned dates, and should have been.
In an interview on 02/12/2025 at 2:46PM, S2Director of Nursing confirmed the facility had no evidence Resident #16's physician was notified when Resident #16's blood sugar was greater than 250 mg/dL on the above mentioned dates, and should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's physician was notified when a scheduled medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's physician was notified when a scheduled medication was withheld for 1 (Resident #9) of 19 (Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, Resident #13, Resident #15, Resident #16, Resident #17, Resident #19, Resident #21, Resident #22, Resident #26, Resident #29, Resident #40, Resident #41, Resident #43, Resident #50, Resident #57) sampled residents reviewed for pharmacy services.
Findings:
Review of the facility's undated Medication Administration General Guidelines policy revealed, in part, medications were to be administered as ordered by the physician. Further review revealed if a scheduled medication was withheld, the medication would be documented as not given and an explanatory note was to be entered in the electronic document. Further review revealed if several doses of a vital medication were withheld, the physician should be notified and a response documented.
Review of Resident #9's clinical record revealed, in part, Resident #9 was admitted to the facility on [DATE] with a diagnosis of, in part, type 2 diabetes mellitus (a condition which causes uncontrolled blood sugars).
Review of Resident #9's Order Summary revealed, in part, an order with a start date of 10/08/2024 to administer Novolog (a medication to control blood sugar) 10 units subcutaneously (SQ) with meals related to type 2 diabetes mellitus.
Review of Resident #9's November 2024 electronic Medication Administration Record (eMAR) revealed the following documentation:
- On 11/05/2024 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 5 (5 indicated medication was held and see progress notes);
- On 11/06/2024 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 5;
- On 11/06/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13 (13 indicated insulin was not required);
- On 11/12/2024 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 5;
- On 11/12/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5;
- On 11/15/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/18/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/19/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/20/2024 at 12:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5;
- On 11/20/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/21/2024 at 12:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5;
- On 11/21/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/22/2024 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/25/2025 at 12:00PM, Novolog 10 units SQ with meals was not administered with a documented code 5;
- On 11/25/2025 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/26/2025 at 8:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/26/2025 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13;
- On 11/27/2025 at 6:00PM, Novolog 10 units SQ with meals was not administered with a documented code 13; and,
- On 11/28/2025 at 8:00AM, Novolog 10 units SQ with meals was not administered with a documented code 13.
Review of Resident #9's November 2024 progress notes revealed, in part, no documented evidence, and the facility did not present any evidence, Resident #9's physician was notified when the above mentioned medication was not administered as ordered.
In an interview on 02/11/2025 at 4:36PM, S3Assistant Director of Nursing (ADON) indicated there was no documented evidence Resident #9's physician was notified when the above mentioned medication was not administered as ordered, and should have been.
In an interview on 02/12/2025 at 2:04PM, S4Corporate Compliance Officer indicated Resident #9's physician should have been notified when his medication was not administered as ordered.
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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to ensure the required number of Certified Nursing Assistants (CNAs) were present and working per the facility assessment for 2 (02/05/2025,...
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Based on interviews and record reviews, the facility failed to ensure the required number of Certified Nursing Assistants (CNAs) were present and working per the facility assessment for 2 (02/05/2025, and 02/06/2025) of 2 (02/05/2025, and 02/06/2025) days reviewed for sufficient CNA staff.
Findings:
Review of the facility's assessment, dated 10/20/2024 revealed, in part, the average facility census was 116 residents. Further review revealed based on the acuity and needs of its resident population, the facility identified 19 CNAs were required on the weekday day shift, 12 CNAs were required on the weekday evening shift, and 8 CNAs were required on the weekday night shift.
Review of the facility's 24 hour staffing sheets dated 02/05/2025 and 02/06/2025 revealed, in part, the day shift was from 6:00AM to 2:00PM, the evening shift was from 2:00PM to 10:00PM, and the night shift was from 10:00PM to 6:00AM.
Review of the facility's Nursing Staff Directly Responsible for Resident Care form dated 02/05/2025 and 02/06/2025 revealed, in part, the facility's census was 113 residents.
In an interview on 02/10/2025 at 10:18AM, S49Licensed Practical Nurse (LPN) indicated he often worked without CNAs to care for his residents at or around shift change because the off going CNAs left without giving report to the oncoming CNAs.
In an interview on 02/13/2025 at 2:45PM, S1Administrator indicated the facility usually staffed 12 CNAs on the day shift, 8 CNAs on the evening shift, and 8 CNAs on the night shift to provide care to residents.
Review of the facility's time sheets dated 02/04/2025 to 02/05/2025 for the 10:00PM to 6:00AM shift revealed, in part:
-On 02/05/2025, from 12:00AM to 4:12AM, S54CNA, S63CNA, S64CNA, S65CNA, S66CNA, S67CNA, and S68CNA were clocked in for a total of 7 CNAs working in the facility.
Review of the facility's time sheets dated 02/05/2025 for the 6:00AM to 2:00PM shift revealed, in part:
-On 02/05/2025, from 6:00AM to 6:06AM, S10CNA, S69CNA, S70CNA, S71CNA, S72CNA, S73CNA, S74CNA, S75CNA, S76CNA, and S78CNA were clocked in for a total of 10 CNAs working in the facility; and,
-On 02/05/2025, from 6:07AM to 6:15AM, S10CNA, S69CNA, S70CNA, S71CNA, S72CNA, S73CNA, S74CNA, S75CNA, S76CNA, S78CNA, and S79CNA were clocked in for a total of 11 CNAs working in the facility.
Review of the facility's time sheets dated 02/05/2025 for the 2:00PM to 10:00PM shift revealed, in part:
-On 02/05/2025, from 4:57PM to 6:22PM, S63CNA, S70CNA, S80CNA, S81CNA, S82CNA, S83CNA, and S84CNA were clocked in for a total of 7 CNAs working in the facility;
-On 02/05/2025, from 6:49PM to 8:31PM, S54CNA, S63CNA, S70CNA, S80CNA, S81CNA, S82CNA, and S83CNA were clocked in for a total of 7 CNAs working in the facility; and,
-On 02/05/2025, from 8:32PM to 8:59PM, S54CNA, S63CNA, S70CNA, S80CNA, S81CNA, and S83CNA were clocked in for a total of 6 CNAs working in the facility; and,
-On 02/05/2025, from 9:00PM to 9:02PM, S54CNA, S63CNA, S70CNA, S80CNA, S81CNA, S83CNA, and S85CNA were clocked in for a total of 7 CNAs working in the facility.
Review of the facility's time sheets dated 02/05/2025 to 02/06/2025 for the 10:00PM to 6:00AM shift revealed, in part:
-On 02/05/2025, from 10:35PM to11:58PM, S54CNA, S64CNA, S63CNA, S83CNA S85CNA, S86CNA, and S87CNA were clocked in for a total of 7 CNAs working in the facility.
-On 02/05/2025, from 11:59PM to 4:29AM on 02/06/2025, S85CNA, S86CNA, S64CNA, S63CNA, S83CNA, and S54CNA were clocked in for a total of 6 CNAs working in the facility.
-On 02/05/2025, from 4:30AM to 4:50AM on 02/06/2025, S85CNA, S86CNA, S64CNA, S63CNA, S83CNA, S54CNA, and S88CNA were clocked in for a total of 7 CNAs working in the facility.
Review of the facility's time sheets dated 02/06/2025 to 02/07/2025 for the 10:00PM to 6:00AM shift revealed, in part:
-On 02/06/2025, from 10:07PM to 10:27PM, S63CNA, S77CNA, S64CNA, S85CNA, S54CNA, and S86CNA were clocked in for a total of 6 CNAs working in the facility.
There was no documented evidence, and the facility did not present any documented evidence, any other CNAs worked during the above mentioned time frames.
In an interview on 02/17/2025 at 11:59AM, S6Chief Operations Officer acknowledged the facility should be staffed according to the facility assessment.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to:
1. Ensure medications were available for use for 3 (Resident #1, R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to:
1. Ensure medications were available for use for 3 (Resident #1, Resident #8, Resident #57) of 19 (Resident #1, Resident #7, Resident #8, Resident #9, Resident #11, Resident #13, Resident #15, Resident #16, Resident #17, Resident #19, Resident #21, Resident #22, Resident #26, Resident #29, Resident #40, Resident #41, Resident #43, Resident #50, Resident #57) sampled residents reviewed for pharmacy services; and,
2. Maintain a system to periodically reconcile controlled drugs for 3 (Medication Cart a, Medication Cart b, Medication Cart c) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances.
1.
Review of the facility's undated Medication Administration General Guidelines policy revealed, in part, medications were to be administered as ordered by the physician. Further review revealed when a medication could not be located the pharmacy was to be contacted and/or the medication was to be removed from the Emergency Drug Kit. Further review revealed if a scheduled medication was withheld or not available, the medication was documented as not given and an explanatory note should have been entered in the electronic document.
Resident #1
Review of Resident #1's clinical record revealed, in part, Resident #1 had diagnoses, which included, hypertension (a condition with elevated blood pressure), upper respiratory infection (an infection that affects the upper part of your respiratory system, including your sinuses and throat) and urinary tract infection (an infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra).
Review of Resident #1's February 2025 physician's orders revealed, in part, Resident #1 had the following orders:
- Cozaar (a medication used to treat high blood pressure) 50 milligrams (mg) daily with a start date of 07/01/2024;
- Levofloxacin (an antibiotic used to treat respiratory infections) 500 mg daily with a start date of 02/07/2025; and,
- Doxycycline (a medication used to treat urinary treat infections) 100 mg two times daily for seven days with a start date of 02/07/2025.
Review of Resident #1's February 2025 electronic Medication Administration Record (eMAR) revealed, in part, the following documentation:
- On 02/01/2025 Cozaar 50 mg was not administered;
- On 02/02/2025 Cozaar 50 mg was not administered;
- On 02/07/2025 doxycycline 100 mg was not administered;
- On 02/08/2025 levofloxacin 500 mg was not administered; and,
- On 02/09/2025 levofloxacin 500 mg was not administered.
Review of Resident #1's progress notes revealed, in part, the following documentation:
- On 02/01/2025 Cozaar 50 mg was not available for administration;
- On 02/02/2025 Cozaar 50 mg was not available for administration;
- On 02/07/2025 doxycycline 100 mg was not available for administration;
- On 02/08/2025 levofloxacin 500 mg was not available for administration; and,
- On 02/09/2025 levofloxacin 500 mg was not available for administration;
Record review revealed there was no documented evidence, and the provider did not present any documented evidence, Resident #1's above mentioned medications were available and/or administered as ordered.
Resident #8
Review of Resident #8's clinical record revealed, in part, Resident #8 admitted to the facility on [DATE] with diagnoses, which included, hypertension and overactive bladder (a condition that caused sudden urination).
Review of Resident #8's Order Summary Report revealed, in part, the following orders:
- Ciprofloxacin hydrochloride 500 mg tablet to be administered twice a day related to urinary tract infection with a start date of 12/13/2024;
- Tamsulosin hydrochloride 0.4 mg capsule to be administered once a day related to overactive bladder with a start date of 11/20/2024; and,
- Potassium chloride 20 milliequivalent (mEq) to be administered twice a day related to hypertensive heart disease (heart condition caused by high blood pressure) with a start date of 12/30/2024.
Further review of Resident #8's December 2024 and January 2025 eMAR revealed, in part, the following documentation:
- On 12/24/2024 the morning (AM) dose of ciprofloxacin hydrochloride 500 mg was documented as a 9 (9 indicated other and see progress notes);
- On 12/30/2024 the evening (HS) dose of tamsulosin hydrochloride 0.4 mg was documented as 9; and,
- On 01/02/2025 the HS dose of potassium chloride 20 mEq was documented as a 9.
Review of Resident #8's progress notes revealed, in part, S5Unlicensed Personnel documented the following documentation:
- On 12/24/2024 at 12:09PM, ciprofloxacin hydrochloride 500 mg was reordered;
- On 12/30/2024 at 9:39PM, tamsulosin hydrochloride 0.4 mg was waiting on insurance; and,
- On 01/02/2025 at 7:38PM, potassium chloride 20 mEq was reordered.
Record review revealed there was no documented evidence, and the provider did not present any documented evidence, Resident #8's above mentioned medications were available and/or administered as ordered.
In an interview on 02/12/2025 at 8:58AM, S3Assistant Director of Nursing (ADON) indicated ciprofloxacin hydrochloride was maintained in the facility's Emergency Drug Kit. S3ADON further indicated Resident #8's ciprofloxacin hydrochloride could have been administered by the facility's nurses from the Emergency Drug Kit.
In an interview on 02/12/2025 at 2:56PM, S2Director of Nursing indicated Resident #8's above mentioned medications were not available for use and/or not administered as ordered, and should have been.
Resident #57
Review of Resident #57's clinical record revealed, in part, Resident #57 admitted to the facility on [DATE] with diagnoses, which included, hypertension and chronic heart failure.
Review of Resident #57's January 2025 eMAR revealed, in part, an order for hydralazine hydrochloride 25 mg (a medication use to treat high blood pressure) to be administered every 8 hours with a start date of 01/27/2025. Further review revealed the following documentation:
- On 01/27/2025 at 4:00PM, hydralazine hydrochloride 25 mg was documented as 9;
- On 01/28/2025 at 12:00AM, hydralazine hydrochloride 25 mg was documented as 9;
- On 01/28/2025 at 8:00AM, hydralazine hydrochloride 25 mg was documented as 9;
- On 01/29/2025 at 12:00AM, hydralazine hydrochloride 25 mg was documented as 9; and,
- On 01/29/2025 at 4:00PM, hydralazine hydrochloride 25 mg was documented as 9.
Review of Resident #57's January 2025 progress notes revealed, in part, the following documentation:
- On 01/27/2025 at 8:16PM, hydralazine hydrochloride 25 mg was not available;
- On 01/28/2025 at 1:13AM, hydralazine hydrochloride 25 mg was faxed to pharmacy;
- On 01/28/2025 at 9:52AM, hydralazine hydrochloride 25 mg was not available; and,
- On 01/29/2025 at 2:41AM, hydralazine hydrochloride 25 mg was not available.
In an interview on 02/12/2025 at 2:04PM, S4Corporate Compliance Officer acknowledged Resident #1, Resident #8, and Resident #57 should have received their medications as ordered.
S4Corporate Compliance Officer further indicated it was the responsibility of the nurses to obtain medications from the Emergency Drug Kit if the medication was available in the Emergency Drug Kit, and to ensure medication were received from the pharmacy in a timely manner to be available for use.
2.
Review of the facility's undated Medication-Controlled Substances policy and procedure, revealed, in part, nurses were to perform a reconciliation of all controlled substances at the beginning and the end of every shift according to the narcotic log.
Review of the facility's undated Narcotic Count Sign Sheet form revealed, in part, by signing, the nurses were verifying the narcotic count was accurate, the nurses had reconciled the narcotics with the applicable off going/oncoming licensed nurse, and both licensed nurses verified by signatures that the facility's policy and procedure had been followed.
Review of November 2024 Narcotic Count Sign Sheet for Medication Cart b revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty:
-11/13/2024 at 11:00PM.
Review of November 2024 Narcotic Count Sign Sheet for Medication Cart c revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty:
-11/22/2024 at 11:00PM;
-11/28/2024 at 3:00PM; and,
-11/28/2024 at 11:00PM.
Review of the February 2025 Narcotic Count Sign Sheet for Medication Cart a revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty:
-02/09/2025 at 11:00PM; and,
-02/09/2025 at 7:00AM.
Review of the February 2025 Narcotic Count Sign Sheet for Medication Cart b revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs by the nurse coming on duty and/or the nurse going off duty:
-02/10/2025 at 11:00PM.
In an interview on 02/17/2025 at 1:19PM, S2DON indicated S16LPN did not sign the November 2024 Narcotic Count Sign Sheet for Medication Cart b, S17LPN did not sign the November 2024 Narcotic Count Sign Sheet for Medication Cart c, S14Agency LPN did not sign the February 2025 Narcotic Count Sign Sheet for Medication Cart a, and S15LPN did not sign the February 2025 Narcotic Count Sign Sheet for Medication Cart b on the above mentioned dates and times, as required. S2DON further indicated anyone who reconciled the medication carts' narcotics should have signed the Narcotic Count Sign Sheet.
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for 2 (Resident R1, Resident R2) of 8 (Resident R1, Resident R2, Resident R3,...
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Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for 2 (Resident R1, Resident R2) of 8 (Resident R1, Resident R2, Resident R3, Resident R4, Resident R5, Resident R6, Resident R7, Resident R8) sampled residents observed and reviewed for medication administration which resulted in a medication error rate of 7.6%.
Findings:
Resident R1
Review of Resident R1's January 2025 Physician's Orders revealed, in part, an order to administer Valsartan-Hydrochlorothiazide (HCTZ) (a medication to treat high blood pressure) 160-25 milligrams (mg) tablet once a day.
Observation on 01/14/2025 at 9:09AM revealed S4Licensed Practical Nurse (LPN) administered Valsartan/HCTZ 160/12.5 mg tablet.
In an interview on 01/14/2025 at 3:32 PM, S4Licensed Practical Nurse (LPN) indicated she administered Valsartan/HCTZ 160/12.5 MG Tab. S4LPN further indicated this was not the correct dosage as ordered by the physician
In an interview on 01/14/2025 at 4:00 PM, S1Administrator indicated Resident R1 should have received his medication as ordered by the physician and did not.
Resident R2
Review of Resident R2's January 2025 Physician's Orders revealed, in part, an order to administer Artificial Tears Ophthalmic Solution 1% Carboxymethylcellulose Sodium eye drops (eye drops used for dry eyes) instill one drop in both eyes every 6 hours.
Observation on 01/14/2025 at 11:12AM revealed S5Licensed Practical Nurse (LPN) instill 1 ddrop of Advance Relief Eye Drops Polyethylene Glycol 400 1% Tetrahydrozoline HCI 0.05% Lubricant/Redness Reliever (eye drops to treat allergic reactions in the eyes) in each of Resident R2's eyes.
In an interview on 01/14/2025 at 3:32PM, S5LPN indicated he administered Advance Relief Eye Drops Polyethylene Glycol 400 1% Tetrahydrozoline HCI 0.05% Lubricant/Redness Reliever one drop in each eye to Resident R2. S5LPN further indicated this was not the medication that was ordered by the physician for Resident R2.
In an interview on 01/14/2025 at 4:00PM, S1Administrator indicated Resident R2 received Advance Relief Eye Drops Polyethylene Glycol 400 1% Tetrahydrozoline HCI 0.05% Lubricant/Redness Reliever and should have received Artificial Tears Ophthalmic Solution 1% Carboxymethylcellulose Sodium. S1Administrator further indicated S5LPN administered the wrong medication to Resident R2.
Dec 2024
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
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, it was determined the facility failed to ensure a resident's adaptive call light was within reach for 1 (Resident #5) of 2 sampled residents with ...
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Based on observations, interviews, and record review, it was determined the facility failed to ensure a resident's adaptive call light was within reach for 1 (Resident #5) of 2 sampled residents with the ability to use a call light in a total sample of 8 investigated for Activities of Daily Living (ADLs).
Findings included:
Review of Resident #5's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/01/2024 revealed, in part, Resident #5 had a diagnosis of hemiplegia (a condition that causes weakness) affecting both left and right side of the body and was dependent on staff for ADLs.
Review of Resident #5's Care Plan revealed, in part, Resident #5 required staff assistance with ADL's due right sided weakness and impaired mobility. Further review revealed staff was to ensure Resident #5's adaptive call light was within reach.
Observation on 12/16/2024 at 11:45 AM revealed Resident #5 was lying in bed and Resident #5's adaptive call light was noted out of reach on the bed above her left shoulder.
Observation on 12/17/2024 at 8:30 AM revealed Resident #5's adaptive call light was out of reach on Resident #5's bed above her left shoulder.
In an interview on 12/17/2024 at 8:30 AM, Resident #5 indicated she had a bowel movement and needed to be changed. Resident #5 indicated she knew how to use the adaptive call light, but did not know where the adaptive call light was.
In an interview on 12/17/2024 at 9:34 AM, S19Certified Nursing Assistant (CNA) indicated Resident #5 was dependent on staff for all ADLs. S19CNA further indicated Resident #5 was able to use her adaptive call light.
Observation on 12/18/2024 at 10:40 AM revealed Resident #5 was lying in bed and Resident 5's Adaptive call light was out of reach on the bed above her left shoulder.
In an interview on 12/18/2024 at 10:40 AM, Resident #5 indicated she did not know where the adaptive call light was. Resident #5 further indicated she could not reach above her left shoulder to use the adaptive call light to get staff assistance. Resident further indicated it bothered her that she was unable to reach her call light/pad to get staff assistance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, record review, facility policy review, and interviews, it was determined the facility failed to administer a resident's enteral feeding (intake of food through a tube placed into...
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Based on observation, record review, facility policy review, and interviews, it was determined the facility failed to administer a resident's enteral feeding (intake of food through a tube placed into the stomach) as ordered for 1 (Resident #5) of 1 sampled residents who received enteral feedings in a total sample of 8 investigated for dietary services.
Findings included:
Review of the facility's undated policy titled, Enteral Nutritional Therapy-Tube Feeding Policy and Procedure revealed, in part, for enteral feedings using a feeding pump the nurse was to enter the amount to be infused according to the physician's order and to verify pump settings each shift.
Review of Resident #5's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/01/2024 revealed, in part, Resident #5 had dysphagia (difficulty swallowing) and required nutrition and hydration through a feeding tube.
Review of Resident #5's December 2024 physician's orders revealed, in part, an order with a start date of 12/13/2024 for Glucerna 1.2 Cal (a tube feeding formula) 65 milliliters per hour (mL/hour ) nocturnal feedings (occurring at night). Start feeding at 6:00 PM and stop feeding at 6:00 AM.
Observation on 12/16/2024 at 10:58 AM revealed Resident #5 had Glucerna 1.2 Cal infusing at 55 mL/hour via a tube feeding pump.
In an interview on 12/17/2024 at 1:02 PM, S5Licensed Practical Nurse (LPN) indicated Resident #5's physician's order for the enteral feeding had recently changed and she was not aware. S5LPN confirmed Resident #5's enteral feeding should have been stopped at 6:00 AM, and should not have been infusing at 55 mL/hr.
In an interview on 12/18/2024 at 9:15 AM, S3Assistant Director of Nursing (ADON) indicated S6LPN, the night nurse, should have stopped Resident #5's enteral feeding on 12/16/2024 at 6:00 AM.
In an interview on 12/18/2024 at 12:36 PM, S6LPN indicated she was responsible to stop Resident #5's enteral feedings on 12/16/2024 at 6:00 AM. S6LPN further indicated she could not recall if she verified Resident #5's formula was infusing at the rate as order, and could not recall if she stopped Resident #5's enteral feeding at 6:00 AM as required.
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 F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on record reviews, observations, and interviews, the facility failed to provide a resident with the correct diet to meet their needs for 1 (Resident #2) of 8 sampled residents reviewed for dieta...
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Based on record reviews, observations, and interviews, the facility failed to provide a resident with the correct diet to meet their needs for 1 (Resident #2) of 8 sampled residents reviewed for dietary services.
Findings included:
Review of the facility's Diet Orders policy, undated, revealed in part, when there is a nutritional indication, the facility will provide a diet that is individualized to meet the clinical needs and desires of the resident.
Review of Resident #2's active diagnosis listed revealed, in part, Resident #2 had a of dysphagia following a cerebral infarction.
Review of Resident #2's Quarterly and State Optional Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) of a 5, which indicated severe cognitive impairment, had a diagnosis of dysphagia following a cerebral infarction, and received a mechanically altered diet.
Review of Resident #2's care plan with an initiation date of 08/20/2024 and revision date of 12/11/2024 revealed, in part, Resident #2 required a mechanically altered diet due too risk of aspiration.
Review of Resident #2's meal ticket on 12/16/2024 at 11:10 AM revealed Resident #2 was to receive a mechanical soft diet with chopped meats, add puree soup; special instructions no soup, no cereal & milk, no gumbo, no straws, and puree rice only.
Observation on 12/16/2024 at 11:10 AM revealed Resident #2 was served white beans and regular rice, chopped sausage, mustard greens, a slice of bread, and a piece of cake.
In an interview on 12/16/2024 at 11:10 AM, S17Certified Nursing Assistant confirmed Resident #2's meal ticket indicated he was to have puree rice only and he was served and currently eating regular rice with white beans.
In an interview on 12/18/2024 at 11:30 AM, S3ADON confirmed Resident #2 was served the wrong diet on Monday, 12/16/20024 when Resident #2 was served regular rice for the lunch meal service. S3ADON further indicated she was present and observed Resident #2's tray and confirmed Resident #2 was served regular rice and should have been served pureed rice.
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 F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
Based on interviews, policy review, and record reviews it was determined the provider failed to ensure staff provided planned restorative services to assist with active range of motion, passive range ...
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Based on interviews, policy review, and record reviews it was determined the provider failed to ensure staff provided planned restorative services to assist with active range of motion, passive range of motion, walking, transfer, and eating for 12 (Resident #2, Resident #5, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18) of 12 sampled residents reviewed for restorative services.
Findings included:
Review of the facility's policy titled Restorative Program Policy and Procedure undated, in part, residents will be assessed to identify possible need or benefit of a restorative program. After potential benefit is identified, specific program will be implemented as deemed medically. Restorative activities including repetition (reps), physical or verbal cueing, and task segmentation will be provided by any trained staff member under the supervision of a licensed nurse.
Review of Resident #2's task schedule with a start date of 11/18/2024 revealed Resident #2 was to receive active range of motion to bilateral lower extremities x 1 limited assistance up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/18/2024 revealed Resident #2 was to receive walking with rolling walker x 1 person limited assistance up to 300 feet.
Review of Resident #5's review of restorative program list Resident #5 was to receive passive range of motion and eating swallowing service. Review of Resident #5's therapy referral to restorative nursing with a date of 08/29/2024 revealed resident is to consume no more than 3 ounces of pleasure feeding of puree bolus with use of feeding strategies (small ½ tsp bolus, dry swallow after 2 boluses) with trained staff without signs and symptoms of aspirating (cough, wet voice, throat clearing) to maintain current swallow function.
Review of Resident #9's task schedule with a start date of 11/18/2024 revealed Resident #9 was to receive active range of motion to bilateral lower extremities x 1 person with standby assistance for cueing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/19/2024 revealed Resident #9 was to receive assistance with sit to stand transfers using grab bars and or wheelchair up to 3 reps.
Review of Resident #10's task schedule with a start date of 11/22/2024 revealed Resident #10 was to receive active range of motion to bilateral lower extremities x 1 person standby assistance for cueing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/22/2024 revealed Resident #10 was to receive walking with rolling walker up to 200 feet with staff assistance and with staff reminding resident of safety and proper body mechanics when ambulating.
Review of Resident #11's task schedule with a start date of 11/25/2024 revealed Resident #11 was to receive active range of motion to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 11/25/2024 revealed Resident #11 was to receive walking with rolling walker up to 200 feet or more with staff assistance and with staff reminding resident of safety and proper body mechanics when ambulating.
Review of Resident #12's task schedule with a start date of 11/26/2024 revealed Resident #12 was to receive active range of motion to bilateral upper and lower extremities at 3 sets of 10. Further review of task schedule with a start date of 11/26/2024 revealed Resident #12 was to receive walking using a rolling walker with standby assistance for 15 feet or more.
Review of Resident #13's task schedule with a start date of 12/11/2024 revealed Resident #13 was to receive active range of motion exercises to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #13 was to receive walking with rolling walker and staff assistance up to 200 feet or more.
Review of Resident #14's task schedule with a start date of 12/11/2024 revealed Resident #14 was to receive active range of motion exercises to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #14 was to receive walking with rolling walker and staff assistance up to 20 feet or more.
Review of Resident #15's task schedule with a start date of 12/11/2024 revealed Resident #15 was to receive active range of motion exercises to bilateral lower extremities x1 person standby assistance for cuing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #15 was to receive walking with rolling walker x 1 person standby limited to extensive assistance up to 100 feet or more and to remind resident of safety and proper body mechanics when ambulating.
Review of Resident #16's task schedule with a start date of 12/11/2024 revealed Resident #16 was to receive active range of motion to right upper extremity x 1 person standby assistance with cuing and supervision up to 3 sets of 10 reps each. Further review of task schedule with a start date of 12/11/2024 revealed Resident #16 was to receive passive range of motion exercises to left upper extremity up to 3 sets of 10 reps each.
Review of Resident #17's task schedule with a start date of 10/25/2024 revealed Resident #17 was to receive active range of motion to bilateral lower extremities joints at 3 sets of 10. Further review of task schedule with a start date of 10/25/2024 revealed Resident #17 was to receive walking using a rolling walker and standby assist of one person to ambulate 250 feet or more.
Review of Resident #18's task schedule with a start date of 10/30/2024 revealed Resident #18 was to receive active range of motion to bilateral lower extremities up to 3 sets of 10 reps each. Further review of task schedule with a start date of 10/30/2024 revealed Resident #18 was to receive dressing/grooming tasks to upper body with staff set up assistance.
In an interview on 12/16/2024 at 1:02 PM, S18Certified Nursing Assistant (CNA), indicated she was pulled from restorative services to work the hall.
In an interview on 12/17/2024 at 12:57 PM, S18CNA indicated both restorative aides were pulled to the floor and no restorative services were completed on 12/16/2024.
In an interview on 12/17/2024 at 2:28 PM, S7Certified Nursing Assistant (CNA) Supervisor, indicated restorative services were not provided on 12/16/2024.
In an interview on 12/17/2024 at 2:35 PM, S3Assistant Director of Nursing (ADON), indicated restorative was to be done Monday through Saturday and due to restorative aides being pulled to the hall on 12/16/2024, restorative services were not provided on 12/16/2024 as required.
In an interview on 12/18/2024 at 10:15 AM, S18CNA, indicated restorative schedule was Monday through Friday and every other Saturday and due to being pulled to the floor on 12/16/2024, restorative services were not provided.
In an interview on 12/18/2024 at 10:15 AM, S7CNASupervisor, indicated the restorative aides were pulled to the floor on 12/16/2024 and restorative services were not provided 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observations, interviews, record reviews, facility document review, and facility policy review it was determined the facility failed to ensure:
1. A resident who was cognitively impaired, ha...
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Based on observations, interviews, record reviews, facility document review, and facility policy review it was determined the facility failed to ensure:
1. A resident who was cognitively impaired, had a high risk of falls, and a history of falls had appropriate interventions to decrease the risk of future falls (Resident #4); and,
2. A resident who required a two-person assistance with transfers received adequate assistance with transfers (Resident #8).
This deficient practice was identified for 2 (Resident #4 and Resident #8) of 8 sampled residents reviewed for accidents.
Findings included:
1.
Review of Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/2024, revealed, in part, Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #4 had severe cognitive impairment. Further review revealed Resident #4 required limited assistance of one person physical assist for bed mobility; and extensive assistance of one person physical assist for transfers.
Review of Resident #4's annual MDS with an ARD date of 07/23/2024 revealed, in part, Resident #4 had a BIMS of 3, which indicated Resident #4 had severe cognitive impairment.
Review of the facility's incident report dated 11/20/2024 revealed, in part, Resident #4 had an unwitnessed fall on 11/20/2024. Further review of the facility's incident report revealed Resident #4 had unwitnessed fall on 10/15/2024 and 10/29/2024.
Review of Resident #4's care plan with an initiation date of 08/09/2024 and a revision date of 11/21/2024, revealed in part, Resident #4 was at risk for falls due to a diagnosis of Parkinson's disease. Further review of Resident #4's fall care plan revealed:
Resident #4 had a fall on 02/03/2024 with an intervention of staff to offer coffee in AM upon arrival to dining, a fall on 05/23/2024 with an intervention to apply bright colored tape to brake extender and apply grip strips to the floor in front of the recliner, a fall on 06/04/2024 with an intervention to remove the lotion from room and staff to apply as needed, a fall on 10/15/2024 with an intervention for the fall mat to be removed from the room, a fall on 10/29/2024 with an intervention to offer a busy blanket when in the recliner, and a fall on 11/20/2024 with an intervention of grip strips to floor in front of commode. Other interventions for falls included place Resident #4's call bell in reach and encourage resident too call for assistance. Further review of Resident #4's care plan revealed, in part, Resident #4 had impaired cognitive function, impaired thought processes, and episodes of confusion due to Parkinson's disease.
Observation on 12/16/2024 of Resident #4's wheelchair revealed, in part the bright colored tape on the extender arms was peeling off of the left side and there was no bright colored tape on the right side extender. Further observation revealed a sign was posted on the wall as to remind Resident #4 to call for assistance.
In an interview on 12/16/2024 at 11:50 AM, S11Certified Nursing Assistant (CNA) indicated Resident #4 was care planned for colored tape, but could not explain the purpose of the colored tape.
Observation on 12/16/2024 of Resident #4's wheelchair revealed, in part, the bright colored tape was removed from the left arm extender and replaced with a rubber gray stopper to both extenders.
In an interview on 12/18/2024 9:45 AM, Resident #4 indicated she could not see the sign posted on the wall and did not know what the sign posted was for, nor could Resident #4 verbalize why the bright color tape was on the extender of the wheelchair.
Observation on 12/18/2024 of Resident #4 revealed, in part, the colored tape was absent from both brake extenders.
The facility staff was informed of the above mentioned interview with Resident #4 and was unable to offer any evidence, cognitively impaired Resident #4 understood the sign posted on the wall as a reminder to call for assistance, or understood the reason for the bright colored tape was applied to the wheelchair extenders.
2.
A review of the facility's Transfer of the Resident policy, undated, revealed, in part, the purpose of the policy is to provide and assist residents with transfers in a safe manner, and staff is to obtain help when necessary when assisting residents with transfers.
Review of Resident #8's Quarterly/State Optional Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/2024 revealed, in part, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #8 had moderate cognitive impairment, and required extensive assistance of two or more persons for transfers.
Review of Resident #8's electronic care plan with a revision date of 09/06/2024 revealed, in part, Resident #8 required assistance of two staff members for transfers.
Review of the facility's incident report revealed, in part, S8Certified Nursing Assistant (CNA) attempted to transfer Resident #8 without assistance of a second staff member on 11/29/2024 and Resident #8 sustained a 6 centimeter x 3 centimeter bruise to the left forearm.
Review of Resident #8's Nurses Progress Notes dated 11/29/2024 revealed, in part, S8CNA reported she attempted to transfer Resident #8, and Resident #8 was unsteady and S8CNA grabbed Resident #8 left arm to keep Resident #8 from falling.
Review of S8CNA's witness statement dated 11/29/2024 revealed, in part, S8CNA attempted to transfer Resident #8 without assistance of a second staff member and Resident #8 started to fall and S8CNA grabbed Resident #8's arm to stop her from falling.
Review of Resident #8's witness statement dated 11/30/2024 revealed, in part, on 11/29/2024 S8CNA attempted to transfer Resident #8 without assistance of a second staff member. Further review of Resident #8's witness statement revealed Resident #8 told S8CNA she needed two people to transfer because Resident #8 could not stand.
Review of the facility's investigation report revealed, in part, Resident #8's cognitively intact (BIMS 13) roommate witnessed the above mentioned incident on 11/29/2024, and verified S8CNA attempted to transfer Resident #8 without the assistance of a second staff member.
In an interview on 12/16/2024 at 3:00 PM, S7CNA Supervisor indicated Resident #8 required the assistance of two staff members for assistance for assistance with transfers. S7CNA Supervisor further indicated on 11/29/2024, S8CNA attempted to transfer Resident #8 without the assistance of a second staff member.
In an interview on 12/16/2024 at 3:07 PM, S9CNA indicated on 11/29/2024 she asked S8CNA for assistance in transferring Resident #8 from the chair to the bed because Resident #8 required two staff members for assistance with transfers. S9CNA further indicated S8CNA attempted to transfer Resident #8 without assistance of a second staff member.
In an interview on 12/16/2024 at 4:12 PM, S10Licensed Practical Nurse (LPN) indicated on 11/29/2024 S8CNA reported while transferring Resident #8 she grabbed Resident #8's arm to keep her from falling, and Resident #8 sustained a bruise to her left arm. S10LPN further indicated Resident #8 required two staff members assist with transfers and S8CNA attempted to transfer Resident #8 without assistance of a second staff member.
In an interview on 12/17/2024 at 1:00 PM, S2Director of Nursing (DON) verified Resident #8 required two or more persons for assistance with transfers. S2DON confirmed S8CNA attempted to transfer Resident #8 without assistance of a second staff member. S2DON indicated S8CNA should not have not attempted to transfer Resident #8 without assistance of a second staff member.
In an interview on 12/17/2024 at 1:05 PM, S1Administrator indicated after the facility's investigation it was determined S8CNA failed to follow Resident #8's required transfer assistance of two staff members and she should have.
May 2024
4 deficiencies
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
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to ensure a person-center plan of care consisted of i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to ensure a person-center plan of care consisted of individualized interventions, that was reflective of a resident's status was developed and/or implemented, for a resident whose cognition was severely impaired and assessed as being at high risk for falls.
This deficient practice was identified for 1 (Resident #69) of 3 (Resident #21, Resident #26, and Resident #69) sampled residents reviewed for falls.
Findings:
Review of Resident #69 record revealed Resident #69's current admit date was 03/18/2024, and had the following diagnoses, in part: Stroke, Hemiplegia, Aphasia, and Post Traumatic Head Trauma.
Review of Resident #69's Re-entry Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/2024 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 2 which identified Resident #69's cognition as being severely impaired. Further review revealed Resident #69 required assistance with ambulation and transfers.
Review of Resident #69's Facility Fall Risk assessment dated [DATE] revealed, in part, a score of 18, which identified Resident #69 as being at high risk for falls.
Review of Resident #69's current care plan with a goal date of 07/09/2024 revealed, in part, Resident #69 was at risk for falls due to having decreased safety awareness and generalized weakness. Further review revealed, Resident #69's interventions included:
Resident #69 was to have a call light within reach, and to be reminded by staff to call for assistance;
Resident #69 was to be reminded by staff to ask for assistance for all ambulation and transfers;
Resident #69 was to have bright signage in his room to remind to him to call for assistance;
Resident #69 was to have bright tape on his wheelchair brakes/extenders to remind him to lock his wheelchair.
Review of Resident #69's Physician Progress Note dated 03/05/2024, revealed, in part, Resident #69 had short term memory loss.
Review of Resident #69's Nurse's Progress Note dated 03/22/2024 reveled, in part, Resident #69 displayed multiple attempts to self-transfer without assistance.
Observation on 05/28/2024 at 9:19 a.m. revealed Resident #69 lying in bed sleeping. Further observation revealed no colored signage on Resident #69's walls in his room and bright colored tape on his wheelchair extenders/brakes on his wheelchair.
Observation on 05/28/2024 at 2:20 p.m. revealed, Resident #69 was at the nursing station, visibly confused, and was unable to answer questions appropriately.
In an interview on 05/28/2024 at 2:26 p.m. S10Registered Nurse indicated Resident #69 had difficulty making his needs known.
In an interview on 05/28/2024 at 2:36 p.m., S9Licensed Practical Nurse (LPN) indicated Resident #69 was cognitively impaired, and was not able to use the call bell to ask for assistance.
In an interview on 05/29/2024 at 11:50 a.m. S8MDC/LPN indicated Minimum Data Set (MDS) nurses were responsible for updating care plans. S8MDC/LPN further indicated care plan interventions were based upon resident's capability, and whether a resident can be educated, can perform the intervention and/or the activity, and according to their cognitive ability. S8MDC/LPN indicated bright colored signage, colored tape on wheelchair extenders, using a call bell to call for assistance, reminding Resident #69 to use the call bell to ask for assistance were all interventions that were not appropriate for Resident #69 who had a BIMS score of 2 due to his cognitive impairment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record reviews, observations, and interviews, the facility failed to:
1.) Ensure staff handled soiled towels appropriately for 1 (Resident #1) of 2 (Resident #1 and Resident #58) residents re...
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Based on record reviews, observations, and interviews, the facility failed to:
1.) Ensure staff handled soiled towels appropriately for 1 (Resident #1) of 2 (Resident #1 and Resident #58) residents reviewed for urinary catheter (a tube inserted into the bladder to allow urine to drain) care; and,
2.) Ensure a resident's urinary catheter bag was not touching the floor for 3 (Resident #58, Resident #89, and Resident #169) of 4 (Resident #1, Resident #58, Resident #89, and Resident #169) sampled residents with urinary catheters.
Findings:
1.
Review of the facility's undated Perineal Care Policy and Procedure revealed, in part, soiled linen should be discarded appropriately.
Review of Resident #1's Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 05/03/2024, revealed Resident #1 had an indwelling urinary catheter.
Observation on 05/29/2024 at 4:08 p.m. revealed S14Certified Nursing Assistant (CNA) wiped Resident #1's urinary catheter from the urinary meatus (opening to the bladder) and then placed the soiled towel on Resident #1's bedside table. Further observation revealed S14CNA wiped Resident #1's urinary catheter from the urinary meatus outward with another towel and placed the soiled towel on Resident #1's bedside table. S14CNA was then observed taking another towel, and wiped Resident #1's catheter from the urinary meatus outward and placed the soiled towel on Resident #1's bedside table.
Observation on 05/29/2024 at 4:18 p.m. revealed S14CNA provided incontinent care to Resident #1 after she had a bowel movement. Observation further revealed S14CNA wiped Resident #1's genital area with a wet towel and placed the visibly soiled towel on Resident #1's bedside table.
In an interview on 05/29/2024 at 4:32 p.m., S14CNA confirmed she placed the above mentioned soiled towels on Resident #1's bedside table and should not have.
In an interview on 05/29/2024 at 4:49 p.m., S2Director of Nursing (DON) confirmed towels used for catheter care and/or incontinence care should nog have been placed on Resident #1's bedside table.
In an interview on 05/30/2024 at 1:41 p.m., S3Assistan Director of Nursing (ADON)/Infection Preventionist (IP) indicated towels used for catheter care and incontinence care that were placed on Resident #1's bedside table was an infection control problem.
2.
Resident #58
Review of Resident #58's record revealed, in part, a diagnosis of neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems).
Review of Resident #58's Minimum Data Set with an Assessment Reference Date of 05/13/2024 revealed, in part, Resident #58 had an indwelling urinary catheter.
Review of Resident #58's record revealed, in part, Resident #58 had a history of urinary tract infections.
Observation on 05/27/2024 at 9:10 a.m. revealed Resident #58 lying in bed. Further review revealed Resident #58's uncovered urinary catheter bag was attached to the right side of the bed frame with the bottom of the urinary catheter bag touching the floor.
In an interview on 05/29/2024 at 10:30 a.m., S2DON indicated Resident #58's uncovered urinary catheter bag should not be touching the floor.
Resident #89
Review of Resident #89's record revealed, in part, a diagnosis of neurogenic bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems).
Review of Resident #89's Minimum Data Set with an Assessment Reference Date of 03/13/2024 revealed, in part, Resident #89 had an indwelling urinary catheter.
Observation on 05/24/2024 at 9:55 a.m. revealed Resident #89's lying in bed. Further review revealed Resident #89's uncovered urinary catheter bag was attached to the bed frame with the bottom of the urinary catheter bag touching the floor.
In an interview on 05/29/2024 at 10:30 a.m., S2DON indicated Resident #89's uncovered urinary catheter bag should not be touching the floor.
Resident #169
Review of Resident #169's record revealed, in part, a diagnosis of neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems).
Review of Resident #169's current Physician Orders dated 05/2024 revealed, in part, Resident #169 had an indwelling urinary catheter connected to a urinary bag.
Review of Resident #169's Minimum Data Set with an Assessment Reference Date of 05/16/2024 revealed, in part, Resident #169 had an indwelling urinary catheter.
Review of Resident #169's Care Plan revealed, in part, a review date of 08/10/2024, and Resident #169 will have no infections from catheter use.
Observation on 05/30/2024 at 8:15 a.m., revealed Resident #169's urinary catheter bag was hanging down and touching the floor.
In an interview on 05/30/2024 at 8:18 a.m., S1Administrater indicated he observed Resident #169's urinary catheter bag hanging down and touching the floor and it should not be.
In an interview on 05/30/2024 at 9:00 a.m., S2DON indicated Resident #169's indwelling urinary catheter should not be touching the floor due to the possible transmission of infections.
Jul 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect a resident's right to be free from neglect ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect a resident's right to be free from neglect for 1 (Resident #93) of 1 (Resident #93) sampled resident investigated for neglect by failing to:
1. Ensure S8Certified Nursing Assistant(CNA) communicated a change in Resident #93's condition during a transfer;
2. Ensure S4Licensed Practical Nurse(LPN) initiated an investigation to identify the cause of Resident #93's new complaint of right leg pain; and
3. Ensure S4LPN contacted Resident #93's physician following a change in Resident #93's condition.
Findings:
Review of the facility's Abuse and Neglect Policy and Procedure revealed, in part, each resident had the right to be free from types of abuse such as neglect and injuries of unknown source. Further review revealed neglect occurred when the facility was aware of or should have been aware of goods or services that a resident required but the facility failed to provide that had resulted in or could result in physical harm, pain, mental anguish, or emotional distress. Further review revealed, reporting of neglect, should have occurred when the facility employee or agent, who became aware of abuse or neglect, including injuries of unknown source, should immediately report the matter to the facility administrator of Director of Nurses.
Review and summary of the facility's Statewide Incident Management Systems (SIMS) report with incident ID #117302 revealed an incident occurred on 07/02/2023, it was discovered 07/05/2023 at 9:30 a.m. and reported on 07/05/2023 at 11:30 a.m. Review of the SIMS revealed an allegation of neglect. Incident description revealed on 07/02/2023, Resident #93 reported pain in her knee. Resident #93 was assessed and sent to the hospital. Resident #93 was diagnosed with a closed fracture of the right tibial plateau. The cause of the fracture was unknown. There were no reported falls.
Review of Resident #93's medical record revealed she discharged to the hospital on [DATE] and readmitted on [DATE] with diagnoses, in part, closed fracture of right tibia plateau, pain and swelling of right lower extremity, osteopenia and osseous demineralization.
Review of Resident #93's physician orders dated July 2023 revealed, in part:
07/06/2023-Right Knee immobilizer for 2 weeks, and
07/06/2023-Non weight bearing to right lower extremity for 2 weeks.
Review of Resident #93's Quarterly Minimum Data Set (MDS) with Assessment Reference Date of (06/21/2023) revealed, in part:
Section C-Cognitive patterns revealed Brief Interview of Mental Status (BIMS) of 9 indicating cognitive impairment,
Section E-Behaviors revealed no behaviors observed, and
Section G-Functional status revealed total dependent with locomotion, extensive assistance x 2 person for bed mobility, transfers, and toileting needs.
Review of Resident #93's nursing progress note on 07/02/2023 by S4LPN revealed the note was a late entry. Review of the nursing progress note revealed Resident #93 complained of pain to right ankle and right knee. Resident #93 stated she was unable to move her knee, yelled in pain and was not able to be quieted down. Resident #93 yelled and stated to please help her because her leg hurts. S4LPN documented there were no falls. Resident #93 stated she does not know why it hurts and wanted to go to the emergency room. S4LPN documented no pain medicine orders noted so Tylenol given for pain which did not help relieve Resident #93's pain. The ambulance service was called at 5:50 p.m. and Resident #93 was sent to the hospital.
Review of Resident #93's hospital record revealed on 07/02/2023, Resident #93 presented as a transfer with complaint of worsening pain and swelling of Resident #93's right lower extremity in the setting of possible trauma after Resident #93 banged her knee while being moved at the nursing home. Review of Resident #93's CAT scan of the right knee on 07/03/2023 revealed fracture of lateral tibial plateau and osteopenia. Review of Resident #93's X-ray of the right ankle on 07/03/2023 revealed no evidence of fracture and patchy osteopenia. Review of Resident #93's X-ray of the right tibia fibula on 07/02/023 revealed no definite acute fracture, subluxation or dislocation and osseous demineralization. Review of Resident #93's final active diagnoses revealed, in part, closed fracture of right tibial plateau and pain and swelling of right lower extremity.
In an interview on 07/11/2023 at 10:20 a.m., S8CNA stated on 07/02/2023 at 1:00 p.m., Resident #93 was transferred from Geri chair to bed by S8CNA, S20CNA and S9CNA. S8CNA indicated during transfer she noted Resident #93's legs straddled the pole of the Hoyer lift and S8CNA indicated she repositioned Resident #93's right leg around the Hoyer lift pole. S8CNA indicated after repositioning Resident #93's right leg around pole, Resident #93 complained her leg hurt and continued to holler after being placed in bed. S8CNA indicated around 1:30 p.m., she informed S4LPN, Resident #93 complained her leg was broken and complained of pain. S8CNA stated she was not asked by S4LPN what Resident #93 was doing at time when she complained of pain to her leg. S8CNA confirmed she did not inform S4LPN Resident #93 complained of pain during transfer.
In an interview on 07/11/2023 at 11:15 a.m., S9CNA indicated on 07/02/2023 at approximately 1:00 p.m. she assisted S8CNA and S20CNA with transfer of Resident #93 from Geri chair to bed with Hoyer lift. S9CNA indicated Resident #93 complained of right leg pain but she did not witness Resident #93's leg being hit during transfer.
In an interview on 07/11/2023 at 12:50 p.m., S4LPN indicated she recalled Resident #93 yelled and screamed out in pain approximately at 1:30 p.m. S4LPN confirmed S8CNA did not communicate Resident #93's pain occurred during transfer. S4LPN confirmed she did not ask S8CNA what Resident #93 was doing when Resident #93 complained of pain. S4LPN stated she assessed Resident #93's leg around 1:30 p.m. and witnessed no bruising or marks on skin of Resident #93's right leg and Resident #93 did not complain of pain when leg was touched or moved. S4LPN stated she gave Resident #93 Tylenol from standing orders because she had no other orders for pain medication as needed and confirmed Resident #93's physician was not contacted. S4LPN indicated Resident #93 continued to complain about pain and she notified S21Registered Nurse (RN) who examined Resident #93's leg. S4LPN indicated no bruising or abnormal swelling was observed but Resident #93 complained of pain when right knee was touched. S4LPN indicated she asked Resident #93 stated she did not fall and could not remember hitting her leg. S4LPN stated when it did not appear Resident #93's pain was relieved, S4LPN sent Resident #93 out to the emergency room at approximately 5:30 p.m. S4LPN stated she did not notify Resident #93's physician.
In an interview on 07/12/2023 at 10:44 a.m., S21RN indicated she was not aware Resident #93's physician was not notified by S4LPN.
In an interview on 07/13/2023 at 12:49 p.m. S2DON stated she was notified Resident #93 was being sent out on 07/02/2023 around 6:00 p.m. for right leg pain. S2DON stated S4LPN did not inform her that Resident #93's change in condition and pain occurred during a transfer. S2DON indicated it is the expectation of the floor nurse when a resident has a change in condition to attempt to identify the cause and notify the physician. S2DON stated S4LPN did not call the hospital to follow up and S4LPN should have. S2DON further confirmed S4LPN should have notified the physician. S2DON confirmed that the physician was not notified about Resident #93's change in condition.
In an interview on 07/13/2023 at 12:50 p.m., S1Adm stated he was not notified of the incident that occurred with Resident #93 until 07/05/2023. S1Adm stated upon being notified he immediately initiated the SIMS report. S1Adm stated had he been notified of the incident the facility would have and should have initiated an investigation on 07/02/2023 when the incident occurred. S1Adm stated it is the expectation of the nursing staff present in the facility to initiate an investigation when a resident begins to complain of pain during a transfer. S1Adm further stated it is the expectation of the CNA assigned to the resident to notify the nurse of any abnormalities or signs or symptoms of pain during a transfer that occurred. S1Adm stated the CNA neglected to inform the nurse of all the details of the Resident #93's incident to include that the pain Resident #93 experienced began occurring when the transfer was performed. S1Adm further stated S4LPN assigned to Resident #93 neglected to inform the physician of the change in condition of Resident #93 and neglected to initiate an investigation to aide in assisting the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, record reviews, and interviews, the facility failed to implement a fall intervention for 1 (Resident #53) of 2 (Resident #53 and Resident #48) sampled residents reviewed for fall...
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Based on observation, record reviews, and interviews, the facility failed to implement a fall intervention for 1 (Resident #53) of 2 (Resident #53 and Resident #48) sampled residents reviewed for falls.
Findings:
Review of Resident #53's record revealed an admit date of 02/25/2023 and had a diagnosis of Alzheimer's disease.
Review of Resident #53's Quarterly Minimum Data Set with an Assessment Reference Date of 04/03/2023 revealed, in part, Resident #53 had a Brief Interview for Mental Status score of 3 indicating severe cognitive impairment and used a wheelchair for mobility.
Review of Resident #53's Care Plan with a start date of 11/02/2021 revealed, in part, a problem of at risk for falls. Further review revealed a revision dated 12/27/2022 with an intervention for staff to apply Dycem (a non-slip material to provide better grip or hold objects in place) to Resident #53's wheelchair. Further review revealed an intervention dated 06/26/2023 for staff re-education on the proper placement of Dycem in relation to the wheelchair.
Review of a facility statement of in-service training for employees dated 06/28/2023 at 10:00 a.m. revealed an in-service training occurred in the following areas of instructions: Resident #53; Dycem was to be put on top of wheelchair cushion.
Observation on 07/11/2023 at 10:17 a.m. revealed Resident #53 sitting in the day room in a manual wheelchair with no Dycem observed on top of Resident #53's wheelchair cushion.
Observation on 07/11/2023 at 12:17 p.m. revealed Resident #53 sitting in the day room in a manual wheelchair with no Dycem observed on top of Resident #53's wheelchair cushion
Observation on 07/12/2023 at 9:30 a.m. revealed Resident #53 sitting in the shower room in a manual wheelchair with no Dycem observed on top of Resident #53's wheelchair cushion.
In an interview on 07/12/2023 at 3:47 p.m., S15MDS (Minimum Data Set) Coordinator stated she did not know why the Dycem was placed underneath Resident #53's wheelchair cushion, but it should have been placed on top of the wheelchair cushion.
In an interview on 07/13/2023 at 9:41 a.m., S6Licensed Practical Nurse stated she was aware the sticky sheet of plastic that stops Resident #53 from sliding should have been positioned on top of the wheelchair cushion but, Resident #53 pulled it off so it had been placed underneath the cushion.
In an interview on 07/13/2023 at 1:34 p.m., S2Direector of Nursing stated the Dycem should have been placed on top of Resident #53's wheelchair cushion to prevent falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Assess and/or provide wound care for a wound for ...
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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. Assess and/or provide wound care for a wound for 1 (Resident #27) resident of 4 (Resident #15, Resident #27, Resident # 31, and Resident #114) sampled residents investigated for wound care; and,
2. Ensure a resident received neurological assessments following an unwitnessed fall for 1 (Resident #48) of 2 (Resident #48 and Resident #53) sampled residents investigated for falls.
Findings:
1.
Review of facility's wound care and treatment policy revealed, in part, an identified wound/skin concern will be assessed by the nurse upon being notified of the wound/skin concern. Further review revealed, the wound assessment/skin concern assessment will be documented in the resident clinical record, and the physician will be notified.
Review of Resident #27's care plan revealed, in part, a goal of Resident #27 would have minimal to no skin breakdown. Further review revealed, interventions included, in part, observe Resident #27's skin when providing routine care, and allow for a wound consultant as appropriate.
Observation on 07/10/2023 at 10:26 a.m. revealed an open wound to Resident #27's left upper cheek, and another open wound to the right side of Resident #27's face that had bright red surrounding tissue.
Observation on 07/11/2023 at 09:20 a.m., revealed, Resident #27 had a closed wound to her left upper cheek and another closed wound to the right side of Resident #27's face that had bright red surrounding tissue.
In an interview on 07/11/2023 at 09:20 a.m., Resident #27 stated staff had not performed wound care or assessed the wound to the right side of Resident #27's face or the wound to Resident #27's left upper cheek.
Review of Resident #27's July 2023 Physician's orders revealed, in part, an order dated 07/11/2023 to clean the abrasion to the right side of Resident #27's face with wound cleanser, dry, and apply Bactroban (an antibiotic) until healed.
Review of Resident #27's wound assessment dated [DATE] revealed Resident #27 had an abrasion to her right cheek that was self-inflicted due to scratching/picking and measured 2.50 centimeters (cm) x 1.3 cm x 0.10 cm.
In an interview on 07/12/2023 at 9:31 a.m., S19Treatment Nurse (TN) stated she should be notified of any new wounds on a resident, so that the wounds could be evaluated and treated. S19TN further stated if she was not available, the facility nurses were responsible for assessing new wounds and providing wound care based on the facility's standing orders.
In an interview on 07/13/2023 at 9:00 a.m., S3Licensed Practical Nurse (LPN) stated she first noted a scratch on Resident #27's left cheek on 07/07/2023 and notified S19TN that same day. S3LPN also stated she first noted the abrasion to the right side of Resident #27's face on 07/10/2023 and notified S19TN the afternoon of 07/10/2023. S3LPN further stated that she did not perform any wound care to Resident #27's left cheek wound or Resident #27's wound to the right side of her face.
Review of Resident #27's nurse's note revealed no documentation, and the facility did not present any documentation, regarding wounds to right side of Resident #27's face or the left upper cheek on 07/07/2023 or 07/10/2023.
In an interview on 07/13/2023 at 11:45 a.m., S19TN stated if the left upper cheek wound was present on 07/07/2023, the wound should have been assessed on 07/07/2023 and wound care started. S19TN further stated that if the abrasion to the right side of Resident #27's face was present on 07/10/2023, the wound should have been assessed on 07/10/2023 and wound care started.
In an interview on 07/13/2023 at 11:53 a.m., S2DON stated the wound to the right side of Resident #27's face and the wound to Resident #27's left upper cheeked should have been assessed and wound care started on the day the above wounds were first noted. S2DON further stated S19TN or any nurse could have performed an assessment of Resident #27's wounds and wound care started per the facility's standing orders.
2.
Review of the facility's Incident and Accident Policy and Procedure revealed, in part, the purpose was to assure that all persons who were involved in an incident or accident, or suspected to have had an incident or accident, were evaluated, and received treatment as indicated and were monitored for disposition of incident and accident. Further review revealed following a resident's unwitnessed fall, neurological checks and vital signs should be obtained and documented every 15 minutes times four, then every 30 minutes times four, then every hour times five, then every shift for the remainder of the 72 hour neurological observation period.
Review of Resident #48's Minimum Data Set with an Assessment Reference Date of 03/21/2023 revealed, in part, Resident #48 had a Brief Interview for Mental Status score of 1, which indicated severe cognitive impairment. Further review revealed Resident #48 had a history of falls and received anticoagulant medication.
Review of Resident #48's July 2023 physician's orders revealed Resident #48 had an order for Eliquis (an anticoagulant medication used to prevent blood clots) 2.5 milligrams twice a day.
Review of Resident #48's Fall Risk Assessment completed on 02/17/2023 revealed, in part, Resident #48 scored a 14 on the assessment, which indicated Resident #48 was a high risk for falls.
Review of Resident #48's care plan revealed, in part, Resident #48 was at risk for bleeding and bruising related to the use of an anticoagulant medication. Further review revealed Resident #48 needed to be monitored for signs and symptoms of bleeding.
Review of Resident #48's Incident Report revealed, in part, Resident #48 had an unwitnessed fall on 03/12/2023 at 2:45 p.m.
Review of Resident #48's record revealed no documented evidence and the facility was unable to provide any documented evidence Resident #48 had neurological checks and/or had vital signs obtained after Resident #48's unwitnessed fall on 03/12/2023 per facility policy.
Review of Resident #48's Incident Report revealed, in part, Resident #48 had an unwitnessed fall on 06/01/2023 at 3:12 p.m.
Review of Resident #48's Neurological Observation record revealed, in part, no documented evidence and the facility was unable to provide any documented evidence Resident #48 had neurological checks and/or had vital signs obtained from 06/01/2023 at 9:30 p.m. until 06/02/2023 at 9:30 a.m.
In an interview on 07/13/2023 at 12:05 p.m. S18LPN confirmed Resident #48 was a fall risk and had a history of falls. S18LPN further stated neurological checks and vital signs should be completed following an unwitnessed fall.
In an interview on 07/13/2023 at 12:24 p.m., S2DON stated neurological checks and vital signs should be assessed for 72 hours following a resident's unobserved fall. S2DON confirmed Resident #48 did not have documented neurological checks or vital signs from 06/01/2023 at 9:30 p.m. until 06/02/2023 at 9:30 a.m. following Resident #48's unwitnessed fall on 06/01/2023.
In an interview on 07/13/2023 at 12:50 p.m., S2DON confirmed there was no documented evidence Resident #48 had neurological checks or vital signs assessed following Resident #48's unwitnessed fall on 03/12/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure a urinary catheter (a tube that is passed through the urethra and into the bladder to drain urine) drainage bag did not touch the floo...
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Based on observation and interview, the facility failed to ensure a urinary catheter (a tube that is passed through the urethra and into the bladder to drain urine) drainage bag did not touch the floor for 1(Resident #15) of 1 resident in the facility that had an indwelling urinary catheter.
Findings:
Review of Resident #15's Significant Change Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 06/12/2023 revealed, in part, Resident #15 had an indwelling catheter.
Observation on 07/11/2023 at 1:40 p.m., revealed S8Certified Nursing Assistant (CNA) removed Resident #15's urinary catheter drainage bag from its privacy bag. S8CNA then slid the urinary catheter drainage bag on the floor underneath the back of Resident #15's wheelchair to the front of the wheelchair when transferring Resident #15 from the wheelchair to the bed to perform catheter care.
Observation on 07/11/2023 at 1:43 p.m. revealed, S8CNA slid Resident #15's urinary catheter drainage bag on the floor underneath the front of Resident #15's wheelchair to the back of the wheelchair when transferring Resident #15 from the bed to the chair after completing catheter care.
In an interview on 07/11/2023 at 1:45 p.m., S8CNA stated she slid Resident #15's urinary catheter drainage bag on the floor and should not have slid Resident #15's urinary catheter drainage bag on floor.
In an interview on 07/12/2023 at 1:27 p.m., S10Licensed Practical Nurse (LPN) stated resident's urinary catheter drainage bags should not be placed on the floor.
In an interview on 07/12/2023 at 1:45 p.m. S17Infection Preventionist (IP) stated Resident #15's urinary catheter drainage bag should not have been placed on the floor at any time.
In an interview on 07/13/2023 at 9:00 a.m., S3LPN stated that Resident #15's urinary catheter drainage bag should not be placed on the ground at any time.
In interview on 07/13/2023 at 09:15 a.m., S2Director of Nursing stated that S8CNA should not have slid Resident #15's urinary catheter drainage bag on the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure staff had competencies and skill set to manage the care of a knee immobilizer for1(Resident #93) of 1 sampled resident reviewed for ...
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Based on observations and interviews, the facility failed to ensure staff had competencies and skill set to manage the care of a knee immobilizer for1(Resident #93) of 1 sampled resident reviewed for hospitalization.
Findings:
Review of Resident #93's July 2023 Physician's orders revealed, in part, an order dated 07/06/2023 for a right knee immobilizer for 2 weeks.
Observation on 07/11/2023 at 9:25 a.m. revealed Resident #93 was up in the Geri chair with a right knee immobilizer on her right leg. Observation of Resident #93's knee immobilizer revealed the top of the knee immobilizer was at the top of the knee, the notch (hole) was located over the shin and the bottom of the knee immobilizer was located on the ankle.
Observation on 07/11/2023 at 10:10 a.m. revealed S3Licensed Practical Nurse (LPN) refastened the knee immobilizer to Resident #93's right leg, with the top of the knee immobilizer touching the top of the knee, the notch (hole) over the right shin and the bottom of the knee immobilizer at the ankle.
In an interview on 07/11/2023 at 10:10 a.m., S3LPN indicated she was not sure if the knee immobilizer on Resident #93's right leg was properly placed.
Observation on 07/12/2023 at 8:45 a.m., revealed Resident #93 up in the Geri chair with the right knee immobilizer on the right leg. Observation further revealed the top of the knee immobilizer was on the knee, the notch (hole) was placed over the right shin and the bottom of the knee immobilizer was on top of the right foot.
In an interview on 07/12/2023 at 9:01 a.m., S7Certified Nursing Assistant (CNA) indicated she had not been trained on what to look for or how to apply a knee immobilizer. S7CNA indicated she did know how the knee immobilizer should be placed.
In an interview on 07/12/2023 at 9:30 a.m., S10Licensed Practical Nurse indicated she had not received any formal training at the facility on care of the knee immobilizer.
Observation on 07/13/2023 at 8:50 a.m. revealed Resident #93 up in the Geri chair with her right leg hanging off of the Geri chair and right knee immobilizer in place. Observation further revealed Resident #93's knee immobilizer was placed with top of the knee immobilizer at the knee level, the notch(hole) was over resident #93's shin, and the bottom of the knee immobilizer was on top of the foot next to Resident #93's toes.
In an interview on 07/13/2023 at 8:50 a.m., S3LPN indicated she did not know if Resident #93's knee immobilizer was positioned correctly.
In an interview on 07/13/2023 at 9:15 a.m., S16Physical Therapist confirmed Resident #93's knee immobilizer to the right leg was not applied correct.
In an interview on 07/13/2023 at 9:20 a.m., S3LPN confirmed that the placement of knee immobilizer prior to physical therapist repositioning it was not correct.
In an interview on 07/13/2023 at 8:40 a.m., S2Director of Nursing (DON) confirmed that training was not provided on Resident #93's knee immobilizer to nursing staff. DON confirmed the facility did not have a policy or competency checklist for knee immobilizers and the nursing staff should have been trained on the knee immobilizer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interviews, the facility failed to administer a resident's enteral flush per the physician orders for 1(Resident #50) of 1 residents investigated for enteral f...
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Based on record review, observation, and interviews, the facility failed to administer a resident's enteral flush per the physician orders for 1(Resident #50) of 1 residents investigated for enteral feedings.
Findings:
Review of the facility's Enteral Nutritional Therapy- Tube Feeding Policy and Procedure revealed, in part, the proper procedure was to administer the prescribed amount of water following the administration of an enteral feeding.
Review of Resident #50's current physician orders revealed, in part, an order with a start date of 06/28/2022 that read flush Resident #50's peg tube (an alternative means to provide nutrition to a resident) with 250 cubic centimeters (cc) of water four times daily.
Observation on 07/10/2023 at 11:17 a.m. revealed, Resident #50's enteral feeding pump set to infuse enteral flush at 150 milliliters (ml) every three hours.
Observation on 07/10/2023 at 1:06 p.m. revealed, Resident #50's enteral feeding pump set to infuse enteral flush at 150 ml every three hours.
Observation on 07/11/2023 at 9:43 a.m. revealed, Resident #50's enteral feeding pump set to infuse enteral flush at 150 ml every three hours.
Observation on 07/11/2023 at 2:43 p.m. revealed, Resident #50's enteral feeding pump set to infuse enteral flush at 150 ml every three hours.
Observation on 07/11/2023 at 3:03 p.m. revealed Resident #50's enteral feeding pump set to infuse enteral flush at 250 ml every six hours.
In an interview on 07/11/2023 at 3:20 p.m., S18Licensed Practical Nurse (LPN) stated she hung a flush bag for Resident #50 and noticed Resident #50's flush had been infusing at 150 ml every 3 hours since the previous bag was hung on 07/09/2023. S18LPN stated she checked Resident #50's physicians order and identified Resident #50's enteral flush should infuse at 250ml every 6 hours.
In an interview on 07/12/2023 at 10:30 a.m., S2Director of Nursing(DON) stated the facility's process for ensuring the correct enteral flush was administered was for the floor nurse to ensure the enteral pump was infusing correctly each shift when they review the Electronic Medication Administration Record (eMAR). S2DON stated Resident #50 received enteral flush at the incorrect rate and she should not have.
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 review, observations, and interviews, the facility failed to ensure controlled drugs were accurately reconciled for 2 (Medication Cart y and Medication Cart z) of 3 (Medication Cart x,...
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Based on record review, observations, and interviews, the facility failed to ensure controlled drugs were accurately reconciled for 2 (Medication Cart y and Medication Cart z) of 3 (Medication Cart x, Medication Cart y, and Medication Cart z) medication carts observed for controlled drug reconciliation.
Findings:
Review of the facility's Controlled Substances Policy and Procedure revealed, in part, an accurate accountability of the inventory of all controlled drugs must always be maintained. Further review revealed when a controlled substance was administered, the licensed nurse administering the medication immediately entered the following information on the accountability record and the medication administration record (MAR): the date and time of administration; the amount of controlled medication administered; the remaining quantity of controlled medication; and, the initials of the nurse who administered the controlled medication.
Observation on 07/12/2023 at 11:48 a.m. of Medication Cart z revealed the following:
-Resident #6's controlled medication card had 17 tablets of Hydrocodone-Acetaminophen (APAP) (a controlled medication used to treat pain) 5-325 milligram (mg) available; and,
-Resident #24's controlled medication card had 13 tablets of Hydrocodone-APAP 7.5-325mg available.
Review of the Narcotic Record on Medication Cart z revealed the following:
-Resident #6's Individual Narcotic Record had a remaining quantity of 18 Hydrocodone-APAP 5-325mg tablets documented; and,
-Resident #24's Individual Narcotic Record had a remaining quantity of 14 Hydrocodone-APAP 7.5-325mg tablets documented.
In an interview on 07/12/2023 at 11:50 a.m., S5Licensed Practical Nurse (LPN) confirmed Resident #6 and Resident #24's controlled medications were not accurately reconciled. S5LPN stated he had administered Resident #6 and Resident #24's controlled medications earlier in the shift, but he had not recorded the administration on the narcotic logs. S5LPN further stated the controlled medications should have been reconciled at the time they were administered.
Observation on 07/12/2023 at 12:13 p.m. of Medication Cart y revealed the following:
-Resident #12's controlled medication card had 42 tablets of Tramadol (a controlled medication used to treat pain) 50mg available;
-Resident #41's controlled medication card had 33 tablets of Alprazolam (a controlled medication used to treat anxiety) 0.5mg available;
-Resident #102's controlled medication card had 41 tablets of Hydrocodone-APAP 7.5-325mg available;
-Resident #92's controlled medication card had 31 tablets of Lorazepam (a controlled medication used to treat anxiety and agitation) 0.5mg available;
-Resident #13's controlled medication card had 46 tablets of Hydrocodone-APAP 5-325mg available;
-Resident #82's controlled medication card had 17 tablets of Alprazolam 0.25mg available; and,
-Resident #108's controlled medication card had 38 tablets of Tramadol 50mg available.
Review of the Narcotic Record on Medication Cart y revealed the following:
-Resident #12's Individual Narcotic Record had a remaining quantity of 43 tablets of Tramadol 50mg documented;
-Resident #41's Individual Narcotic Record had a remaining quantity of 34 tablets of Alprazolam 0.5mg documented;
-Resident #102's Individual Narcotic Record had a remaining quantity of 42 tablets of Hydrocodone-APAP 7.5-325mg documented;
-Resident #92's Individual Narcotic Record had a remaining quantity of 32 tablets of Lorazepam 0.5mg documented;
-Resident #13's Individual Narcotic Record had a remaining quantity of 47 tablets of Hydrocodone-APAP 5-325mg documented;
-Resident #82's Individual Narcotic Record had a remaining quantity of 18 tablets of Alprazolam 0.25mg documented; and,
-Resident #108's Individual Narcotic Record had a remaining quantity of 39 tablets of Tramadol 50mg documented.
In an interview on 07/12/2023 at 12:20 p.m., S6LPN stated she had administered Resident #12's, Resident #41's, Resident #102's, Resident #92's, Resident #13's, Resident #82's, and Resident #108's controlled medications, but S6LPN had not documented the administration on the respective narcotic logs. S6LPN confirmed she should have reconciled the controlled medications at the time of administration.
In an interview on 07/12/2023 at 2:26 p.m., S2Director of Nursing (DON) confirmed the above mentioned controlled medications should have been signed out on the residents' Individual Narcotic Record at the time they were administered to the residents. S2DON stated the Individual Narcotic Record should accurately reconcile with the quantity of controlled medication available.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on record review, observations and interviews, the facility failed to:
1. Ensure a medication cart was locked for 1 (Medication Cart z) of 3 (Medication Cart x, Medication Cart y, and Medication...
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Based on record review, observations and interviews, the facility failed to:
1. Ensure a medication cart was locked for 1 (Medication Cart z) of 3 (Medication Cart x, Medication Cart y, and Medication Cart z) medication carts observed;
2. Ensure expired medications were not available for use on 2 (Medication Cart y and Medication Cart z) of 3 (Medication Cart x, Medication Cart y, and Medication Cart z) medication carts observed; and,
3. Ensure multiuse insulin pens were labeled with an open date for 1 (Medication Cart y) of 3 (Medication Cart x, Medication Cart y, and Medication Cart z) medication carts observed.
Findings:
1.
Review of the facility's policy Medication Administration General Guidelines Policy and Procedure revealed, in part, the medication cart was to be kept closed and locked when out of the sight of the medication nurse.
Review of the facility's Medication Administration Policy and Procedure revealed, in part, all medication storage areas were to be locked at all times unless in use and under the direct observation of the nurse.
Observation on 07/12/2023 at 11:37 a.m. revealed Medication Cart z was unlocked and unattended by the nurse until S5Licensed Practical Nurse (LPN) arrived to the cart at 11:47 a.m.
In an interview on 07/12/2023 at 11:47 a.m., S5LPN confirmed Medication Cart z was not locked and left unattended.
2.
Observation on 07/12/2023 at 11:48 a.m. of Medication Cart z revealed a bottle of Docusate Sodium (a medication used to treat constipation) 100 milligram tablets had an expiration date of 03/2023.
In an interview on 07/12/2023 at 11:50 a.m., S5LPN confirmed the bottle of Docusate Sodium had an expiration date of 03/2023 and was available for use.
Observation on 07/12/2023 at 12:13 p.m. of Medication Cart y revealed a bottle of Vitamin D (a vitamin supplement) 25 microgram tablets had an expiration date of 05/2023.
In an interview on 07/12/2023 at 12:20 p.m., S6LPN confirmed the bottle of Vitamin D had an expiration date of 05/2023 and was available for use.
3.
Review of the facility's Medication Administration Policy and Procedure revealed, in part, the nurse opening a multi-dose vial must place the open date on the vial.
Observation on 07/12/2023 at 12:13pm of Medication Cart y revealed the following:
-Resident #80's Basaglar insulin pen (a medication used to lower blood sugar) had no open date present; and,
-Resident #41's Lantus insulin pen (a medication used to lower blood sugar) had no open date present.
In an interview on 07/12/2023 at 12:20 p.m., S6LPN confirmed Resident #80's and Resident #41's insulin pens had been used and did not have an open date written on them. S6LPN stated she was unsure the date Resident #80's and Resident #41's insulin pens were first used.
In an interview on 07/12/2023 at 2:26 p.m., S2Director of Nursing (DON) confirmed medication carts should be locked when not attended by the nurse. S2DON stated Resident #80's and Resident #41's insulin pens should have had a written open date present so the nurse would know when the insulin pen expired. S2DON further stated expired medications should not have been available for use on the medication carts.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that a freezer in the nutrition room had a thermometer that monitored the temperature at which foods available for res...
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Based on observation, interview, and record review, the facility failed to ensure that a freezer in the nutrition room had a thermometer that monitored the temperature at which foods available for resident consumption were kept.
Findings:
Review of the United States Drug and Food Administration (FDA) Food Code 2022 revealed, in part, cold holding equipment used for temperature control for food safety shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the devices temperature display.
Observation on 07/10/2023 at 10:33 a.m., revealed that a thermometer was not present in the nutrition room freezer. Further observation revealed there was one large tub of vanilla ice cream that was full, one large tub of vanilla ice cream that was one-fourth full, and a bag of popsicles present in the nutrition room freezer.
Observation on 07/11/2023 at 10:00 a.m., revealed a thermometer was not present in the nutrition room freezer. Further observation revealed there was one large tub of vanilla ice cream that was full, one large tub of vanilla ice cream that was one-fourth full, and a bag of popsicles present in the nutrition room freezer.
Observation on 07/12/2023 at 9:15 a.m., revealed a thermometer was not present in the nutrition room freezer. Further observation revealed there was one large tub of vanilla ice cream that was full, one large tub of vanilla ice cream that was one-fourth full, and a bag of popsicles present in the nutrition room freezer.
Observation on 07/13/2023 at 9:28 a.m., revealed a thermometer was not present in the nutrition room freezer. Further observation revealed there was one large tub of vanilla ice cream that was full, one large tub of vanilla ice cream that was one-fourth full, and a bag of popsicles present in the nutrition room freezer.
Review of the May, June, and July 2023 temperature logs for the facility refrigerators and freezers revealed, in part, no log that the temperatures in the nutrition room freezer were checked. The facility was unable to provide documented evident the nutrition room freezer temperature was monitored.
In an interview on 07/13/2023 at 9:32 a.m., S11Licensed Practical Nurse (LPN) stated she did not check the temperature of the nutrition room freezer when she performed equipment temperature checks, and that she has never checked the temperature of the nutrition room freezer.
In an interview on 07/13/2023 at 9:52 a.m., S13 Dietary Supervisor there should be a thermometer in the nutrition room freezer, and confirmed that no thermometer was present in the nutrition room freezer. S13Dietary Supervisor further stated the temperature of the nutrition room freezer should be checked daily as it contained food for resident consumption.
In an interview on 07/13/2023 at 10:11 a.m., S2Director of Nursing stated the nutrition room freezer should have had a thermometer to monitor the temperature as it contained food for resident consumption.
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, observations, and interviews, the facility failed to:
1. Ensure the Certified Nursing Assistant (CNA) performed hand hygiene during meal assistance for 2 (Resident #47 and Resi...
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Based on record review, observations, and interviews, the facility failed to:
1. Ensure the Certified Nursing Assistant (CNA) performed hand hygiene during meal assistance for 2 (Resident #47 and Resident #31) of 7 residents observed during dining; and
2. Ensure the CNA completed hand hygiene during catheter care for 1 (Resident #15) of 1 residents observed for catheter care in a total sample of 22. There was 1 resident in the facility identified as having a urinary catheter as documented on the facility's Resident Census and Conditions of Residents.
Findings:
Review of the facility's Hand Hygiene policy and procedure revealed, in part, it was the policy of the facility that all staff members will perform good hand washing techniques to prevent cross contamination and reduce the spread of infection. Further review of the facility's Hand Hygiene policy and procedure revealed, in part, it was the procedure of the facility for staff to perform hand hygiene before and after direct resident contact; before and after assisting a resident with meals and personal care; and after handling soiled catheters.
1.
Observation on 07/11/2023 at 11:40 a.m. revealed S14CNA sat across the table from Resident #47 and Resident #31 to provide feeding assistance. Further observation revealed S14CNA touched Resident #47's hands and clothing protector, did not perform hand hygiene, then touched Resident #31's tray and spoon, and fed Resident #31 a bite of food from the spoon.
Observation on 07/11/2023 at 11:53 a.m. revealed S14CNA touched the top and bottom of Resident #47's hamburger bun with her bare right hand and fed Resident #47 a bite. Further observation revealed S14CNA crossed her arms against her chest and laid the palm of her right hand against the left sleeve of her uniform shirt. S14CNA did not perform hand hygiene and picked up Resident #47's hamburger with her bare right hand and fed Resident #47 another bite.
In an interview on 07/11/2023 at 12:07 p.m., S14CNA stated she should have performed hand hygiene after direct contact with Resident #47's hands before she touched Resident #31's tray and utensils, and after direct contact with her uniform before she touched Resident #47's hamburger.
In an interview on 07/13/2023 at 10:20 a.m., S2Director of Nursing (DON) confirmed S14CNA should have performed hand hygiene after direct contact with Resident #47's hands before she touched Resident #31's utensil. S2DON also confirmed S14CNA should have performed hand hygiene after she touched her uniform shirt and before she touched Resident #47's hamburger bun. S2DON confirmed it was cross contamination.
2.
Review of Resident #15's July 2023 Physician Orders revealed, in part, an order dated 05/26/2023 to perform Foley catheter care daily by washing with soap and water.
Observation on 07/11/2023 at 1:40 p.m., revealed S8Certified Nursing Assistant (CNA), put on gloves, performed Resident #15's catheter care, then proceeded to open Resident #15's bedside table drawer, and reached into Resident #15's bedside table without removing gloves or performing hand hygiene.
In an interview on 07/11/2023 at 1:45 p.m., S8CNA stated she had not removed her gloves or performed hand hygiene after she performed Resident #15's catheter care, opened Resident #15's bedside table drawer, and reached into Resident #15's bedside table drawer to grab the container of cream, and stated she should have.
In interview on 07/13/2023 at 9:15 a.m., S2DON stated that S8CNA should have removed her gloves and performed hand hygiene between performing Resident #15's catheter care, opening Resident #15's bedside table drawer, and grabbing a container of cream out of Resident #15's bedside table drawer.
May 2023
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse for 1 (Resident #2) of 6 (Residents #1, #2, #3, #4, #5, and #6) samp...
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Based on interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse for 1 (Resident #2) of 6 (Residents #1, #2, #3, #4, #5, and #6) sampled residents. S15Certified Nursing Assistant (CNA) verbally and physically abused Resident #2.
Findings:
Review of the facility's Abuse and Neglect Policy and Procedure revealed in part, residents must not be subjected to abuse by anyone, including, but not limed to, facility staff, other residents, consultants or volunteers, staff and/or other agencies serving the residents. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience intimidation or fear. Verbal abuse may be considered to be a type of mental abuse. Examples of mental and verbal abuse include but are not limited to: Yelling or hovering over a resident, with the intent to intimidate and threaten a resident. Physical abuse includes shoving a resident.
Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date of 02/23/2023 Section C revealed in part, Resident #2 had a Brief Interview Mental Status (BIMS) score of 5 which indicated Resident #2 had a severe cognitive impairment.
Review of a State Incident Management System (SIMS), presented by the facility, dated 03/27/2023 revealed in part, the facility reported on 03/27/2023 allegations of physical and verbal abuse of a resident by a staff member with four staff members as witnesses.
Review of S12 Housekeeping Supervisor's written witness statement revealed in part, I witnessed S15Certificed Nursing Assistant (CNA) holding Resident #2 by both arms forcing her back into the hall and Resident #2 stated you are hurting my arms.
Review of S13Dietary Aide's written witness statement revealed in part, I witnessed S15CNA grab Resident #2 with both hands on her with force and pushed Resident #2 into the building. Resident #2 stated my arms are hurting.
Review of S10Certified Nursing Assistant's written witness statement revealed in part, I witnessed S15CNA forcefully grabbing Resident #2 by her arm dragging her inside the facility. S15CNA aggressively came back towards Resident #2 and raised her hands in an aggressive fighting stance as to hit Resident #2. Resident #2 put up her hand as to protect herself from being hit.
Review of S14Dietary Cook's written witness statement revealed in part, S15CNA began to push Resident #2 and handled her in a rough manner.
In an interview on 05/08/2023 at 1:25p.m., S12Housekeeping Supervisor stated on 03/27/2023 she observed S15CNA grab Resident #2 by both arms and pushed Resident #2 into the building. S12Houskeeping Supervisor stated Resident #2 sat in a chair in the hallway and S15CNA raised both of her hands in a fist as she stood over Resident #2 asking her do you want some of this?
In an interview on 05/08/2023 at1:34p.m., S13Dietary Aide stated on 03/27/2023 she observed S15CNA grab Resident #2's upper arms with both of her hands and pushed her inside the building. S13Dietary Aide stated S15CNA was yelling get inside to Resident #2 as she pushed her.
In an interview on 05/08/2023 at 1:42p.m., S14Dietary [NAME] stated on 03/27/2023 she observed S15CNA grab Resident #2 by both arms and pushed her into the building.
In an interview on 05/08/2023 2:10p.m., S10CNA stated on 03/27/2023 she observed S15CNA grab Resident #2 by both arms and pulled her in the building. S10CNA stated S15CNA raised her fists to Resident #2 and Resident #2 raised her hand to protect her face.
In an interview on 05/08/2023 at 2:25p.m., S1Administrator stated he investigated the incident that occurred on 03/27/2023 of suspected verbal and physical abuse of a resident by a staff member. S1Administrator stated based on his investigation he substantiated verbal abuse but unsubstantiated physical abuse because Resident #2 did not have any injuries. After review of the findings S1 Administrator agreed physical abuse can occur without injury. S1Administrator confirmed the incident involved both verbal and physical abuse.
Attempted to contact S15CNA for an interview on 05/08/2023, 05/09/2023, and 05/10/2023 without success.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a violation of exploitation to the state agency within 24 ho...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a violation of exploitation to the state agency within 24 hours in accordance with state law for 1 (Resident #6) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5, and Resident #6) sampled residents.
Findings:
Review of the facility's Abuse and Neglect Policy and Procedure revealed in part, the administrator or designee should complete a report to be submitted to the mandated state agency according to state guidelines for an alleged violation of exploitation.
Review of S13Dietary Aide personnel file revealed a disciplinary action dated 03/29/2023, which revealed in part, S13Dietary Aide received a written warning because she borrowed $200 from Resident #6.
In an interview on 05/10/2023 at 11:56a.m., S16Dietary Supervisor stated S13Dietary Aide was given a written warning because she borrowed $200 from Resident #6. S16Dietary Supervisor stated S1Administrator was notified of the incident on 03/30/2023.
In an interview on 5/10/2023 at 8:32a.m., S1Adminitrator stated he was aware S13Dietary Aide borrowed money from Resident #6. S1Administrator stated the incident was not reported to the appropriate state agency.
In an interview on 5/10/2023 at 12:40p.m., S1 Administrator stated he did complete a Statewide Incident Management ([NAME]) report when he was made aware S13Dietary Aide borrowed money from Resident #6. S1Administrator confirmed S13Dietary Aide borrowed $200 for Resident #6 and stated S13Dietary Aide should have never borrowed money from Resident #6. S1Administrator further stated employees should never borrow money from residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable disease an...
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Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infections by failing to ensure staff utilized the appropriate personal protective equipment when entering rooms where a COVID-19 positive resident was housed. This deficient practice was identified for 6 staff members (S4LPN, S5LPN, S8CNA, S9CNA, S10CNA, and S11CNA).
Findings:
Record review revealed, in part, a policy on COVID-19 Outbreak Policy and Procedure indicated staff who enter the room of a resident with known or suspected COVID-19 will adhere to respiratory/droplet precautions requiring the use of a NIOSH approved facemask (N95), gown, gloves, and eye protection. Personal protective equipment (PPE) was to be applied prior to entering room and disposed of prior to exiting the resident room.
Observation on 05/08/2023 at 9:35 a.m., revealed S4LPN entered Room f (a room with a resident that is on isolation for COVID-19) and did not wear a N95 mask nor eye protection.
In an interview on 05/08/2023 at 9:35 a.m., S4LPN confirmed she did not wear a N95. S4LPN further stated she did not wear eye protection into Room f because there was no face shield available in the 3 drawer PPE container.
Observation on 05/08/2023 at 11:36 a.m., revealed S11CNA entered Room g (a room with a resident that is on isolation for COVID-19) and did not wear eye protection.
In an interview on 05/08/2023 at 11:41 a.m., S11CNA confirmed she did not wear eye protection, but should have in Room g.
Observation on 05/08/2023 at 11:38 a.m., revealed S8CNA entered Room f (a room with a resident that is on isolation for COVID-19) and did not wear eye protection.
Observation on 05/08/2023 at 12:05 p.m., revealed S10CNA entered Room a (a room with a resident that is on isolation for COVID-19) and did not wear eye protection.
Observation on 05/08/2023 at 12:06 p.m., revealed S9CNA entered Room b (a room with a resident that is on isolation for COVID-19) and did not wear eye protection. Further observation revealed, when S9CNA left Room b she removed PPE and entered Room c (a room with a resident that is on isolation for COVID-19) and did not wear eye protection.
Observation on 05/08/2023 at 12:08 p.m., revealed S10CNA removed PPE when she left Room a and entered Room d (a room with a resident that is on isolation for COVID-19) and did not wear eye protection. Further observation revealed, when S9CNA left Room d she removed PPE and entered Room e (a room with a resident that is on isolation for COVID-19) and did not wear eye protection.
Observation on 05/08/2023 at 1:45 p.m., revealed S5LPN entered Room d (a room with a resident that is on isolation for COVID-19) and did not wear a N95 mask nor eye protection.
In an interview on 05/08/2023 at 1:48 p.m., S5LPN confirmed she should have worn a N95 mask and eye protection when she entered Room d (a room with a resident that is on isolation for COVID-19).
Observation on 05/09/2023 at 9:32 a.m., revealed S4LPN entered Room f, but did not wear a N95 mask.
In an interview on 05/09/2023 at 10:34 a.m., S3Infection Preventionist stated the appropriate PPE to be worn in a room where the resident was on isolation due to COVID-19 would be a gown, eye protection, a N95 mask, and gloves.
In an interview on 05/09/2023 at 1:25 p.m., S2 Director of Nursing stated N95 masks and eye protection should be worn in all rooms of residents who are on COVID-19 precautions and confirmed (Room a, Room b, Room c, Room d, Room e, Room f, and Room g) were on COVID-19 precautions.
In an interview on 05/09/0223 at 1:25 p.m., S1Administrator stated N95 masks and eye protection should be worn in all rooms of residents who are on COVID-19 precautions.
Dec 2022
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review, observations, and interviews, the facility failed to maintain accurate reconciliation records of controlled medication for destruction for 8 controlled medications for 6 reside...
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Based on record review, observations, and interviews, the facility failed to maintain accurate reconciliation records of controlled medication for destruction for 8 controlled medications for 6 residents (Resident #7, R6, R7, R8, R9, and R10) being stored for destruction in the Director of Nursing Office (DON). This deficient practice had the potential to affect any of the 114 residents who reside in the facility as per the facility's Resident Census and Conditions of Residents Form (CMS- Form 672).
Findings:
Review of the facility's Medication-Controlled Substances Policy and Procedure revealed, in part, accurate accountability of the inventory of all controlled drugs is always maintained and controlled substances log is to be maintained for all controlled substances. Further review of the policy revealed, controlled medications remaining in the facility after discharge, death, or discontinuation of medication is to be counted and placed in designated lock box with two signatures verifying count.
Review of the facility's Pharmacy Medication Receipt Policy and Procedure revealed, in part, controlled substances are to be reconciled at time of delivery with narcotic count sheet implemented and controlled substance stored according to controlled substance policy.
Observation 12/21/2022 at 12:00 p.m., of the controlled substances for destruction in a locked cabinet in DON's office revealed the following medications:
1.
Resident #7's Morphine Sulfate solution (medication for pain) 20 milligram (mg)/milliliter (ml) and Lorazepam (medication for anxiety) 2 mg/ml vial,
2.
Resident R7's Lorazepam 2 mg/ml solution,
3.
Resident R8's Gabapentin (medication for seizures) 100 mg and Alprazolam (medication for anxiety) 0.25 mg,
4.
Resident R10's Hydrocodone-Acetaminophen (medication for pain) 5 mg-325 mg, and
5.
Resident R9's Alprazolam 0.5 mg had no controlled substance log;
6.
Resident R6's medication card for Pregabalin (medication for nerve pain) 25 mg had 6 capsules and the narcotic record count was 7 and missing 2 signatures for reconciliation.
In an interview on 12/22/2022 at 10:20 a.m., S2Director of Nursing (DON) confirmed all controlled medications should have a log sheet, medication counted, and medication accurately reconciled with two signatures when placed in the destruction locked box.
In an interview on 12/22/2022 at 10:32 a.m., S1Administrator confirmed all controlled medications should have a log sheet, medication counted, and medication reconciled with two signatures when placed in the destruction lock box.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on record review, observations, and interviews, the facility failed to properly store controlled drugs. This deficient practice was identified for 1 of the 6 areas where controlled medications w...
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Based on record review, observations, and interviews, the facility failed to properly store controlled drugs. This deficient practice was identified for 1 of the 6 areas where controlled medications were stored. This deficient practice had the potential to affect any of the 114 residents who resided in the facility as documented on the facility's Resident Census and Condition of Residents Form CMS-672.
Findings:
Review of the facility's Medication Storage Policy and Procedure revealed, in part, medications and biologicals will be maintained in a secured location only accessible to designated staff and Schedule II controlled medications will be maintained within a separately locked permanently affixed compartment.
In an observation on 12/20/2022 at 1:50 p.m., S2Director of Nursing (DON) office was door open and unoccupied for 35 minutes.
In an interview on 12/21/2022 at 10:45 a.m., S2DON stated discontinued narcotics were stored in a locked cabinet in the DON's office with the office door left open throughout the day even when the office was not occupied.
In an interview on 12/21/2022 at 11:00 a.m., S1Administrator stated DON's office was always open and unlocked when not occupied but should be locked when not occupied.
In an observation on 12/21/2022 at 11:45 p.m., S2DON's office door open and unoccupied for 15 minutes.
In an interview on 12/21/2022 at 12:00 p.m., S2DON arrived to her office and stated her office was left open throughout the day for staff to view the white board and showed the controlled substances are locked in a drawer. S2DON further stated the controlled substances were not double locked during the day when the office was left open and unattended.
In an interview on 12/22/2022 at 10:20 a.m., S2DON confirmed the DON's office door should be closed and locked when unoccupied.
In an interview on 12/22/2022 at 10:32 a.m., S1Administrator confirmed the DON's office door should be closed and locked when unoccupied.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 38% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $44,810 in fines. Review inspection reports carefully.
- • 38 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $44,810 in fines. Higher than 94% of Louisiana facilities, suggesting repeated compliance issues.
- • Grade F (11/100). Below average facility with significant concerns.
Bottom line: Trust Score of 11/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Broadway Nursing And Rehabilitation Ctr's CMS Rating?
CMS assigns THE BROADWAY NURSING AND REHABILITATION CTR 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 The Broadway Nursing And Rehabilitation Ctr Staffed?
CMS rates THE BROADWAY NURSING AND REHABILITATION CTR's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 38%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Broadway Nursing And Rehabilitation Ctr?
State health inspectors documented 38 deficiencies at THE BROADWAY NURSING AND REHABILITATION CTR during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 35 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Broadway Nursing And Rehabilitation Ctr?
THE BROADWAY NURSING AND REHABILITATION CTR is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by ELDER OUTREACH NURSING & REHABILITATION, a chain that manages multiple nursing homes. With 126 certified beds and approximately 112 residents (about 89% occupancy), it is a mid-sized facility located in LOCKPORT, Louisiana.
How Does The Broadway Nursing And Rehabilitation Ctr Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, THE BROADWAY NURSING AND REHABILITATION CTR's overall rating (1 stars) is below the state average of 2.4, staff turnover (38%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Broadway Nursing And Rehabilitation Ctr?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is The Broadway Nursing And Rehabilitation Ctr Safe?
Based on CMS inspection data, THE BROADWAY NURSING AND REHABILITATION CTR has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Broadway Nursing And Rehabilitation Ctr Stick Around?
THE BROADWAY NURSING AND REHABILITATION CTR has a staff turnover rate of 38%, which is about average for Louisiana nursing homes (state average: 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 The Broadway Nursing And Rehabilitation Ctr Ever Fined?
THE BROADWAY NURSING AND REHABILITATION CTR has been fined $44,810 across 2 penalty actions. The Louisiana average is $33,527. 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 The Broadway Nursing And Rehabilitation Ctr on Any Federal Watch List?
THE BROADWAY NURSING AND REHABILITATION CTR 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.