RIVIERE DE SOLEIL COMMUNITY CARE CENTER
Non profit - Corporation
130 Beds
COMMCARE CORPORATION
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
11/100
#153 of 264 in LA
Last Inspection: September 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Riviere de Soleil Community Care Center has a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #153 out of 264 nursing homes in Louisiana, placing it in the bottom half of facilities in the state, and #7 out of 8 in Avoyelles County, meaning there is only one local option that is better. The facility is showing signs of improvement, with the number of issues decreasing from 12 in 2024 to 5 in 2025. Staffing is relatively strong, rated at 4 out of 5 stars, with a turnover rate of 46%, slightly below the Louisiana average. However, the facility has incurred $92,470 in fines, which is concerning and suggests ongoing compliance issues. Specific incidents from recent inspections raise serious concerns. For instance, the facility failed to supervise a resident at high risk of elopement, resulting in that resident leaving the premises unsupervised on two occasions. Additionally, a resident was injured during a transfer when staff did not place a lift pad properly, leading to a fall that required emergency treatment. While the staffing levels appear strong, the facility's serious and critical deficiencies highlight significant areas for improvement.
- Trust Score
- F
- In Louisiana
- #153/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $92,470 in fines. Higher than 52% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
11/100
Bottom 43%
Review needed
12 → 5 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 5 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 46%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $92,470
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: COMMCARE CORPORATION
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
2 life-threatening 1 actual harm
Sept 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (Resident #44) of 4...
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Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (Resident #44) of 4 (Resident #44, Resident #48, Resident #87, and Resident #90) resident's reviewed for accidents. The facility failed to ensure Resident #44 had a call light in reach in order to call for assistance. The total sample size was 41. Findings:Review of the facility's current policy titled Call light/Call Pager Systems with effective date of 09/09/2022 read in part. To provide a means of communication to staff for notification of resident needs and a system of communication of staff in the facility; including emergency notifications. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.Review of Resident #44's medical record revealed an admission date of 04/15/2024. Resident #44 had diagnoses that included in part . Hemiplegia affecting Left Non-dominant Side, Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery, Generalized Muscle Weakness, Unsteadiness on Feet, and Repeated Falls.Review of Resident #44's Quarterly MDS with ARD of 08/13/2025 revealed Resident had a BIMS of 09, indicating moderate cognitive impairment. Resident #44 had upper and lower extremity range of motion impairment on one side. Resident #44 required substantial/maximal assistance from staff for chair/bed to chair transfers.Review of Resident #44's Comprehensive Person Centered Care Plan revealed in part.I am at risk for falls related to hemiplegia affecting left non dominant side and generalized weakness. Interventions: Follow facility fall protocol. I need a safe environment with a working and reachable call light. I will have my call light within reach.Review of Resident #44's Fall Risk Evaluation Report dated 08/12/2025 revealed Resident #44 was determined at risk for falls. Review of Resident #44's Departmental Progress Notes revealed in part.09/07/2025 9:38 a.m. S9 LPN documented in part; Front desk notified this nurse that resident's daughter called and said her mom was on the floor and needed help. Resident was trying to elevate legs in recliner, due to chair being too close to the wall, resident slid out of chair on the floor.09/07/2025 9:40 a.m. S9 LPN documented in part; Post Fall Evaluation- Bedside call light on when Resident was found: No.Interview on 09/08/2025 at 10:35 a.m. with Resident #44 revealed on 09/07/2025 she had a fall when she slipped out of her recliner. Resident #44 stated she did not have her call light by her, so she had to call her daughter from her cellphone to get help off of the floor.Observation on 09/09/2025 at 9:05 a.m. of Resident #44 revealed she was sitting up in her wheelchair that was located in the middle of her room. Resident #44's call light was not within reach of resident and was observed hanging on the wall, on the call light box, on the left side of her bed. Resident #44 stated she could not reach her call light, and that staff forgot to give it to her when they got her out of bed and into her wheelchair this morning.Interview on 09/09/2025 at 9:19 a.m. with S4 LPN confirmed Resident #44 had a fall on 09/07/2025 when she slipped out of her recliner, and no injury had occurred. Observation of Resident #44's room with S4 LPN confirmed resident's call light was not in reach of resident, but should be.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure that residents with an order for psychotropic medication were not subjected to chemical restraints for 1 (#75) of the 5 residents (#...
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Based on record review and interview, the facility failed to ensure that residents with an order for psychotropic medication were not subjected to chemical restraints for 1 (#75) of the 5 residents (#4, #5, #12, #38, #75) reviewed for unnecessary medications. The facility failed to:1. Ensure as needed or PRN (pro re nata) orders for a psychotropic medication were limited to 14 days for Resident #75.Findings:Resident #75Review of the facility's policy titled, Psychotropic and Antipsychotic Medications and Non-pharmaceutical Intervention, Revision #5, with an effective date of 01/25, reveals in part under the section heading, PRN Psychotropic Medications.if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.Review of Resident #75's medical record revealed a readmission date of 05/09/2022 with diagnoses that included, in part, Parkinson's Disease with dyskinesia, without mention of fluctuations; Psychotic Disorder with delusions due to known physiological condition; Bipolar Disorder, current episode mixed, severe, with psychotic features; General Anxiety Disorder; Major Depressive Disorder; and Muscle Weakness.Review of Resident #75's current medication orders revealed in part, an order for as needed or PRN Trazodone HCl Oral Tablet 50 MG (milligram) (a medication given to treat major depressive disorder) with directions to Give 1 tablet by mouth every 24 hours as needed for Anxiety/Depression/Insomnia/Paranoia related to psychotic disorder with delusions due to known physiological condition; Bipolar Disorder, Current Episode Mixed, Severe, with Psychotic Features; Major Depressive Disorder, Recurrent, Unspecified Take at bedtime. The order had a start date of 03/25/2025 with no end date indicated.Review of the 05/27/2025 Gradual Dose Reduction initiated by the pharmacist and signed on 06/23/2025 by the physician, revealed the following, in part.7. Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth every 24 hours as needed for Anxiety/Depression/Insomnia/Paranoia. Take at bedtime. (Please provide a specific duration/stop date)8. (PRN Psychotropic: is limited to 14 days and requires the prescriber to evaluate the resident prior to extending the order; if extending, document the rationale for the extended time period in the medical record and indicate a specific duration).Review of Resident #75's medical record revealed there was no rationale provided for the continuation of the as needed Trazodone by the attending physician or prescribing practitioner to extend the orders past 14 days.On 09/10/2025 at 12:45 p.m., S1 DON was notified about the PRN psychotropic medication for Resident #75, and she confirmed that the PRN psychotropic medication was not limited to 14 days.
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 observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #42 and Resident #70) of 3 (Resident #24, Resid...
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Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #42 and Resident #70) of 3 (Resident #24, Resident #42, and Resident #70) sampled residents reviewed for respiratory care. The facility failed to ensure physician orders were followed for oxygen administration for Residents #42 and #70, and that oxygen equipment was stored appropriately for Resident #70.Findings:
Review of the facility's undated policy titled, “Oxygen Administration,” read in part…Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
Resident #42
Review of Resident #42's medical record revealed an admit date of 08/23/2024 with a re-entry date of 08/06/2025 with diagnoses that included in part .Heart Failure, Chronic Respiratory Failure with Hypoxia, and Pleural Effusion in Other Conditions.
Review of Resident #42's 09/2025 Physician orders revealed the following orders in part .07/14/2025 Oxygen: Oxygen at 2 liters/nasal cannula.
Review of Resident #42's Significant Change MDS with an ARD of 08/12/2025 revealed a BIMS summary score of 15 indicating intact cognition. Resident #42 required oxygen therapy.
Observation on 09/08/2025 at 10:48 a.m. revealed Resident #42 lying in bed awake and alert with oxygen infusing via nasal cannula. Resident #42 stated he required continuous oxygen at 2liters/minute. Oxygen concentrator observed with oxygen set at 3 liters/minute.
Observation on 09/08/2025 at 3:46 p.m., revealed Resident #42 lying in bed asleep wearing a nasal cannula with oxygen infusing at 3 liters/minute via oxygen concentrator.
Observation on 09/09/2025 at 8:27 a.m., revealed Resident #42 lying in bed asleep on room air. Nasal cannula observed next to Resident #42. Oxygen concentrator observed on and oxygen infusing at 3 liters/minute.
Interview on 09/09/2025 at 8:31 a.m., with S3 LPN revealed Resident #42 wore oxygen continuously and staff made frequent rounds on Resident #42. S3 LPN stated Resident #42 was originally on 3 liters/minute and requested to have his oxygen down to 2 liters/minute. S3 LPN revealed Resident #42 was ordered oxygen at 2liters/minute. S3 LPN stated all staff are required to follow the physician orders for oxygen administration and that Resident #42 should currently be on 2 liters/minute. S3 LPN observed Resident #42's oxygen concentrator and confirmed that the oxygen concentrator was set at 3 liters/minute and should have been on 2 liters/minute.
Resident #70
Review of Resident #70's medical record revealed an admission date of 07/24/2020. Resident #70 had diagnoses that included in part… Chronic Respiratory Failure with Hypoxia, and COPD (Chronic Obstructive Pulmonary Disease).
Review of Resident #70's Quarterly MDS with ARD of 07/09/2025 revealed the resident had a BIMS of 08, indicating moderate cognitive impairment. Resident #70 was not coded for refusals of care. Resident#70 received oxygen therapy.
Review of Resident #70's current 09/2025 physician orders revealed in part…
Order date: 07/14/2024: Oxygen every shift at 2L/NC, may remove for bathing and ADL care.
Order date: 04/24/2023: Ensure resident has continuous oxygen in place at all times. Every 4 hours for low oxygen saturation.
Order Date: 04/09/2025: Respiratory Therapy 7 days a week, 2 times a day for 15 minutes.
Review of Resident #70's Comprehensive Person Centered Care Plan revealed in part…
I am currently receiving respiratory therapy services related to diagnoses of: COPD, Chronic Respiratory Failure with Hypoxia, and Pneumonia. Interventions: Oxygen Settings: Administer Oxygen as ordered by the MD.
I am high risk for falls related to history of falls, poor balance, increased weakness, and diagnosis of dementia. Interventions: Nurse to ensure oxygen is in place while resident is in bed. Nurses are educated to ensure resident has continuous oxygen in place at all times due to increased confusion from oxygen deprivation.
Observation on 09/08/2025 at 10:42 a.m. of Resident #70 revealed her nasal cannula oxygen tubing was lying uncovered and draped over the first drawer of her nightstand beside her bed. Resident #70 was observed sitting up in her recliner without oxygen therapy being administered. Resident #70 stated she always wore oxygen, and did not know why staff did not give her oxygen back to her when they assisted her out of her bed to her chair this morning.
Observation on 09/08/2025 at 3:50 p.m. revealed Resident #70 remained out of bed, sitting in her recliner without oxygen therapy being administered as ordered. Resident #70's nasal cannula oxygen tubing remained uncovered, draped over the first drawer of her nightstand.
Interview on 09/08/2025 at 3:57 p.m. with S9 LPN confirmed Resident #70 should be wearing oxygen at 2L per nasal cannula continuously, and if not in use the oxygen tubing should have been stored covered within a bag, but was not.
Observation on 09/09/2025 at 9:11 a.m. of Resident #70 revealed she was without oxygen therapy as ordered, and the oxygen tubing was laid uncovered draped over the top of her oxygen concentrator machine.
Observation on 09/09/2025 at 4:15 p.m. of Resident #70 revealed she was without oxygen therapy as ordered, and the oxygen tubing was laid uncovered draped over the top of her oxygen concentrator machine.
Observation on 09/10/2025 at 8:35 a.m. of Resident #70 revealed she was without oxygen therapy as ordered.
Interview on 09/10/2025 at 8:40 a.m. with S3 LPN confirmed Resident #70 was without oxygen therapy as ordered, and confirmed according to physician orders, Resident #70 was to wear oxygen continuously.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
.Based on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help pre...
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.Based on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. During a COVID outbreak, the facility failed to ensure:1. Staff performed hand hygiene between residents while preparing and serving lunch trays to residents; and2. Staff donned PPE appropriately while preparing and serving lunch trays to residents.This deficient practice had the potential to affect all 12 residents who resided in Neighborhood X.Findings:On 09/10/2025, a review of the facility's policy titled Infection Control Interim Policy for Coronavirus dated 02/21/2025 revealed in part.Source control options for HCP (health care professional) include.a well-fitting facemask.On 09/10/2025, a review of the facility's policy titled Handwashing/Hand Hygiene revised 08/2015 revealed in part.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: o. before and after eating or handling food; p. before and after assisting a resident with meals. In an interview on 09/10/2025 at 10:35 a.m., S3 LPN confirmed there were 7 positive cases of COVID at this time in Neighborhood X. Observation in Neighborhood X on 09/10/2025 at 11:30 a.m., revealed S8 CNA wearing a surgical mask covering her mouth and chin, but not covering her nose. S8 CNA filled a glass with water, covered it with plastic wrap, placed the glass on a lunch tray, and then carried the tray to the door of a resident's room. S8 CNA passed the tray to another CNA in the resident's room. S8 CNA then returned to the kitchen counter and repeated these steps twice more without washing or sanitizing her hands. At 11:35 a.m., S8 CNA entered a resident's room. Upon exiting the room, S8 CNA returned to the kitchen counter, without washing or sanitizing her hands. S8 CNA removed plastic wrap from the box and covered the drink for the next resident's lunch tray. S8 CNA then touched the kitchen counter, put her hands in her pockets, then prepared and served lunch trays without sanitizing her hands. In an interview on 09/10/2025 at 11:36 a.m., S8 CNA confirmed her mask was not covering her nose and stated I chew gum so my mask falls down a lot. S8 CNA confirmed she prepped the glasses of water and delivered multiple lunch trays without gelling or washing her hands between trays. S8 CNA stated it gets crazy and I forgot. S8 CNA confirmed she should have sanitized her hands. In an interview on 09/10/2025 at 11:43 a.m., S2 LPN confirmed she was the facility's Infection Preventionist. S2 LPN was notified of the lunch observations on Neighborhood X. S2 LPN acknowledged S8 CNA was not wearing her mask properly and not performing hand hygiene between resident trays, but should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure medications and wound care products were stored in accordanc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure medications and wound care products were stored in accordance with currently accepted professional principles. The facility failed to ensure:1. Treatment carts were free from expired wound care products and medications; and2. Prescription medication had a pharmacy label and was stored in original packaging.A review of the facility policy titled Storage of Medication, revised [DATE], revealed in part. The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.A review of facility policy titled Labeling of Medication Containers, revised [DATE], revealed in part. All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. 2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. Labels for individual resident medications include all necessary information, such as: a. the resident's name. b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; e. The prescription number (if applicable); f. The date the medication was dispensed; i. directions for use.1.On [DATE] at 12:06 p.m., observation of Cart A with S6 Treatment RN revealed the following:- Ten Petroleum Gauze dressings with expiration date of 08/2024.- Five 6-inch x 6-inch Extra absorbent adhesive pads with an expiration date of [DATE].- One 8-inch x 10-inch Silicone Super Absorbent Dressing with an expiration date of [DATE].- Ten Excel Silicone Superabsorbent dressings with an expiration date of [DATE]. - Eight Excel Silicone Superabsorbent dressings with an expiration date of [DATE].On [DATE] at 12:10 p.m., S6 Treatment RN confirmed the above listed wound care products stocked on Cart A were expired, and should not have been. On [DATE] at 12:15 p.m., observation of Cart B with S6 Treatment RN revealed one 473 ml bottle of Dakin's Solution Half Strength with an expiration date of [DATE]. S6 Treatment RN confirmed that the Dakin's Solution Half Strength stocked on Cart B was expired, and should not have been.2.On [DATE] at 12:50 p.m., observation of Cart C with S7 RN revealed one tube of Diclofenac Sodium Topical Gel 1% without the original product box and pharmacy label. The tube of medication read in part . RX Only, indicating the medication was a prescription, and USE DOSING CARD INSIDE CARTON. S7 RN confirmed that the prescription medication should have been stored in the original packaging for proper storage and dosing, but was not. S7 RN confirmed the prescription medication should have had a pharmacy label, and did not. In an interview on [DATE] at 2:03 p.m., S1 DON confirmed expired items were present on facility treatment and medication carts and should not have been. S1 DON confirmed that the prescription medication Diclofenac Sodium Topical Gel 1% should have been stored in the original product packaging for proper storage and dosing, and was not. S1 DON confirmed that the prescription medication Diclofenac Sodium Topical Gel 1% should have had a pharmacy label, and did not
Oct 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) out of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents, by failing to ensure she was free of facial hair and by failing to honor her food choices.
Findings:
Review of the facility's policy titled Dignity with a revision date of 02/2021 revealed in part .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
Policy Interpretation and Implementation
1. Residents are treated with dignity and respect at all times.
2. The facility culture supports dignity and respect by honoring resident goals, choices, preferences, values and beliefs.
5. When assisting with care, residents are supported in exercising their right, for example, residents are: groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).
1. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Type 2 Diabetes Mellitus, Pressure Ulcer of Sacral Region Stage 3, Chronic Kidney Disease Unspecified, Dysphagia following Cerebral Infarction, and Malignant Neoplasm of Unspecified Ovary.
Review of Resident #1's Quarterly MDS with an ARD of 08/23/2024, revealed she had a BIMS score of 5 (indicating severe cognitive impairment). The MDS revealed Resident #1 required substantial/maximal assistance with oral hygiene, bathing, dressing and personal hygiene; and dependent for toileting hygiene. Partial/moderate assistance with eating. Resident #1's MDS coded for with no behaviors.
Review of Resident #1's care plan revealed she required assistance with personal hygiene, eating, grooming/dressing, and bathing as needed.
Observation and interview on 10/17/2024 at 10:20 a.m. revealed Resident #1noted to have long chin hair approximately half an inch long. S2 CNA revealed she had just bathed Resident #1, and had not offered to remove Resident #1's facial hair. S3 LPN entered the room and confirmed Resident #1 had long chin hair approximately half an inch long.
2. Review of Resident #1's current physician's orders read in part .Ice Cream one time a day for weight loss, administer with lunch tray.
Telephone interview on 10/21/2024 at 8:21 a.m. with Resident #1's Responsible Party, revealed Resident #1 did not like ice cream.
Observation on 10/21/2024 at 11:33 a.m. revealed, Resident #1 had two bowls of ice cream with her lunch tray.
Interview on 10/21/2024 at 1:05 p.m. with S2 CNA revealed Resident #1 did not eat the ice cream at lunch time, and that Resident #1 didn't like ice cream.
Interview on 10/21/2024 at 2:25 p.m. with S4 RN Clinical Coordinator revealed, she was aware of Resident #1's dislike of dairy products.
Interview on 10/21/2024 at 2:53 p.m. with S1 DON revealed, she was aware of Resident #1's dislike of dairy products, but continued to serve different flavors to Resident #1 due to the Registered Dietician's recommendation to give ice cream with lunch tray.
Telephone Interview on 10/21/2024 at 3:23 p.m. with S5 Registered Dietician revealed she was not aware of Resident #1's dislike of ice cream. S5 Registered Dietician revealed ice cream was not listed on Resident #1's diet order details.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all Residents who were unable to carry out...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all Residents who were unable to carry out ADLs (Activities of Daily Living) received necessary services to maintain good grooming and personal hygiene. The facility failed to provide trimmed nails and oral care to dependent Residents for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents.
Findings:
Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting with a revision date of 03/2018 revealed in part .
Policy Statement
Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
Residents who are unable to carry out Activities of Daily Living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus, Pressure Ulcer of Sacral Region Stage 3, Chronic Kidney Disease Unspecified, Dysphagia following Cerebral Infarction, Malignant Neoplasm of Unspecified Ovary and Aphasia following Cerebral Infarction.
Review of Resident #1's Quarterly MDS with an ARD of 08/23/2024 revealed she had a BIMS score of 5 (indicating severe cognitive impairment). The MDS revealed Resident #1 required substantial/maximal assistance with oral hygiene, bathing, dressing and personal hygiene; and dependent for toileting hygiene. Resident #1's MDS coded with no behaviors.
Review of Resident #1's care plan revealed she required assistance with personal hygiene, grooming/dressing, and bathing as needed with approaches that included assist me with bed mobility, toileting, eating, personal hygiene, grooming/dressing, and bathing as needed.
Observation and interview on 10/17/2024 at 10:20 a.m. revealed Resident #1 lying in bed fully dressed. Resident #1 noted to have a dried brown substance around her mouth and fingernails approximately one inch long. S2 CNA revealed she had just bathed Resident #1. S2 CNA revealed the dried brown substance around Resident #1's might have been food. S3 LPN entered room and confirmed Resident #1 had a dried brown substance around her mouth and fingernails were long. S3 LPN asked Resident #1 if she would like her nails cleaned and trimmed and Resident #1 shook her head yes.
Telephone interview on 10/21/2024 at 8:21 a.m. with Resident #1's Responsible Party revealed the facility had not notified her of Resident #1 ever refusing nail care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure that a Resident maintains acceptable parameters of nutritiona...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure that a Resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable weight range for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents.
Findings:
Review of the Facility policy titled: Weight Assessment and Intervention, with a revision date of 03/2022 revealed in part .
Policy Statement:
Resident weights are monitored for undesirable or unintended weight loss or gain.
Policy Interpretation and Implementation:
Weight Assessment
1. Residents are weighed upon admission and readmission to the facility, as well as weekly x 4 after admission and readmission.
5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria:
A. 1 month - 5% weight loss is significant; greater than 5% is severe.
B. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe.
C. 6 months - 10% weight loss is significant; greater than 10% is severe.
Review of the Weight Assessment and Intervention policy revealed there were no additional instructions for obtaining weights after instructions listed in #1 above.
Resident #1
Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Anorexia, Type 2 Diabetes Mellitus, Pressure Ulcer of Sacral Region Stage 3, Chronic Kidney Disease Unspecified, Dysphagia following Cerebral Infarction, Malignant Neoplasm of Unspecified Ovary, and Aphasia following Cerebral Infarction.
Review of Resident #1's Quarterly MDS, with an ARD of 08/23/2024, revealed she had a BIMS score of 5 (indicating severe cognitive impairment). The MDS revealed Resident #1 required partial/moderate assistance with eating.
Review of Resident #1's care plan (with no review date listed), revealed in part . I am at risk for a nutritional problem related to diagnoses: Anorexia, Dysphagia, and Diabetes, and poor appetite at times. Approaches included: Monitor/record/report to MD PRN if exhibit signs and symptoms of significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months.
Review of Resident #1's weights revealed the following:
08/19/2024 = 131.5 pounds (return from the hospital on [DATE]).
09/05/2024 = 125 pounds (6.5 pound/4.9% weight loss in 2 weeks).
Review of Resident #1's medical record revealed Resident #1 was not weighed upon readmission to the facility from a hospital stay, and was not weighed weekly times four upon readmission to the facility on [DATE], as directed in the Facility's Weight Assessment and Intervention Policy.
Review of the Registered Dietician's Progress Note dated 09/05/2024, revealed in part . Ensure clear 4 ounces BID added on this date.
Interview on 10/21/2024 at 2:41 p.m. with S1 DON, revealed the facility's procedure was to weigh all new admissions and readmissions within 24 hours of returning to the facility; record the weight, and then weigh weekly for four weeks. S1 DON confirmed Resident #1 should have been weighed on 08/17/2024 or 08/18/2024 (within 24 hours of returning from the hospital), and was not weighed until 08/19/024. S1 DON confirmed Resident #1's weight on 08/19/2024 was 131.5 pounds, and that she was not weighed again until 09/05/2024. S1 DON stated Resident #1's weight was 125 pounds, a 6.5 pound and 4.9% weight loss in 16 days. S1 DON confirmed Resident #1 was not weighed weekly when she returned from the hospital.
Resident #3
Review of Resident #3's medical record revealed he was admitted to the facility on [DATE], with diagnoses which included: Heart Failure, Hypertension, Anemia, Major Depressive Disorder, Unspecified Atrial Fibrillation, Chronic Kidney Disease Stage 3, Hyperlipidemia, and Transient Cerebral Ischemic Attack Unspecified.
Review of Resident #3's admission MDS with an ARD of 09/04/2024, revealed a BIMS score of 11 (indicating moderate cognitive impairment). The MDS revealed Resident #3 required setup or clean-up assistance with eating.
Review of Resident #3's care plan (with no review date listed), revealed in part .I have a potential for a nutritional problem related to poor appetite at times with approaches that included: Monitor/record/report to MD PRN if exhibit signs and symptoms of significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months.
Review of Resident #3's weights revealed the following:
08/23/2024 = 148.8 pounds (admission weight)
09/05/2024 = 145 pounds
10/11/2024 = 136.2 pounds
Review of the Registered Dietician's Progress Note dated 10/11/2024 read in part .Trigger for significant weight loss noted. Current weight 136.2 pounds (10/11/2024) 8.8 pounds weight loss in the past month. House supplement 4 ounces once daily added on this date. Recommend add double desserts to meals.
Interview on 10/21/2024 at 2:41 p.m. with S1 DON, confirmed Resident #3's weight on 09/04/2024 was 145 pounds, and he was not weighed again until 10/11/2024. Resident #3's weight on 10/11/2024 was 136.2 pounds, a 8.8 pound and 5.9% weight loss in 36 days. S1 DON revealed the facility's procedure was to weigh all new admissions and readmissions within 24 hours of returning to the facility; record the weight, and then weigh weekly times four weeks. S1 DON confirmed Resident #3 had not been weighed weekly for four weeks, but should have been.
Jul 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of h...
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Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to wait until all residents eating at a table were finished with their meal before picking up trays. Total sample size was 26.
Findings:
Observation of X Hall dining room on 07/09/2024 at 11:43 a.m. revealed S7 CNA removing plates from the dining table, while other residents at the same dining table were still eating.
Interview on 07/09/2024 at 11:45 a.m. with S7 CNA revealed she did not know she should wait until all residents at the dining table were finished eating before removing their plates.
Interview on 07/09/2024 at 11:50 a.m. with S10 LPN confirmed S7 CNA should have waited until all residents at the dining table were finished eating, before removing any plates from the table.
Interview on 07/10/2024 at 1:40 p.m. with Resident #57 who had a BIMS score of 14 (indicating intact cognition), revealed on yesterday (07/09/2024) when S7 CNA started removing plates from the dining table while she was still eating, it made her feel rushed to finish eating.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a personal funds statement was provided quarterly for 1(#24)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a personal funds statement was provided quarterly for 1(#24) of 1 resident reviewed for personal funds.
Findings:
Review of an undated facility policy titled Resident Trust Fund Policy/Procedure Manuel read in part: .Quarterly Statements. The facility provides a written statement quarterly to each resident or authorized representative within 30 days after the end of the quarter. A copy is also filed in the resident's trust fund folder. The quarterly statement includes the following: balance at the beginning of the statement period, total deposits and withdrawals, interest earned, if any, and ending balance. A Resident Trust Fund Quarterly Statement Distribution Form should be signed and dated by the Administrator and two witnesses indicating that the quarterly accounting statements have been distributed and the completed form is to be kept in the Administrative office with the trust fund records .
Review of Resident #24's Medical Record revealed she was admitted to the facility on [DATE], with a primary diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation.
Review of Resident #24's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/17/2024 revealed Resident #24 had a BIMS (Brief Interview for Mental Status) of 10 (moderately impaired cognition).
Interview with Resident #24 on 07/09/2024 at 9:21 a.m. revealed the facility managed her money. Resident #24 stated she was admitted to the facility approximately 6 months ago and had not received a quarterly account statement.
Interview with S2 Administrative Assistant, on 07/09/2024 at 10:30 a.m. revealed she was responsible for sending out quarterly account statements. S2 Administrative Assistant indicated that she mailed the statements out to the resident's responsible party quarterly. S2 Administrative Assistant stated for residents that were their own RP, she provided account balances when resident's came to request money. S2 Administrative Assistant indicated she did not have a system for residents that were their own responsible party, to receive quarterly statements. S2 Administrative Assistant indicated that Resident #24 had withdrawn money on 04/21/2024, 04/23/2024 and 04/24/2024, and thinks she would have given Resident #24 an account balance then, but could not confirm Resident #24 received a quarterly statement.
Interview with S1 Administrator, on 07/09/2024 at 4:20 p.m. revealed he signed the Trust Fund Quarterly Statement Distribution Form. S1 Administrator indicated that his signature was acknowledgment he received the statements from cooperate office, but not a verification that the quarterly statements were distributed to residents. S1 Administrator indicated that he had spoken to Resident #24 and verified she did want to receive her statements quarterly. S1 Administrator stated he did not have documentation that Resident #24 received her quarterly statement, but should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure resident equipment, a Pommel cushion, was in good repair for 1 (#49) of 4 (#23, #43, #49 and #85) residents reviewed for...
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Based on observation, interview and record review the facility failed to ensure resident equipment, a Pommel cushion, was in good repair for 1 (#49) of 4 (#23, #43, #49 and #85) residents reviewed for environment.
Findings:
Review of the facility's policy Assistive Devices and Equipment with Revision date January 2020 revealed . c. Device condition- devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired .
Review of the Resident #49's MDS with ARD of 05/21/2024, revealed Resident #49 had a BIMS of 12 which indicated moderate cognitive impairment.
Review of Resident #49's current Care Plan revealed .Pommel cushion applied to my wheelchair to aid in the prevention of me slipping out of chair . with start date 09/10/2019.
Observation on 07/08/2024 at 10:21 a.m. revealed Resident #49 was seated in his wheelchair with Pommel cushion in place. Resident #49's Pommel cushion had a 3 inch tear along the seam with the inner foam exposed.
Observation on 07/09/2024 at 8:43 a.m. revealed Resident #49 was seated in his wheelchair with Pommel cushion in place. Resident #49's Pommel cushion had a 3 inch tear along the seam with the inner foam exposed. Resident #49 stated It's been like that for 2 ½ to 3 weeks.
Interview on 07/09/2024 at 1:00 p.m. with S4 LPN revealed she was responsible for overseeing the care of Resident #49. S4 LPN stated Resident #49's pommel cushion should be inspected and cleaned every day, and replaced if in disrepair. S4 LPN indicated Resident #49's Pommel cushion should have been replaced.
CONCERN
(D)
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 observation, interview and record review the facility failed to ensure that residents received treatment and care in ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #26, and Resident #46) of 26 sampled Residents. Findings:
Resident #26
Review of Resident #26's medical record revealed an admit date of 08/17/2021. Resident #26 had the following diagnoses in part . Primary Osteoarthritis of Right Shoulder, Retention of Urine, Urinary Tract Infection, Constipation, Paroxysmal Atrial Fibrillation, and Generalized Anxiety Disorder.
Review of Resident #26's Quarterly MDS with an ARD of 05/22/2024 revealed Resident #26 had a BIMS of 15 (Cognition Intact). Resident #26 was dependent on staff for toileting.
Review of Resident #26's Comprehensive Person Centered Care Plan with a target completion date of 07/16/2024 revealed the following in part . I have constipation. I have occasional diarrhea. Interventions included the following in part . Record my bowel movement pattern each day. Describe amount, color and consistency.
Review of Resident #26's medical record revealed she was hospitalized [DATE]- 05/16/2024 with a diagnosis of Fecal Impaction.
Review of Resident #26's 05/2024 Bowel and Bladder Elimination Record revealed 14 out of 40 documented bowel movements did not have size and consistency documented.
Interview on 07/08/2024 at 9:26 a.m. with Resident #26 revealed she had been recently hospitalized . Resident #26 stated she had stomach issues, and I had to get my belly cleaned out at the hospital.
Interview on 07/09/2024 at 2:50 p.m. with S5 DON confirmed CNA's are required to document Bowel Continence, Size, and Consistency of bowel movements on resident's Bowel and Bladder Elimination Record. Review of Resident #26's 05/2024 Bowel and Bladder Elimination record with S5 DON revealed Resident #26's 05/2024 Bowel and Bladder Elimination record did not have documentation to include bowel size and consistency, and it should have been.
Interview on 07/10/2024 at 9:59 a.m. with S11 LPN revealed Resident #26 had a history of constipation and diarrhea. S11 LPN stated she sent Resident#26 to the hospital on [DATE] due to the resident vomiting, and not feeling well. S11 LPN stated Resident#26 denied constipation on 05/13/2024, and stated Resident #26 was good about letting staff know if she did not have a bowel movement. Review of Resident #26's 05/2024 Bowel and Bladder Elimination report with S11 LPN. S11 LPN stated Resident #26 had bowel movements on 05/09/2024, and 05/11/2024, but the size and consistency were not documented. S11 LPN confirmed CNA's should document bowel movement size and consistency on the record when documenting bowel movements, but had not.
Interview on 07/10/2024 at 2:16 p.m. with S12 CNA revealed she was required to document bowel movement continence, size, and consistency on the Bowel and Bladder Elimination Report, and had failed to do so.
Resident #46
Review of the facility's policy dated 2017 titled Medication and Treatment Orders read in part: Policy Statement - Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation - Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.
Review of Resident #46's EHR revealed an admit date of 08/03/2023 with the following diagnoses including: Acute Respiratory Failure and CHF.
Review of Resident #46's 07/2024 MD Orders revealed the following including:
08//23/2023 - DNR
04/30/2024 - Admit to All Saints Hospice: Dx: CHF
05/10/2024 - Feeder and assist per staff with all meals
06/17/2024 - MS 100 mg/5 ml Concentrate - give 0.5 ml SL every 2 hours prn pain/air hunger
06/20/2024 - crush medications every shift
06/26/2024 - Lorazepam Oral Concentrate 2 mg/ml Give 0.5 ml sublingually every 4 hours as needed for Anxiety for 14 Days
07/02/2024 - Tramadol HCL 50 mg q 8 hours prn
Review of Resident #46's 04/30/2024 - 07/09/2024 Nurse Notes revealed Resident #46 was admitted to hospice on 04/30/2024. On 07/08/2024 there was documentation that stated the MD visited today with new orders to hold medication due to Resident #46 not swallowing; RP notified.
Review of Resident #46's 07/2024 e-MAR revealed the Resident #46 had not been given any po medications since 07/08/2024.
Review of Resident #46's facility chart revealed no MD order concerning holding medications.
Interview on 07/09/2024 at 1:22 p.m. with S6 LPN revealed Resident #46's physician made rounds yesterday (07/08/2024) and gave a verbal order to hold po medications due to Resident #46 having problems swallowing. S6 LPN stated she did not write an order for the verbal order given by Resident #46's physician and she should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to keep all information in the Medical Record confidential for 4 (Resident #92, Resident #74, Resident #57 and Resident #58) 6 residents receivin...
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Based on observation and interview the facility failed to keep all information in the Medical Record confidential for 4 (Resident #92, Resident #74, Resident #57 and Resident #58) 6 residents receiving Dialysis outside of the facility. Total sample size was 26. Findings:
Observation on 07/09/2024 at 4:05 p.m. of the facility's front desk revealed a sheet attached to a clip board, which contained 4 Residents full name and the times they needed to be at Dialysis. The list was visible to the public. Visitors were observed at the front desk several times throughout the survey process.
The sheet read in part .
Dialysis Schedule:
Monday, Wednesdays and Friday
Resident #92-chair time 6:15 a.m.
Resident #74-chair time 11:20 p.m.
Tuesdays, Thursdays and Saturdays
Resident #57-chair time 5:50 a.m.
Resident #58-chair time 11:30 a.m.
Interview on 07/09/2024 at 4:05 p.m. with S5 DON confirmed the list with resident's full names and Dialysis times were visible to visitors, and it should not have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents obtained routine dental services for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents obtained routine dental services for 1 (Resident #89) of 2 (Resident #89 and Resident #98) sampled residents for dental. Total sample size was 26. Findings:
The Facility's Policy Titled Dental Examination/Assessment with a Revision date of December 2013, read in part .
Policy statement:
Each resident shall undergo a dental assessment prior to or within 90 days of admission.
Policy Interpretation and Implementation:
1. Resident shall be offered dental services as needed.
Review of Resident #89's clinical record revealed an admit date of 03/09/2023 with diagnoses which included in part: Type 1 Diabetes Mellitus, Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side.
Review of Resident #89's Quarterly MDS with an ARD of 05/29/2024 revealed a BIMS score of 14 indicating intact cognition. Resident #89 required setup or clean-up assistance with meals and oral hygiene.
Review of Resident #89's care plan with a target date of 08/08/2024 read in part .I am at risk for oral/dental health problems related to poor oral hygiene with approaches that included arrangements coordinated for dental care, transportation as needed.
Observation and interview on 07/08/2024 at 10:47 a.m. revealed Resident #89 was edentulous. Resident #89 stated he was [AGE] years old and had not seen the dentist since he was admitted to the facility. Resident #89 stated he would like to be seen by the dentist for dentures.
Review of Resident #89's Dental progress notes revealed Resident #89 had scheduled dental appointments on 03/09/2024 and the appointment was rescheduled, for 09/07/2023 with no documented reason of why. On 09/07/2023, Resident #89 was not seen by the Dentist as the dental progress notes read in part . 09/07/2023 patiently currently in patient care. Will reschedule.
Review of Resident #89's Dental Visit Notification Forms revealed the following:
09/07/2024- Therapy Conflict (Resident #89 was in therapy).
10/25/2024-Time conflict (Dentist ran out of time before Resident #89 could be seen).
01/26/2024-Resident #89 not seen due to scheduling (Dentist ran out of time).
Interview on 07/09/2024 at 1:47 p.m. with Resident #89 revealed he had spoken to the staff (unable to recall the date and/or staff) requesting to see the dentist and as of today, he was still waiting on a reply and/or on an appointment.
Interview on 07/09/2024 at 1:50 p.m. with S9 RN confirmed after reviewing Resident #89's dental progress notes that Resident #89 had not been seen by a dentist since admission and should have been.
Interview on 07/09/2024 at 1:55 p.m. with S8 Social Worker revealed she was uncertain as to why Resident #89's appointments had been rescheduled and he had not been seen by a Dentist before now. After reviewing Resident #89's Dental Visit Notification Forms, S8 Social Worker confirmed Resident #89 should have been seen by the Dentist.
Interview on 07/09/2024 at 3:00 p.m. with S5 DON confirmed that Resident #89 had been scheduled but was not seen and/or had a Dental assessment within 90 days of his admission to the facility and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings:
Review of the facility'...
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Based on observation and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings:
Review of the facility's policy dated 09/2004 titled Food Service Operational Standards for Purchasing, Cooking and Storage read in part: Policy: The facility stores, prepares, distributes and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety.
Procedure: 8. Cooling and storing - g. Label and store foods with the date and time they were prepared to indicate when to discard.
Review of the facility's policy dated 09/2004 titled Storage of Cooked Foods read in part: Procedure: 5. Discard food that has exceeded maximum storage time. j. Gravy - Discard.
Review of the facility's policy dated 10/2017 titled Food Receiving and Storage read in part: Policy Statement - Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation - 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (received and/or open date).
Observation on 07/08/2024 at 8:55 a.m. of the facility kitchen with S3 Dietary Manager revealed the following expired items noted in the pantry and in the reach in refrigerator:
Plate Scraper - 2 cans - expired 11/22/2023
Tomato Paste 12 ounce cans - 20 cans - expired 12/25/2023 and 02/05/2024
Potato Salad - 1 gallon - expired 05/31/2024
Garlic in Water - 2 jars - expired 06/03/2024
1 unlabeled, undated pitcher of prepared brown gravy
Interview on 07/08/2024 at 9:45 a.m. with S3 Dietary Manager confirmed the above findings. S3 Dietary Manager stated the items should have been disposed and were not.
Feb 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable phys...
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Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. The facility failed to ensure a comprehensive care plan was developed for a resident diagnosed with Chronic Diastolic (CHF) Congestive Heart Failure who required fluid restriction and to be weighed every 3 days. Findings:
Review of Resident #1's electronic Medical Record revealed an admission date of 10/25/2023 with diagnoses that included: Acute Renal Failure with Hypoxia, Essential Primary Hypertension, Hypo-osmality and Hyponatremia, Type 2 DM, Morbid Obesity due to Excess Calories, Hypotension, Chronic Diastolic Congestive Heart Failure and Chronic COPD with Acute Exacerbation.
Review of Resident #1's Physician's Orders for 11/2023 and 12/2023 revealed in part . 10/26/2023 - Fluid restriction 1500ml TID 10/26/2023 - Weigh every 3 days in the morning for monitoring related to Chronic Diastolic CHF.
Review of Resident #1's admission MDS with an ARD of 10/30/2023 revealed a BIMS score of 12 (moderately impaired cognition).
Review of Resident #1's Care Plan revealed no care plan developed for Fluid restrictions related to diagnosis of Chronic Diastolic Congestive Heart Failure.
Interview on 02/07/2024 at 4:45 p.m. with S3 MDS RN revealed she was responsible for resident care plans. She stated she had not developed a care plan for Resident #1's fluid restrictions and weights every 3 days related to her diagnosis of Chronic CHF and should have.
Interview on 02/08/2024 at 11:15 a.m. with S2 ADON revealed S3 MDS RN was responsible for Resident #1's care plan. S2 ADON confirmed Resident #1 was not care planned for 1500ml fluid restrictions and weight every 3 days related to her diagnosis of Chronic CHF and should have been.
Interview on 02/08/2024 at 12:20 p.m. with S1 DON confirmed that Resident #1 did not have a comprehensive care plan in place to ensure 1500ml restricted fluids daily that required her to be weighed every 3 days related to her diagnosis of Chronic CHF and should have.
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
Based on interview and record revealed the facility failed to provide care and services that meet professional standards of practice and quality care for 1 (Resident #1) of 2 (Resident #1 and Resident...
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Based on interview and record revealed the facility failed to provide care and services that meet professional standards of practice and quality care for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents reviewed for hydration. The facility failed to ensure a resident diagnosed with Chronic Diastolic Congestive Heart Failure (CHF) with restricted fluids was weighed every 3 days as ordered. Findings:
Review of the facility's policy titled, Heart Failure - Clinical Protocol read in part . Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with a history of heart failure (HF) and will clarify, as much as possible, its severity and underlying causes. Treatment/ Management: 1.The physician will review and make recommendations for relevant aspects of the nursing care plan, for example, what symptoms to expect, how often and what (weights, renal function, etc.) to monitor, when to report findings to the physician, etc.
Review of Resident #1's electronic Medical Record revealed an admission date of 10/25/2023 with diagnoses that included: Acute Renal Failure with Hypoxia, Essential Primary Hypertension, Hypo-osmality and Hyponatremia, Type 2 DM, Morbid Obesity due to Excess Calories, Hypotension, Chronic Diastolic Congestive Heart Failure and Chronic COPD with Acute Exacerbation.
Review of Resident #1's Physician's Orders for 11/2023 and 12/2023 revealed in part . 10/26/2023 - Fluid restriction 1500ml TID 10/26/2023 - Weigh every 3 days in the morning for monitoring related to Chronic Diastolic CHF.
Review of Resident #1's admission MDS with an ARD of 10/30/2023 revealed a BIMS score of 12 (moderately impaired cognition).
Review of Resident #1's Care Plan revealed no care plan developed for Fluid restrictions related to diagnosis of Chronic Diastolic Congestive Heart Failure.
Review of Resident #1's MARs for 11/2023 and 12/2023 revealed no documentation of weights on: 11/30/2023, 12/15/2023, 12/18/2023, 12/21/2023 and 12/24/2023.
Interview on 02/08/2024 at 4:30 p.m. with S2 ADON confirmed the above findings. S2 ADON confirmed Resident #1 was on 1500ml fluid restrictions and required to be weighed every 3 days related to her diagnosis of Chronic Diastolic CHF and was not.
Interview on 02/08/2024 at 4:50 p.m. with S1 DON confirmed that Resident #1 had Physician's orders for 1500ml fluid restriction that required her to be weighed every 3 days and was not done as ordered.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure Resident #3's RP was informed of changes in the resident's condition for 1 (Resident #3) of 3 (Resident #1, Resident #2 and Resident ...
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Based on interview and record review the facility failed to ensure Resident #3's RP was informed of changes in the resident's condition for 1 (Resident #3) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings:
Review of the facility policy titled: Change in Resident's Condition or Status, revealed in part .Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the residents medical/mental condition and/or status.
Review of Resident #3's clinical record revealed an admission date of 04/22/2023, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for orthopedic aftercare following surgical amputation, encounter for attention to gastrostomy and pressure ulcer.
Review of Resident #3's quarterly MDS assessment with ARD 08/01/2023 revealed a BIMS score of 12, indicating mild cognitive impairment. Review also revealed Resident #3 was incontinent of bowels of bladder and required assistance with toileting, personal hygiene, bed mobility and transfers.
Telephone interview on 10/26/2023 with Resident #3's RP revealed that while performing incontinent care on Resident #3, while out on pass, she noticed a severe rash to Resident #3's buttocks, groin, thighs and under her breast. Resident #3's RP stated she had been given a tube of cream and a small container of powder when she picked up her mother but had no idea Resident #3's skin was in such a terrible state.
Review of Resident #3's September Physician's Orders revealed in part .Nystatin Powder (Nystatin bulk) Apply to lower abdominal fold and groin topically two times a day for fungal infection until 09/18/2023. Start date 09/04/2023.
Review of a nurses' noted dated 09/03/2023 and documented by S2 LPN revealed in part .Resident c/o itching to left groin area and lower abdominal folds. Fungi, redness and swelling noted to areas. FNP notified of findings. New order for Nystatin BID x 14 days. No c/o pain. Remains afebrile. Call light in reach. Bed in low position.
Telephone interview on 10/30/2023 at 10:24 a.m. with S2 LPN revealed she did not remember if she notified Resident #3's family about the fungal rash and new treatment orders on 09/03/2023. S2 LPN stated she normally documents who she calls and their relationship to the resident when she calls a family member about a resident and she had not done so on 09/03/2023 for Resident #3 and should have.
Interview on 10/30/2023 at 12:15 p.m. with S1 DON revealed there was no evidence that Resident #3's RP had been notified of her skin impairment and new orders for fungal treatment on 09/03/2023. S1 DON confirmed Resident #3's RP should have been notified and had not been.
Sept 2023
4 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to supervise Resident # 1, identified as a high elopement risk, to pre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to supervise Resident # 1, identified as a high elopement risk, to prevent elopement on [DATE] and [DATE], and the facility failed to adequately supervise Resident #3, identified as a high fall risk to prevent an accident that resulted in a major injury, for 2 of 11 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident#5, #R1, #R2, #R3, #R4, #R5, and #R6).
I. Elopement
This deficient practice resulted in an immediate jeopardy situation on [DATE] at 6:06 p.m. when Resident #1, a cognitively impaired resident who was at risk for elopement and wore a wander guard bracelet, exited the facility unsupervised, and was found approximately 700 feet from the front door of the facility near a free-standing physical therapy center. The immediate jeopardy continued for Resident #1 when she exited the facility again on [DATE] and was discovered outside the facility unsupervised approximately 300 feet away from a side exit door. Resident #1 was discharged on [DATE].
This deficient practice continued at a potential for more than minimal harm for the remaining 10 residents (Resident #2, Resident #3, Resident #4, Resident #5, #R1, #R2, #R3, #R4, #R5, and #R6) identified as elopement risks, and wore wander guard devices.
S1 Administrator was notified of the Immediate Jeopardy on [DATE] at 5:50 p.m.
The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following:
On [DATE] and [DATE] Resident #1 was able to exit the facility unsupervised while wearing a wander guard bracelet. These incidents have the potential to affect all 10 residents who are at risk for elopement and have been identified with wandering and/or exit seeking behaviors. On [DATE] surveyors identified two malfunctioning exit doors. Supervision for at risk residents had not been increased, therefore the potential for elopement remained for the 10 residents with elopement risk.
MD/NP and Responsible Party were both notified in a timely manner after each elopement incident.
Residents #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5, and #R6 who were specifically identified to be affected, related to risk for elopement had adequate supervision provided every hour by assigned floor nurses and CNAs to assess for exiting seeking behaviors starting [DATE], so that the staff can account for residents at risk. Residents at risk will be monitored every hour for 2 weeks, then reassessed for the need for continued hourly monitored by Administrator or designee. If no exit seeking behavior is exhibited, resume every 2 hour monitoring.
Care plans for residents at risk for elopement updated [DATE] to reflect frequency of monitoring for adequate supervision.
Facility conducted a Root Cause Analysis on [DATE] to identify failure for F689.
Review of the elopement policy and procedure conducted on [DATE] with no changes needed.
Review of the Secure Care Guardian U-DE owner's manual, of exit door locking mechanisms, conducted on [DATE] with no change needed, developed and implemented a monitoring tool to check all exit doors every shift for 7 days, then every day for 7 days, then weekly thereafter by administrator or designee with Regional Director of Operations supervision daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month.
Education of all staff began immediately on [DATE] to include wandering and elopement policy and procedures, location of elopement binders, including Face Sheet of identified residents at risk for elopement and photo, and Code W procedures completed by DON. Binders are located at incident command center (front desk) and 1 in each neighborhood, totaling 4 in the facility. Administrator or designee will continue in-servicing employees prior to the beginning of shift for conformance with wandering and elopement. Completion date of [DATE].
In reference to above, the Administrator or designee will administer post training evaluation of staff on wandering and elopement policy and procedures and location of elopement binder to be completed before employee begins shift for conformance with wandering and elopement.
Quality Assurance Committee met [DATE] and will monitor for elopement risk to prevent the likelihood of serious harm or death weekly for 8 weeks.
Administrator in-serviced on elopement policy and procedure by Regional Director of Operations and DON in-serviced by Corporate Nurse on [DATE]. Administrator will be supervised on facility compliance by Regional Director of Operations daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month.
Requested and received approval on [DATE] to install a [NAME] mag lock system to the C Hall access door to the exit, plans will be submitted to the fire marshal's office for approval of installation.
Completion date: [DATE].
Findings:
Review of the facility's Wandering and Elopement Assessment/Management/ Security policy dated [DATE] read as follows in part .
Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration, and/or other medical complications, drowning, or being struck by a car.
Interventions which address/prevent unsafe wandering/elopement will be developed within the resident care plan for at risk residents. (i.e., supervision/periodic checks, activity programs, exit door alarms, highlight name on census report at nurses' station, Personal signal device, etc.).
In facilities with electronic wander alarm systems, residents assessed to be at risk for unsafe wandering may be placed on the Resident Security System as a measure to reduce the risk of harm from unsafe wandering activities.
There was no facility policy that addressed the supervision of residents who wandered and/or who wore wander guard devices and were identified at risk for elopement.
Resident #1
Review of Resident #1's Face Sheet revealed an admission date of [DATE]. Diagnosis included: Alzheimer's disease, Major Depressive D/O, Anxiety D/O, and HTN.
Review of Client #1's Risk of Elopement Wandering assessments dated [DATE], [DATE], and [DATE], indicated the resident was a high risk with scores that ranged from 14-19.
Review of Resident #1's Quarterly MDS with an ARD of [DATE], revealed Resident #1 had a BIMS of 10 (moderate cognitive impairment). Resident #1 required supervision with bed mobility, transfers, walk in room/corridor, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #1 ambulated with use of a walker, and used Wander/elopement alarm daily.
Review of Resident #1's Care Plan with target date of [DATE] revealed in part:
An elopement risk/wanderer r/t disoriented to place and verbally saying I'm going home, how I get there? The Care Plan indicated the resident had a Dx. Of Dementia, attempted to open doors at times and that the resident wore a wander guard to left ankle at all times. The Care Plan did not include supervision measures staff were to follow. After the [DATE] elopement, the care plan was updated on [DATE] to reflect the addition of a wind chime to the resident's walker to alert staff when resident is ambulating and on [DATE] to reflect the addition of a wander guard to the resident's walker as an extra security measure due to continued exit seeking behaviors.
There was no Care Plan intervention for the level of supervision required for Resident # 1, or staff training/inservice of the need for increased supervision except for 1:1 supervision for a brief period of time after each elopement.
Review of Resident #1's 2023 Physician's Orders revealed in part:
[DATE], [DATE] and [DATE] - Wander Guard to right ankle-verify placement, inspect skin at band location, and confirm signal operation every shift;
Review of Resident #1's Progress Notes revealed in part:
[DATE] at 10:42 a.m. - Resident continues to stop staff and random visitors at this time asking which way she could exit facility because she needs to go home. Unable to redirect at this time.
[DATE] at 6:02 a.m. - Resident awake and wandering around attempting to exit facility and entering other residents' rooms. Redirected with limited success.
[DATE] at 6:25 p.m. - CNA indicated she did not see resident on the hall. It was confirmed her wander guard was observed intact and working earlier in the shift. CNA stated the resident ambulated in the building to front entrance and other halls. CNA stated she heard a car horn and she went toward the front entrance. Approximately 2-3 minutes later a pager alert went off for the main entrance/front door. Resident #1 was observed ambulating with her walker through front entrance accompanied by 2 CNAs. One of the CNAs saw the resident walking on the driveway, recognized her as a frequent wanderer, and asked the resident to accompany her back inside the facility. No injuries, guard intact.
[DATE] at 9:01 p.m. - LATE ENTRY - one on one observation of resident implemented. Security cameras were viewed to determine how resident left the building. Maintenance department came to facility to determine how resident was able to leave the facility with wander guard in place, and found that the front door was not reset correctly following fire alarm earlier that day. All staff were notified of protocol per DON. RP/MD were notified.
[DATE] at 3:07 p.m. - Resident #1 standing at the door crying saying she needs to get out to go take care of her mom. CNA redirected resident to chair in dining room. Resident #1 states, You people are crazy! First chance I get I'm going to save my mom.
[DATE] at 4:01 p.m. - Resident #1 constantly ambulating asking for someone to open the door. States, I gotta go home, my momma and daddy are waiting on me. Resident redirected.
[DATE] at 3:40 p.m. - LPN spoke with Resident #1's RP, concerning statements of wanting to go home and her saying how she has to get out of here. NP made aware of orders to refer to inpatient behavior unit due to high risk of elopement/safety. admitted to behavior hospital.
[DATE] at 1:50 p.m.-returned to facility from inpatient behavioral hospital
[DATE] at 5:59 p.m. - Resident #1 was hollering, cursing, and threatening to hit staff because she thought they had her car keys. Resident #1 also wanted to be let out. Resident #1 stated, If you don't give me my keys I am going to do something to you, I am not crazy, give me my f .king keys, and then she would bang her walker on the floor.
[DATE] at 12:40 p.m. - Resident up ambulating with walker back and forth between left and middle houses. States, I'm looking for the bus. Resident #1 continues to say she is, tired and needs to go home.
[DATE] at 2:56 p.m. - Resident #1 having bad anxiety. Walking up and down hall looking for someone and saying that we are not taking care of the other residents. Order received to administer Xanax 0.25 mg one time dose.
[DATE] at 7:30 p.m. - Resident #1 began wandering after visit from daughter. Stated she had to go home. Easily redirected.
[DATE] at 10:09 a.m. - Resident #1 wandering from middle house to left house. States, I'm looking for my daddy. Confusion noted. Unable to redirect. Wander guard in place and working properly.
[DATE] at 6:09 p.m. - Resident #1 ambulating all over the building, when nurse attempted to redirect resident back to her room she screamed, You just want to lock me up and kill me. Unable to redirect.
[DATE] at 10:45 a.m. - Resident #1 with increased agitation. Pacing back and forth to doors. States, I have to get to my daddy, he died. Consoled resident and redirected by distracting and offering a snack.
[DATE] at 12:45 p.m. - Fire alarm went off at this time. Staff voiced that Resident #1 pulled alarm in middle Hall f. Asked Resident #1 why she did that? Resident #1 stated, I wanted ya'll to come get me. Monitored on 1:1 until doors reset to maintain safety. Resident #1 voiced concerns of momma is going to be looking for me. Redirected by listening to music.
[DATE] at 4:30 a.m. - Resident #1 ambulating looking for bus. Redirected to room and got back up.
[DATE] at 10:43 a.m. - Resident #1 pacing back and forth from house to house looking for her little children.
[DATE] at 6:40 p.m. - Resident #1 ambulating toward front entrance. LPN attempted to redirect resident. Resident #1 became agitated and stated, I don't know what your problem is telling me what to do, but if it wasn't for me and your grandma your house would be a big pile of sh .t.
[DATE] at 10:45 a.m. - Resident #1 noted in and out of residents' rooms. Easily redirected back to hall.
[DATE] at 11:05 a.m. - Resident #1 ambulating towards the front entrance with bible in her hand and dragging walker. Attempted to redirect, Resident #1 screamed, you don't tell me what to do.
[DATE] at 3:20 p.m. - Resident #1 ambulating up and down hallway with walker. Stated, I have to go check on my momma, she's sick and the baby is running a fever with no meds.
[DATE] at 9:40 a.m. - Resident #1 ambulating up and down hallway with walker. Stated, I'm trying to get out of here to go check on my momma, she's sick. Redirected to her room.
[DATE] at 10:40 a.m. - Resident #1 ambulating back and forth to front door. Stated, I got to get out of here and go catch the bus, daddy is going to be mad if I miss it. Unable to redirect. Continues to pace.
[DATE] at 9:34 p.m. - Resident wandering in other resident rooms turning on their lights looking for her children. Unable to redirect.
[DATE] at 10:35 p.m. - Resident wandering around the house. Refused to put on pajamas. Trying to go home.
[DATE] at 9:55 p.m. - Resident #1 ambulating and going into other residents' rooms. Using racial slurs and combative towards staff.
[DATE] at 10:00 p.m. - Resident ambulated to Hall d looking for her children. Resident assisted back to hall f.
[DATE] at 11:18 p.m. - Resident continues to wander. Went into another resident's room several times. Stated she was going to call the police because another resident was trying to kill her. Resident continues to wander from hall to hall.
[DATE] at 6:42 p.m. - Resident in common area wandering, redirected often, wander guard in place.
[DATE] at 7:30 p.m. - A resident was sitting outside on the porch and noticed Resident #1 walking around the corner of the building, she knocked on the door to alert staff. CNA went outside immediately and went to resident and brought her safely inside. Assessed-no injuries. All residents were checked for safety and accountability. Maintenance called in to check all doors for proper functioning. All wander guards checked including Resident #1's, and were functioning correctly and located on residents as they should be. MD/RP notified. Resident #1 placed on 1:1 observation at all times.
[DATE] at 1:31 p.m., Resident #1 was discharged to another long term care facility.
Interview with S2 DON on [DATE] at 10:15 a.m. revealed she trained staff after each elopement. S2 DON handed the facility's Post elopement binder dated [DATE] to the surveyor. Documentation contained in the binder reflected staff were trained on the wander/elopement policy, abuse/neglect wanderguard system/alarms, the locking system, and barrel key placement. There was no documentation that addressed resident supervision.
Interview on [DATE] at 10:15 a.m. with S1 Administrator revealed after Resident eloped on [DATE], she reviewed the video footage and discovered the resident exited through the front door at 6:06 p.m. and was returned to the facility by staff at 6:16 p.m. S1 Administrator stated, S10 Former [NAME] Clerk reset the front door alarms after they kept going off on [DATE], and apparently did not turn the key to the proper position to keep it locked. She confirmed the wander guard/alarm system was the facility's elopement prevention system used for residents on elopement risk.
Interview on [DATE] at 2:15 p.m. with S12 CNA revealed she worked the 2:00 p.m. to 10:00 p.m. shift on [DATE] and saw Resident #1 wandering up and down the halls. S12 CNA stated around approximately 6:00 p.m. she sat down to do her charting, and after approximately 5 minutes she noticed Resident #1 had not returned to her assigned hall. S12 CNA stated she got up to look for Resident #1, and noticed the lights on the front door alarm panel were blinking. S12 CNA stated she ran back to her hall and alerted the nurse that Resident #1 was missing and then went outside to search for Resident #1. S12 CNA stated she noted an agency CNA was coming up the driveway with Resident #1 in her vehicle. S12 CNA stated she was told the Agency CNA picked up Resident #1 down the facility's driveway at a Physical Therapy office located near the facility.
Interview on [DATE] at 2:30 p.m. with S2 DON stated Resident #1 had a history of wandering in and out of rooms and being anxious. S2 DON confirmed there was no increased supervision for residents with exit seeking or elopement behaviors. S2 DON stated residents who wandered, had wander guard devices in place as a measure to prevent elopement and that all residents were monitored every 2 hours.
Interview on [DATE] at 3:36 p.m. with S16 CNA Coordinator revealed they viewed the video cameras on [DATE], and noted Resident #1 left the facility through one of the therapy department doors.
After Resident # 2's second elopement on [DATE], the Post elopement binder was updated. Review of the [DATE] revealed all staff were inserviced on maintaining pagers on them at all times, responding to alarms immediately, making rounds, and turning barrel key on doors. There was no inservice documentation and/or staff guidance regarding the supervision/monitoring of residents who wander and who were identified at high risk for elopement.
II. Accident - Fall Risk
This deficient practice resulted in an actual harm for Resident #3, a cognitively impaired resident, at high risk for falls, was left unsupervised in the dayroom/dining area of Hall f on [DATE] when the resident stood up and attempted to walk unassisted in full view of S5 CNA. S5 CNA failed to intervene and/or redirect Resident #3 who subsequently fell and sustained an acute burst compression fracture of L1.
Findings:
Review of Resident #3's clinical record revealed an admit date of [DATE], with diagnosis that included: Neuropathy, Insomnia, Major Depressive Disorder, Type II DM, Mood Disorder, and Primary Generalized Osteoarthritis.
Review of Resident #3's Quarterly MDS with an ARD date of [DATE] revealed in part:
BIMS 00 (severe cognitive impairment); Bed mobility, Transfer: extensive assistance/2 persons physical assist; Dressing: Limited assistance/1 person physical assist; Eating: extensive assistance/1 person physical assist; Toilet use: total dependence/2+ person physical assist; Personal hygiene: Limited assistance/1 person physical assist; Bathing: Physical help in part of bathing activity/1 person physical assist; ROM: Upper extremity 0. No impairment, Lower extremity 1. Impairment on one side; and Mobility devices: Wheelchair.
Review of Resident #3's Comprehensive Plan of Care revealed in part: the resident was a
high risk for falls r/t neuropathy. Fall dates, interventions, and staff education noted on the Plan of Care were:
[DATE] no injury: wander guard placed on left ankle and staff to accompany resident to go outside to prevent serious injury.
[DATE] no injury: staff informed and educated on resident decline in status and need for assistance by staff.
[DATE] fall hip fracture: staff to take resident on porch (well lit area) to smoke after hours
[DATE] fall no injury.
[DATE] burst compression fracture at L1: educate staff to offer assistance if they see resident standing.
Resident #3 was not care planned specifically for attempting to stand unassisted; however, on [DATE] staff were informed and educated on the resident's need for assistance by staff related to her high fall potential. There were no planned interventions to increase staff supervision of Resident # 3, who was noted to have severe cognitive impairment.
Review of nurses' notes revealed the following in part .
[DATE] at 3:50 p.m. - documented by S6 Agency LPN - Resident #3 attempted to get out of her wheelchair without assistance and walk to the counter in the main dining room when she lost her balance falling to the floor landing on her buttocks. This nurse was summoned to the main dining room by CNA. Resident #3 was laying on her back in front of the dining counter. When asked what she was trying to do she stated reaching for a snack. Head to toe assessment was done. Active ROM to upper extremities and lower extremities without difficulty. No complaints of pain at this time. Neuros were initiated at this time. CNA supervisor along with another CNA assisted the resident back to her wheelchair. No injuries present at this time. Notified PCP and RP. VS 93/58, 94, 17, 97.8 and 95% on room air. Will continue neuro checks.
[DATE] LPN S7 documented:
3:40 p.m. Resident #3 complains of increased pain r/t fall yesterday. FNP notified. New orders noted to obtain spinal x-ray per imaging. RP notified.
4:00 p.m. X-ray obtained at this time per imaging.
6:34 p.m. Received x-ray results. Impression: Spondylitic changes of the lumbar spine with degenerative changes worse at L5-S1. FNP notified. Phoned RP x 2, no answer.
7:20 p.m. RP returned call. Notified of x-ray results. Verbalized understanding.
8:30 p.m. Received a call from S2 DON, stating that Resident #3's RP is requesting Resident #3 be sent to the ER for evaluation. RP voices that she does not trust portable x-rays. Resident #3 asleep in bed at this time. No further complaints of pain since Ultram was administered. Phoned FNP and notified of the above. New order to send to ER for evaluation and treatment related to fall. Phoned for transfer. Phoned RP and notified of above, Called report to ER.
[DATE] 1:40 a.m. by S9 LPN - Received report per ER. ER staff stated Resident #3 had a lumbar CT done and was noted to have a burst compression fracture at L1. Follow-up with orthopedic. CT scan of head noted with no acute changes.
[DATE] 3:56 a.m. by S9 LPN - Notified RP of Resident #3's return. Explained in detail x-ray and CT results. Voiced understanding and wants Resident #3 to follow-up with Ortho. Explained that resident had an appointment with Orthopedist on 09/25 and RP asked if appointment could be moved up. RP also asked for chair alarm for resident. Will notify DON.
Review of a radiology report dated [DATE] revealed a CT of the Lumbar Spine had been performed on Resident #3. CT findings included: Acute burst compression fracture of L1. 30% loss of height. No retropulsion.
Interview on [DATE] at 1:59 p.m. with S7 LPN revealed Resident #3 was ambulatory and very independent on admission, but declined rapidly. S7 LPN stated Resident #3 was in a wheelchair after her right hip fracture in June and would propel herself around the neighborhood with her left leg. S7 LPN stated Resident #3 was a 2-person transfer, would attempt to stand unassisted, and was not easily redirected.
A telephone interview with S6 Agency LPN on [DATE] at 3:10 p.m. was unsuccessful.
A telephone interview with S9 LPN on [DATE] at 3:16 p.m. was unsuccessful.
Telephone interview on [DATE] at 3:23 p.m. with S5 CNA revealed she worked the 6:00 a.m. to 6:00 p.m. shift on [DATE] with Resident #3. S5 CNA stated Resident #3 was seated in her wheelchair near the water dispenser in the dining area. S5 CNA stated she turned away from Resident #3 and sat down to chart, and she heard another resident yell out Sit down Resident #3 before you fall. S5 CNA stated when she turned around Resident #3 was in the process of falling.
Observation on [DATE] at 4:28 p.m. with S2 DON and S1 Administrator of the facility's video footage from [DATE] at 3:33:31 p.m. to 3:37 p.m. revealed the following:
3:34:31 p.m. - Resident #3 stands up from her wheelchair, in the day/dining area of her assigned hall, takes steps holding onto the counter, and grabs cloth napkins.
3:36:26 p.m. - S5 CNA walks into the dayroom/dining from a side patio door, with an unobstructed view, facing Resident #3 who is standing at the counter directly across from the side patio door. Resident #3, who remains standing, turns and looks at S5 CNA as S5 CNA enters. S5 CNA proceeds to walk over to a desk in the day/dining area and sit down at computer. There were no other staff present.
3:36:44 p.m. - 3:37 p.m. - Resident #3 begins to lose balance and falls to the floor, onto her back. S5 CNA then gets up from the computer desk and walks over to Resident #3 and begins to render aide.
Interview on [DATE] at 4:33 p.m. with S2 DON revealed S5 CNA should have gone over and redirected Resident #3 when she entered the dayroom and saw Resident #3 standing at the counter, and S5 CNA did not.
Telephone interview on [DATE] at 11:59 a.m. with S5 CNA revealed inpart .she was really not familiar with Resident #3, but stated Resident #3 was not supposed to stand unassisted. S5 CNA stated residents at risk for falls are supposed to be assisted and redirected if they try to get up unassisted.
CRITICAL
(J)
📢 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 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to use its resources effectively and efficiently to attain...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#1) of 11 residents (#1, #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5 and #R6) identified as at risk for elopement.
The facility's administration failed to:
1. Ensure increase supervision of Resident #1 who eloped from the facility on 07/01/2023 and 08/18/2023;
2. Ensure an effective system of adequate supervision of the remaining 10 residents who were identified by the facility to be at risk for elopement (Residents #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5, and #R6).
This deficient practice resulted in an immediate jeopardy situation on 07/01/2023 at 6:06 p.m. when Resident #1, a cognitively impaired resident who was at risk for elopement and wore a wander guard bracelet, exited the facility unsupervised, and was found approximately 700 feet from the front door of the facility near a free-standing physical therapy center. The immediate jeopardy continued for Resident #1 when she exited the facility again on 08/18/2023 and was discovered outside the facility unsupervised approximately 300 feet away from a side exit door. Resident #1 was discharged on 08/22/2023.
This deficient practice continued at a potential for more than minimal harm for the remaining 10 residents (Resident #2, Resident #3, Resident #4, Resident #5, #R1, #R2, #R3, #R4, #R5, and #R6) identified as elopement risks, and wore wander guard devices in the facility.
S1 Administrator was notified of the Immediate Jeopardy on 09/20/2023 at 5:50 p.m.
The Immediate Jeopardy was removed on 09/21/2023 at 4:30 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented:
The Facility's plan to remove the immediate jeopardy situation included:
On 07/01/2023 and 08/18/2023 Resident #1 was able to exit the facility unsupervised while wearing a wander guard bracelet. These incidents have the potential to affect all 10 residents who are at risk for elopement and have been identified with wandering and/or exit seeking behaviors. On 09/20/2023 surveyors identified two malfunctioning exit doors. Supervision for at risk residents had not been increased, therefore the potential for elopement remained for the 10 residents with elopement risk.
MD/NP and Responsible Party were both notified in a timely manner after each elopement incident.
Residents #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5, and #R6 who were specifically identified to be affected, related to risk for elopement had adequate supervision provided every hour by assigned floor nurses and CNAs to assess for exiting seeking behaviors starting 09/21/2023, so that the staff can account for residents at risk. Residents at risk will be monitored every hour for 2 weeks, then reassessed for the need for continued hourly monitored by Administrator or designee. If no exit seeking behavior is exhibited, resume every 2 hour monitoring.
Care plans for residents at risk for elopement updated 09/21/2023 to reflect frequency of monitoring for adequate supervision.
Facility conducted a Root Cause Analysis on 09/20/2023 to identify failure for F835.
Review of the elopement policy and procedure conducted on 09/20/2023 with no changes needed.
Review of the Secure Care Guardian U-DE owner's manual, of exit door locking mechanisms, conducted on 09/20/2023 with no changed needed, developed and implemented a monitoring tool to check all exit doors every shift for 7 days, then every day for 7 days, then weekly thereafter by administrator or designee with Regional Director of Operations supervision daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month.
Education of all staff began on immediately on 09/20/2023 to include wandering and elopement policy and procedures, location of elopement binders, including Face Sheets of identified residents at risk for elopement and Photo, and Code W procedures completed by DON. Binders are located at incident command center (front desk) and 1 in each neighborhood, totaling 4 in the facility. Administrator or designee will continue in-servicing employees prior to the beginning of shift for conformance with wandering and elopement. Completion date of 09/22/2023.
In reference to above, the Administrator or designee will administer post training evaluation of staff on wandering and elopement policy and procedures and location of elopement binder to be completed before employee begins shift for conformance with wandering and elopement.
Quality Assurance Committee met 09/21/2023 and will monitor for elopement risk to prevent the likelihood of serious harm or death weekly for 8 weeks.
Administrator in-serviced on elopement policy and procedure by Regional Director of Operations and DON in-serviced by Corporate Nurse on 09/20/2023. Administrator will be supervised on facility compliance by Regional Director of Operations daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month.
Requested and received approval on 09/21/2023 to install a [NAME] mag lock system to the C Hall access door to the exit, plans will be submitted to the fire marshal's office for approval of installation.
Completion date: 09/22/2023.
Findings:
Cross refer to F689.
Review of the facility's Wandering and Elopement Assessment/Management/ Security policy dated 10/28/2022 read as follows in part .
Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration, and/or other medical complications, drowning, or being struck by a car.
Interventions which address/prevent unsafe wandering/elopement will be developed within the resident care plan for at risk residents. (i.e., supervision/periodic checks, activity programs, exit door alarms, highlight name on census report at nurses' station, Personal signal device, etc.).
In facilities with electronic wander alarm systems, residents assessed to be at risk for unsafe wandering may be placed on the Resident Security System as a measure to reduce the risk of harm from unsafe wandering activities.
There was no facility policy that addressed supervision of residents who wandered and/or were at risk for elopement.
Interview with S2 DON on 09/15/2023 at 10:15 a.m. revealed she trained staff after each elopement. S2 DON handed the facility's Post elopement binder dated 07/01/2023 to the surveyor. Documentation contained in the binder reflected staff were trained on the wander/elopement policy, abuse/neglect wanderguard system/alarms, the locking system, and barrel key placement. There was no documentation that addressed resident supervision.
After Resident # 2's second elopement on 08/18/2023, the Post elopement binder was updated. Review of the 08/18/2023 revealed all staff were inserviced on maintaining pagers on them at all times, responding to alarms immediately, making rounds, and turning barrel key on doors. There was no inservice documentation and/or staff guidance regarding the supervision/monitoring of residents who wander and who were identified at high risk for elopement.
Interview on 09/19/2023 at 10:15 a.m. with S1 Administrator revealed S10 Former [NAME] Clerk reset the front door alarms after they kept going off on 07/01/2023, and apparently did not turn the key to the proper position to keep it locked. She confirmed the wander guard/alarm system was the facility's elopement prevention system used for residents on elopement risk.
Interview on 09/19/2023 at 2:30 p.m. with S2 DON stated Resident #1 had a history of wandering in and out of rooms and being anxious. S2 DON confirmed there was no increased supervision for residents with exit seeking or elopement behaviors. S2 DON stated residents who wandered, had wander guard devices in place as a measure to prevent elopement and that all residents were monitored every 2 hours.
Interview on 09/20/2023 at 6:15 p.m. with S1 Administrator confirmed she was the person in charge of the day to day operations of the facility.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to follow infection control practices to prevent the development and tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to follow infection control practices to prevent the development and transmission of COVID-19. The facility failed to ensure staff wore appropriate PPE during, and performed hand hygiene after direct contact with a resident for 1 (Resident #3) of 1 sampled residents on transmission based precautions for COVID-19. Findings:
Review of the facility policy titled: Infection Control Interim Policy for Coronavirus, revealed in part
It is the policy of this facility to minimize exposure to respiratory pathogens and promptly identify clinical features and risks for COVID-19 based on state/local recommendations.
Transmission Based Precautions: Staff should don and doff PPE in accordance with national standards.
Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE]. Resident #3's admission diagnoses included: COPD, Hypothyroidism, Hyperlipidemia, Type II Diabetes Mellitus, and Mild Cognitive Impairment.
Review of a nurses' note dated 09/11/2023 at 8:04 a.m., and documented by S23 RN/IP, revealed in part .Resident swabbed for COVID-19 on 09/10/2023. Will be on contact precautions and single room isolation. NP ordered resident to be sent to ER for evaluation. She will be isolated for 10 days. Day 10 will be 09/20/2023. Resident will be able to discontinue isolation on day 11, 09/21/2023, per infection control policy.
Observation on 09/20/2023 at 8:57 a.m. revealed Resident #3's door was positioned open. Signage was observed on Resident #3's door stating: STOP Contact precautions, STOP do you have PPE before entering. Signage was also noted that contained pictures of the PPE required in order to enter Resident #3's room. A clear plastic storage bin was observed to the right of Resident #3's room entrance with (2) boxes of N95 masks, and a box of gloves on top of the bin. The second drawer of the bin was noted to contain isolation gowns and garbage bags.
Continued observation revealed S4 CNA seated on Resident #3's bed talking with the resident. S4 CNA was noted wearing a N95 mask pulled down under her nose. S4 CNA was not observed wearing gloves, a gown or face shield. S4 CNA was observed to proceed into Resident #3's bathroom, turn the faucet on, and then exit the room without performing hand hygiene.
Interview with S4 CNA after exiting the room revealed she did not see the signage outside Resident #3's door. S4 CNA then proceeded to the facility's clean linen storage area without sanitizing her hands, and removed a washcloth from the cabinet.
Interview on 09/20/2023 at 9:05 a.m. with S3 LPN revealed contact precautions signs and PPE storage bin had been placed on Resident #3's door and outside her room before Resident #3 went to the hospital on [DATE]. S3 LPN stated all staff should don full PPE before entering Resident #3's room. S3 LPN also stated staff should doff in the room and wash and/or sanitize their hands after exiting the room.
Interview on 09/20/2023 at 9:15 a.m. with S4 CNA revealed the PPE bin was outside Resident #3's room when she came on at 6:00 a.m., she just had not paid attention to it.
Interview on 09/20/2023 at 9:37 a.m. with S2 DON revealed Resident #3 was on transmission based precautions until tomorrow. S2 DON stated staff should be wearing N95 mask, eye protection, gown and gloves when entering the room to provide care. S2 DON stated staff should not be sitting on Resident #3's bed without PPE, and should be sanitizing hands after removing gloves and exiting room. S2 DON stated PPE signs and apparel had been posted outside Resident #3's room since testing positive on 09/10/2023.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 review and revise a resident's care plan to include interventions f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview the facility failed to review and revise a resident's care plan to include interventions for increased staff supervision following elopements, and for a severely cognitively impaired resident who experienced frequent falls, for 2 (#1, #3) of 11 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, #R1, #R2, #R3, #R4, #R5, and #R6).
Findings:
Resident #1
Review of the facility's Wandering and Elopement Assessment/Management/ Security policy dated [DATE] read as follows in part .
Interventions which address/prevent unsafe wandering/elopement will be developed within the resident care plan for at risk residents. (i.e., supervision/periodic checks, activity programs, exit door alarms, highlight name on census report at nurses' station, Personal signal device, etc.).
In facilities with electronic wander alarm systems, residents assessed to be at risk for unsafe wandering may be placed on the Resident Security System as a measure to reduce the risk of harm from unsafe wandering activities.
There was no facility policy that addressed the supervision of residents who wandered and/or who wore wander guard devices and were identified at risk for elopement.
Review of Resident #1's Face Sheet revealed an admission date of [DATE]. Diagnosis included: Alzheimer's disease, Major Depressive D/O, Anxiety D/O, and HTN.
Review of Resident #1's Risk of Elopement Wandering assessments dated [DATE], [DATE], and [DATE], revealed Resident #1 had been identified as high risk for elopement.
Review of Resident #1's Quarterly MDS with an ARD of [DATE], revealed Resident #1 had a BIMS of 10 (moderate cognitive impairment). Resident #1 required supervision with bed mobility, transfers, walk in room/corridor, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #1 ambulated with use of a walker, and used Wander/elopement alarm daily.
Review of Resident #1's Care Plan with target date of [DATE] revealed in part .an elopement risk/wanderer r/t disoriented to place and verbally saying I'm going home, how I get there? The Care Plan indicated the resident had a Dx. Of Dementia, attempted to open doors at times and that the resident wore a wander guard to left ankle at all times. The Care Plan did not include specific supervision measures staff were to follow.
There were no Care Plan interventions for increased supervision of Resident #1 due to her exit seeking and wandering behaviors, except for 1:1 supervision for a brief period of time after each elopement.
Review of Resident #1's 2023 Physician's Orders revealed in part .
[DATE], [DATE] and [DATE] - Wander Guard to right ankle-verify placement, inspect skin at band location, and confirm signal operation every shift;
Review of Resident #1's Progress Notes revealed in part:
[DATE] at 10:42 a.m. - Resident continues to stop staff and random visitors at this time asking which way she could exit facility because she needs to go home. Unable to redirect at this time.
[DATE] at 6:02 a.m. - Resident awake and wandering around attempting to exit facility and entering other residents' rooms. Redirected with limited success.
[DATE] at 6:25 p.m. - CNA indicated she did not see resident on the hall. It was confirmed her wander guard was observed intact and working earlier in the shift. CNA stated the resident ambulated in the building to front entrance and other halls. CNA stated she heard a car horn and she went toward the front entrance. Approximately 2-3 minutes later a pager alert went off for the main entrance/front door. Resident #1 was observed ambulating with her walker through front entrance accompanied by 2 CNAs. One of the CNAs saw the resident walking on the driveway, recognized her as a frequent wanderer, and asked the resident to accompany her back inside the facility. No injuries, guard intact.
[DATE] at 9:01 p.m. - LATE ENTRY - one on one observation of resident implemented. Security cameras were viewed to determine how resident left the building. Maintenance department came to facility to determine how resident was able to leave the facility with wander guard in place, and found that the front door was not reset correctly following fire alarm earlier that day. All staff were notified of protocol per DON. RP/MD were notified.
[DATE] at 3:07 p.m. - Resident #1 standing at the door crying saying she needs to get out to go take care of her mom. CNA redirected resident to chair in dining room. Resident #1 states, You people are crazy! First chance I get I'm going to save my mom.
[DATE] at 4:01 p.m. - Resident #1 constantly ambulating asking for someone to open the door. States, I gotta go home, my momma and daddy are waiting on me. Resident redirected.
[DATE] at 3:40 p.m. - LPN spoke with Resident #1's RP, concerning statements of wanting to go home and her saying how she has to get out of here. NP made aware of orders to refer to inpatient behavior unit due to high risk of elopement/safety. admitted to behavior hospital.
[DATE] at 1:50 p.m.-returned to facility from inpatient behavioral hospital
[DATE] at 5:59 p.m. - Resident #1 was hollering, cursing, and threatening to hit staff because she thought they had her car keys. Resident #1 also wanted to be let out. Resident #1 stated, If you don't give me my keys I am going to do something to you, I am not crazy, give me my f .king keys, and then she would bang her walker on the floor.
[DATE] at 12:40 p.m. - Resident up ambulating with walker back and forth between left and middle houses. States, I'm looking for the bus. Resident #1 continues to say she is, tired and needs to go home.
[DATE] at 2:56 p.m. - Resident #1 having bad anxiety. Walking up and down hall looking for someone and saying that we are not taking care of the other residents. Order received to administer Xanax 0.25 mg one time dose.
[DATE] at 7:30 p.m. - Resident #1 began wandering after visit from daughter. Stated she had to go home. Easily redirected.
[DATE] at 10:09 a.m. - Resident #1 wandering from middle house to left house. States, I'm looking for my daddy. Confusion noted. Unable to redirect. Wander guard in place and working properly.
[DATE] at 6:09 p.m. - Resident #1 ambulating all over the building, when nurse attempted to redirect resident back to her room she screamed, You just want to lock me up and kill me. Unable to redirect.
[DATE] at 10:45 a.m. - Resident #1 with increased agitation. Pacing back and forth to doors. States, I have to get to my daddy, he died. Consoled resident and redirected by distracting and offering a snack.
[DATE] at 12:45 p.m. - Fire alarm went off at this time. Staff voiced that Resident #1 pulled alarm in middle Hall f. Asked Resident #1 why she did that? Resident #1 stated, I wanted ya'll to come get me. Monitored on 1:1 until doors reset to maintain safety. Resident #1 voiced concerns of momma is going to be looking for me. Redirected by listening to music.
[DATE] at 4:30 a.m. - Resident #1 ambulating looking for bus. Redirected to room and got back up.
[DATE] at 10:43 a.m. - Resident #1 pacing back and forth from house to house looking for her little children.
[DATE] at 6:40 p.m. - Resident #1 ambulating toward front entrance. LPN attempted to redirect resident. Resident #1 became agitated and stated, I don't know what your problem is telling me what to do, but if it wasn't for me and your grandma your house would be a big pile of sh .t.
[DATE] at 10:45 a.m. - Resident #1 noted in and out of residents' rooms. Easily redirected back to hall.
[DATE] at 11:05 a.m. - Resident #1 ambulating towards the front entrance with bible in her hand and dragging walker. Attempted to redirect, Resident #1 screamed, you don't tell me what to do.
[DATE] at 3:20 p.m. - Resident #1 ambulating up and down hallway with walker. Stated, I have to go check on my momma, she's sick and the baby is running a fever with no meds.
[DATE] at 9:40 a.m. - Resident #1 ambulating up and down hallway with walker. Stated, I'm trying to get out of here to go check on my momma, she's sick. Redirected to her room.
[DATE] at 10:40 a.m. - Resident #1 ambulating back and forth to front door. Stated, I got to get out of here and go catch the bus, daddy is going to be mad if I miss it. Unable to redirect. Continues to pace.
[DATE] at 9:34 p.m. - Resident wandering in other resident rooms turning on their lights looking for her children. Unable to redirect.
[DATE] at 10:35 p.m. - Resident wandering around the house. Refused to put on pajamas. Trying to go home.
[DATE] at 9:55 p.m. - Resident #1 ambulating and going into other residents' rooms. Using racial slurs and combative towards staff.
[DATE] at 10:00 p.m. - Resident ambulated to Hall d looking for her children. Resident assisted back to hall f.
[DATE] at 11:18 p.m. - Resident continues to wander. Went into another resident's room several times. Stated she was going to call the police because another resident was trying to kill her. Resident continues to wander from hall to hall.
[DATE] at 6:42 p.m. - Resident in common area wandering, redirected often, wander guard in place.
[DATE] at 7:30 p.m. - A resident was sitting outside on the porch and noticed Resident #1 walking around the corner of the building, she knocked on the door to alert staff. CNA went outside immediately and went to resident and brought her safely inside. Assessed-no injuries. All residents were checked for safety and accountability. Maintenance called in to check all doors for proper functioning. All wander guards checked including Resident #1's, and were functioning correctly and located on residents as they should be. MD/RP notified. Resident #1 placed on 1:1 observation at all times.
[DATE] at 1:31 p.m., Resident #1 was discharged to another long term care facility.
Interview with S2 DON on [DATE] at 10:15 a.m. revealed she trained staff after each elopement. S2 DON handed the facility's Post elopement binder dated [DATE] to the surveyor. Documentation contained in the binder reflected staff were trained on the wander/elopement policy, abuse/neglect wander guard system/alarms, the locking system, and barrel key placement. There was no documentation that addressed resident supervision.
Interview on [DATE] at 10:15 a.m. with S1 Administrator revealed S10 Former [NAME] Clerk reset the front door alarms after they kept going off on [DATE], and apparently did not turn the key to the proper position to keep it locked. She confirmed the wander guard/alarm system was the facility's elopement prevention system used for residents on elopement risk.
Interview on [DATE] at 2:30 p.m. with S2 DON stated Resident #1 had a history of wandering in and out of rooms and being anxious. S2 DON confirmed there was no increased supervision for residents with exit seeking or elopement behaviors. S2 DON stated residents who wandered, had wander guard devices in place as a measure to prevent elopement and that all residents were monitored every 2 hours.
Resident #3
Review of Resident #3's clinical record revealed an admit date of [DATE], with diagnosis that included: Neuropathy, Insomnia, Major Depressive Disorder, Type II DM, Mood Disorder, and Primary Generalized Osteoarthritis.
Review of Resident #3's Quarterly MDS with an ARD date of [DATE] revealed in part:
BIMS 00 (severe cognitive impairment); Bed mobility, Transfer: extensive assistance/2 persons physical assist; Dressing: Limited assistance/1 person physical assist; Eating: extensive assistance/1 person physical assist; Toilet use: total dependence/2+ person physical assist; Personal hygiene: Limited assistance/1 person physical assist; Bathing: Physical help in part of bathing activity/1 person physical assist; ROM: Upper extremity 0. No impairment, Lower extremity 1. Impairment on one side; and Mobility devices: Wheelchair.
Review of Resident #3's Comprehensive Plan of Care revealed in part: the resident was a high risk for falls r/t neuropathy. Fall dates, interventions, and staff education noted on the Plan of Care were:
[DATE] no injury: wander guard placed on left ankle and staff to accompany resident to go outside to prevent serious injury.
[DATE] no injury: staff informed and educated on resident decline in status and need for assistance by staff.
[DATE] fall hip fracture: staff to take resident on porch (well lit area) to smoke after hours
[DATE] fall no injury.
[DATE] burst compression fracture at L1: educate staff to offer assistance if they see resident standing.
Resident #3 was not care planned specifically for attempting to stand unassisted; however, on [DATE] staff were informed and educated on the resident's need for assistance by staff related to her high fall potential. There were no planned interventions to increase staff supervision of Resident # 3, who was noted to have severe cognitive impairment.
Review of nurses' notes revealed the following in part XXX[DATE] at 3:50 p.m. - documented by S6 Agency LPN - Resident #3 attempted to get out of her wheelchair without assistance and walk to the counter in the main dining room when she lost her balance falling to the floor landing on her buttocks. This nurse was summoned to the main dining room by CNA. Resident #3 was laying on her back in front of the dining counter. When asked what she was trying to do she stated reaching for a snack. Head to toe assessment was done. Active ROM to upper extremities and lower extremities without difficulty. No complaints of pain at this time. Neuros were initiated at this time. CNA supervisor along with another CNA assisted the resident back to her wheelchair. No injuries present at this time. Notified PCP and RP. VS 93/58, 94, 17, 97.8 and 95% on room air. Will continue neuro checks.
[DATE] LPN S7 documented:
3:40 p.m. Resident #3 complains of increased pain r/t fall yesterday. FNP notified. New orders noted to obtain spinal x-ray per imaging. RP notified.
4:00 p.m. X-ray obtained at this time per imaging.
6:34 p.m. Received x-ray results. Impression: Spondylitic changes of the lumbar spine with degenerative changes worse at L5-S1. FNP notified. Phoned RP x 2, no answer.
7:20 p.m. RP returned call. Notified of x-ray results. Verbalized understanding.
8:30 p.m. Received a call from S2 DON, stating that Resident #3's RP is requesting Resident #3 be sent to the ER for evaluation. RP voices that she does not trust portable x-rays. Resident #3 asleep in bed at this time. No further complaints of pain since Ultram was administered. Phoned FNP and notified of the above. New order to send to ER for evaluation and treatment related to fall. Phoned for transfer. Phoned RP and notified of above, Called report to ER.
[DATE] 1:40 a.m. by S9 LPN - Received report per ER. ER staff stated Resident #3 had a lumbar CT done and was noted to have a burst compression fracture at L1. Follow-up with orthopedic. CT scan of head noted with no acute changes.
Review of a radiology report dated [DATE] revealed a CT of the Lumbar Spine had been performed on Resident #3. CT findings included: Acute burst compression fracture of L1. 30% loss of height. No retropulsion.
Telephone interview on [DATE] at 3:23 p.m. with S5 CNA revealed she worked the 6:00 a.m. to 6:00 p.m. shift on [DATE] with Resident #3. S5 CNA stated Resident #3 was seated in her wheelchair near the water dispenser in the dining area. S5 CNA stated she turned away from Resident #3 and sat down to chart, and she heard another resident yell out Sit down Resident #3 before you fall. S5 CNA stated when she turned around Resident #3 was in the process of falling.
Observation on [DATE] at 4:28 p.m. with S2 DON and S1 Administrator of the facility's video footage from [DATE] at 3:33:31 p.m. to 3:37 p.m. revealed the following:
3:34:31 p.m. - Resident #3 stands up from her wheelchair, in the day/dining area of her assigned hall, takes steps holding onto the counter, and grabs cloth napkins.
3:36:26 p.m. - S5 CNA walks into the dayroom/dining from a side patio door, with an unobstructed view, facing Resident #3 who is standing at the counter directly across from the side patio door. Resident #3, who remains standing, turns and looks at S5 CNA as S5 CNA enters. S5 CNA proceeds to walk over to a desk in the day/dining area and sit down at computer.
3:36:44 p.m. - 3:37 p.m. - Resident #3 begins to lose balance and falls to the floor, onto her back. S5 CNA then gets up from the computer desk and walks over to Resident #3 and begins to render aide.
Interview on [DATE] at 4:33 p.m. with S2 DON revealed S5 CNA should have gone over and redirected Resident #3 when she entered the dayroom and saw Resident #3 standing at the counter, and S5 CNA did not.
Telephone interview on [DATE] at 11:59 a.m. with S5 CNA revealed inpart .she was really not familiar with Resident #3, but stated Resident #3 was not supposed to stand unassisted. S5 CNA stated residents at risk for falls are supposed to be assisted and redirected if they try to get up unassisted.
Jun 2023
2 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure facility staff and a contract hospice staff pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure facility staff and a contract hospice staff properly placed a lift pad/sling underneath a resident prior to transferring the resident from the bed to the Geri-Chair with a mechanical lift, for 1 (Resident #5) of 1 residents sampled for accidents.
An Actual Harm occurred for Resident #5 on 06/02/2023 at approximately 10:55 a.m., when S5 CNA, S6 CNA and S7 Hospice RN failed to ensure the lift pad had been properly placed underneath Resident #5 prior to transfer with a mechanical lift. Resident #5 fell from the mechanical lift to the floor during transfer from the bed to the Geri-Chair. Resident #5 was transferred to the emergency department of a local hospital and diagnosed with Traumatic Hemorrhage of Cerebrum, Unspecified, with Loss of Consciousness of Unspecified Duration, and Laceration without Foreign Body of Other Part of Head, that required suturing. Resident #5 was transferred to another hospital on [DATE] at 2:39 p.m. for a higher level of care where she remained hospitalized during time of survey.
The facility implemented corrective actions prior to the State Agency's investigation therefore, it was determined to be a Past Noncompliance citation.
Findings:
Review of the facility's policy titled Transfer and Lift Policy read in part .Each resident will have a Lift Assessment completed by licensed nurse upon admission, quarterly, annually, and with significant change. All staff are responsible for using the required number of assistants for resident transfer and lifts, as well as the appropriated colored sling as designated per the resident's personal lift assessment. Two persons are always required for standup lifts (Vera) and bed lifts ([NAME]), and the ceiling lift (Go Lift Portable 450). A color coded legend is used to designate the type of lift and sling required per the residents lift assessment. Color coded stickers are placed at the head of the resident's bed and/or noted on the computer kiosk: Lifts: Red- Total bed lift (e.g., Vander-Lift), 2 person. Slings: Red (Medium) Average user weight 110-190lbs.
The Vander-Lift was used during Resident #5's transfer from the bed to the Geri-Chair on 06/02/2023.
Review of Resident #5's medical record revealed an admission date of 11/13/2020, with diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Vascular Attack affecting Right Dominant Side, Unspecified Dementia, and Generalized Anxiety Disorder.
Review of Resident #5's Side Rail/Bed Mobility/Lift Assessment completed on 02/19/2023 revealed Resident weighed 136lbs, was non-weight bearing, cooperative and could follow simple commands. Resident had right sided weakness of upper and lower extremities. Resident required: 2 person assist- total bed lift with Vander-Lift-Red dot. Sling type/size for Vander-Lift: Medium-110 to 190lbs (Red).
Review of a Quarterly MDS Assessment with an ARD of 02/22/2023 revealed Resident #5 had a BIMS of 2 (Severe Cognitive Impairment). Resident #5 was totally dependent upon staff and required 2 + person physical assist for bed mobility and transfers.
Review of Resident# 5's Electronic Fall Risk Assessment completed on 05/24/2023 revealed Resident#1 determined by the facility to be at high risk for falls. The assessment revealed a score of 45 or higher indicated a high risk for falls. Resident #5's score was 55.
Review of Resident #5's Care Plan with a target date of 06/20/2023 revealed a problem of: ADL self-care deficit related to right sided hemiplegia following CVA. Approaches included: I am totally dependent on 2 staff for repositioning and turning in bed, turn every 2 hours. Transfer: I require mechanical lift with 2 staff assistance for transfers.
Review of Resident #5's Departmental Notes dated 06/02/2023 at 11:45 a.m. written by S4 RN read as follows: Resident fell during transfer from bed to Geri chair and resident sustained hematoma to right forehead approximately 3cm x 3cm. Left forehead with hematoma and lacerated wound with bleeding noted. Pressure dressings were applied. Below left knee hematoma measuring 6cm x 7cm x 1 cm. Skin tear below left ankle with superficial skin loose measuring 1cm x 1 cm. Resident has eye opening to outside stimuli. Pupil size 3 equally non-reactive to light. B/P 200/73. Doctor and Resident representative notified, Resident sent to local hospital.
Review of a statement dated 06/02/2023 and written by S6 CNA, revealed in part . S6 CNA assisted S7 Hospice RN with placing lift sling underneath Resident. S7 Hospice RN asked S6 CNA if she knew how to use the mechanical lift. S6 CNA then went to get help, and S5 CNA entered room to assist with transfer and operate mechanical lift. S5 CNA, S6 CNA, and S7 Hospice RN connected lift sling to the mechanical lift. S5 CNA began to operate the mechanical lift. Once Resident was off of the bed, S6 CNA heard S7 Hospice RN ask if the Resident was in the correct position, and the Resident then fell from the mechanical lift to the floor.
Review of a statement dated 06/02/2023 and written by S5 CNA revealed in part . S5 CNA entered Resident #5's room and observed a lift sling was already underneath Resident. S5 CNA and S7 Hospice RN connected lift sling to the mechanical lift. S5 CNA began operating the mechanical lift. During transfer when Resident was off of bed, S7 Hospice RN asked if Resident was in the correct position. S5 CNA assessed and stated yes. Immediately after the question was asked the Resident fell forward from mechanical lift to the floor. S4 RN was standing in doorway of room, and S6 CNA was standing on opposite side of bed.
Review of a statement dated 06/02/2023 and written by S7 Hospice RN revealed in part . S7 Hospice RN and S6 CNA placed lift sling underneath Resident. S6 CNA then sought the attention of S5 CNA to operate mechanical lift. S5 CNA and S6 CNA then proceeded with lifting Resident using mechanical lift. Resident fell from mechanical lift to floor. Resident was then assessed by S7 Hospice RN.
Telephone interview on 06/06/2023 at 10:22 a.m. with S5 CNA revealed on Friday 06/02/2023, Resident #5 had a fall. S5 CNA stated, S7 Hospice RN and S6 CNA were present in Resident #5's room around 11:00 a.m. performing ADL care. S5 CNA stated S6 CNA came to her and asked her to help transfer Resident #5 with the mechanical lift. S5 CNA then went to Resident's room. S5 CNA stated S6 CNA and S7 Hospice RN already had the lift sling underneath Resident #5. S5 CNA stated once transfer began She didn't put the sling under her correctly, and she leaned forward and fell from the lift. S5 CNA stated she was unsure who placed the sling underneath Resident #5. S5 CNA stated I wish I had checked, but I automatically thought the sling was correct, and I didn't want to question the nurse. S5 CNA stated the nurses came in to assess Resident #5 after the fall. S5 CNA stated she had received training from the facility on using the lift when she was hired, and stated I know how to work the lift, but I didn't think to check the sling. S5 CNA stated she had training on using the mechanical lift following the incident on 06/02/2023.
Telephone interview on 06/06/2023 at 11:03 a.m. with S7 Hospice RN revealed she and S6 CNA gave Resident #5 a bath on 06/02/2023. S7 Hospice RN stated after the bath, she wanted to place Resident #5 in a Geri Chair so that she could change her bed to an air mattress. S7 Hospice RN stated she and S6 CNA both placed the lift pad under Resident #5. S7 Hospice RN stated she wasn't sure on how to use the mechanical lift, so S6 CNA went to get help from S5 CNA. S7 Hospice RN stated both S5 CNA and S6 CNA connected the lift pad to the mechanical lift. S7 Hospice RN stated Resident was then in the air and fell forward. S7 Hospice RN stated she assessed Resident #5 immediately after the fall, and S4 RN who was also present, helped to assess Resident#5. S7 Hospice RN stated Resident #5 sustained a hematoma to both eyes, skin tear to left knee, abrasion to right great toe, and a laceration above her right eye. S7 Hospice RN stated she had not been trained on how to use the mechanical lift by the facility, nor by the hospice company she worked for. S7 Hospice RN stated she asked S5 CNA and S6 CNA if Resident #5 was positioned on the pad correctly, and S5 CNA stated yes. S7 Hospice RN stated Resident was sent to emergency room, and is currently hospitalized .
Telephone interview on 06/06/2023 at 11:13 a.m. with S6 CNA revealed after she and S7 Hospice RN bathed Resident #5, they were to transfer Resident #5 from the bed to the Geri Chair using a mechanical lift. S6 CNA stated she and S7 Hospice RN placed the lift pad under Resident #5, and S7 Hospice RN then asked, Do you know how to do this? S6 CNA stated she informed S7 Hospice RN No and stated she (S6 CNA) then went to get S5 CNA to help. S6 CNA stated apparently her legs weren't crossed, and she fell forward on the floor. S6 CNA stated S5 CNA thought the pad was under the Resident correctly, but that's why I brought her in there, because we weren't sure S5 CNA stated she received training on using the lift when she first started working at the facility, and again following the incident on 06/02/2023. S6 CNA stated we all should have known better, but it was an accident.
Interview on 06/06/2023 at 11:25 a.m. with S4 RN revealed she was in Resident #5's room near the doorway at time of the incident on 06/02/2023. S4 RN stated she did not check placement of the lift pad, as she only was there to bring a battery to the room. S4 RN stated S5 CNA and S6 CNA did not report to her that they were uncomfortable using the mechanical lift. S4 RN stated immediately after Resident #5 fell, she could see that the lift pad was placed incorrectly. S4 RN stated the lift pad was not crisscrossed as it was still attached to the mechanical lift. S4 RN stated she immediately assessed Resident #5, and could tell Resident #5 was hurt. S4 RN stated she notified the doctor and Resident #5's family. Resident #5 was sent to the emergency room, and remains hospitalized due to her injuries sustained from the fall.
Interview on 06/06/2023 at 12:41 p.m. with S2 DON revealed the facility's process for staff using mechanical lifts on residents was to refer to the resident's lift assessment, and the signage posted in each resident's room. S2 DON stated if a resident is to use a mechanical lift, there would be a red dot located above the resident's head of bed. S2 DON stated each resident who used a mechanical lift for transfers would also have a colored triangle above the resident's head of bed, and that would indicate what size sling to use.
Throughout the survey from 06/05/2023 thru 06/07/2023, random interviews of staff were conducted. Staff stated that they had previously received training on transferring residents with mechanical lifts, and had been recently in-serviced on the use of mechanical lifts.
Review of a list of residents who required a mechanical lift for transfers revealed 21 residents required the use of a lift for transfers, and 12 of the 21 residents received hospice services.
Observations on 06/07/2023 revealed Resident #33, Resident #47, Resident #48, Resident #71, and Resident #92 were transferred with the use of a mechanical lift and the assistance of 2 CNA's. There were no concerns observed with the transfers.
Interview on 06/07/2023 at 9:48 a.m. with S8 Hospice CNA revealed following the incident on 06/02/2023, the facility informed her that Hospice staff would not be allowed to transfer residents with a mechanical lift, and she had not transferred any residents with a mechanical lift since being informed.
Interview on 06/07/2023 at 10:55 a.m. with S1 Administrator revealed following the incident on 06/02/2023, she had spoken to all Hospice providers that service the facility to inform them Hospice Staff would not be allowed to transfer residents with a mechanical lift until further training could be completed with the Hospice staff. S1 Administrator stated the investigation of the incident was complete, but monitoring would continue.
Telephone interview on 06/07/2023 at 11:25 a.m. with the DON of a contract hospice agency revealed S1 Administrator had contacted the hospice agency to inform them that Hospice staff would not be allowed to use mechanical lifts for transfers of residents.
The facility has implemented the following actions to correct the deficient practice:
1. A Root Cause Analysis was completed, and it was determined that the lift pad was not positioned correctly for Resident #5 prior to transfer on 06/02/2023, causing Resident #5 to fall from the lift. Equipment (sling and lift) was in proper working condition. However, the Hospice nurse, and the CNAs involved in the transfer did not follow the education given and criteria for use.
2. All lifts and slings in operation, and over bed signage for all residents evaluated. Results: lifts and slings in good and appropriate condition, and over bed signage correctly displayed - all 21 residents who require a lift for transfer were care planned for lift transfer. Completed 06/02/2023.
3. Staff in-services immediately initiated regarding procedure/steps for proper use of sling and lifts. Initiated 06/02/2023 and is ongoing at the beginning of each shift until all 77 facility staff are re-educated before scheduled shift. Completion date 07/22/2023.
4. Policy/Procedure changes: DON, Staff Development Coordinator, or Designee will observe and supervise as necessary 6 lift transfers per week, per neighborhood (total of 18 lift transfers per week) for 6 weeks. There are a total of 3 neighborhoods in the facility. Any concerns identified will be reported to the IDT and appropriate action taken to include retraining, further observations etc. The results of the observations will be reviewed with the QA Committee Monthly for review of continued compliance.
5. Monitoring: Weekly observations throughout facility, of 21 residents requiring lift transfer (minimum of 18 per week for 6 weeks then re-evaluate). DON, Staff Development and/or other Nursing Administrative staff or IDT members to perform monitoring. QA Committee will monitor monthly or more frequently if needed for continued compliance.
6. Corrective Action Plan effective as of 06/02/2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The facility failed to evaluate the appropriateness for the continued u...
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Based on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The facility failed to evaluate the appropriateness for the continued use of a PRN (as needed) psychotropic medication beyond 14 days for 1 (Resident #71) of 5 (Resident #7, Resident #71, Resident #87, Resident #93 and Resident #96) resident's sampled for Unnecessary Medications.
Findings:
Review of Resident #71's clinical record revealed diagnoses that included Bipolar disorder, Major Depressive Disorder and Dementia.
Review of Resident #71's Physician Order Summary Report revealed an order dated 03/30/2023 for Haloperidol (antipsychotic/psychotropic) tablet 5mg by mouth. Give 1 tablet by mouth every 12 hours as needed for acute psychosis. Review of the Order Summary revealed order end date entered as indefinite.
Review of Resident #71's 04/2023, 05/2023 and 06/2023 Medication Administration Records revealed Resident #71 received administrations of Haloperidol 5mg by mouth on 04/04/2023 at 7:47 a.m. and 04/06/2023 at 7:02 a.m. Resident #71's Medication Administration Records revealed no administrations of Haloperidol during the months of 05/2023 and 06/2023 to date (06/06/2023).
Interview on 06/06/2023 at 3:14 p.m. with S3 RN Clinical Coordinator revealed Resident #71's order for PRN (as needed), psychotropic medication, Haloperidol, had been continued for longer than 14 days and should not have been. S3 RN Clinical Coordinator confirmed Resident #71 had not exhibited behaviors requiring Haloperidol to be administered since 04/06/2023 and Haloperidol should have been discontinued and had not been.
Apr 2023
8 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
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 F0551
(Tag F0551)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to honor the rights of the responsible party for 1 (#2) of 6(#1, #2,#3,#4,#5,#6) sampled residents, and 5 ( R1, R2, R3, R4,and R5) random sa...
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Based on interviews and record reviews, the facility failed to honor the rights of the responsible party for 1 (#2) of 6(#1, #2,#3,#4,#5,#6) sampled residents, and 5 ( R1, R2, R3, R4,and R5) random sampled residents. The facility failed to ensure staff prevented Resident #4 from entering Resident #2's room as instructed by Resident #2's responsible party.
Findings:
Review of Resident #2's clinical record revealed an admit date of 09/02/2022 with diagnoses that included Alzheimer's Disease, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Resident #2's clinical record revealed Resident #2 was admitted to hospice services on 09/21/2022 with a primary diagnosis of Alzheimer's disease.
Review of Resident #2's Quarterly MDS assessment with an ARD of 03/08/2023 revealed Resident #2 had a BIMS score of 5 (severe cognitive impairment), required the extensive assistance of one person for dressing and limited assistance of one person for toileting. Resident #2 had no upper or lower extremity range of motion impairments, received antipsychotic medications and wore a wander guard.
Observation on 04/03/2023 at 9:07 a.m. revealed a Velcro mesh stop sign positioned across the entrance of Resident #2's door. Resident #2 was observed asleep in bed at the time of observation.
Interview on 04/03/2023 at 9:17 a.m. with S3 Clinical Coordinator, revealed the mesh stop signs were placed at certain room entrances to keep wanderers out of others' rooms. S3 Clinical Coordinator stated Resident #2's family had complained that Resident #4 had gone into Resident #2's room, so a stop sign/mesh barrier had been placed. S3 Clinical Coordinator stated Resident #4 had a history of being mean and snapping at other residents. S3 Clinical Coordinator stated Resident #4 had snapped at Resident #2 in the past for calling her the wrong name or sitting in a chair that she claimed was hers (Resident #4's) in the dining room. S3 Clinical Coordinator stated Resident #2's family did not want Resident #4 in her room.
Observation on 04/03/2023 at 11:37 a.m. revealed Resident #2 seated at the dining table feeding herself lunch. Attempted interview revealed Resident #2 was pleasant and oriented to person only.
Review of a facility grievance dated 03/06/2023 and documented by S2 DON revealed in part . Received a complaint from Resident #2's RP alleging Resident #2 is being verbally abused by Resident #4, with the last incident occurring on Mardi-Gras (02/21/2023). RP stated on Mardi Gras, Resident #4 got in Resident #2's face and told her to brush her hair because she looked like an old hag. Resident #2's RP stated she has also seen Resident #4 yell at her mother telling her to get out of her chair in the dining room.
Review of nurses' notes for interactions between Resident #2 and Resident #4 revealed in part .
10/07/2022 at 4:30 p.m. - Resident #2 is feeling depressed, crying and asking to call daughter to pick her up because she wanted to go home. Resident #2 said one of the ladies she talked with made her life miserable, she pointed her hand to Resident #4. Resident #2 was redirected and brought back to her room and advised to ignore what Resident #4 told her.
11/30/2022 at 5:25 p.m. - Resident #2 in day room sitting at dining table talking and socializing with other residents with no problem. Resident #2 started crying and became agitated due to Resident #4 yelled at her and asked her what she was looking at. Resident #2 removed herself from the table and went to her room.
Interview on 04/03/2023 at 12:04 p.m. with S5 LPN revealed she was the nurse assigned to Resident #2. S5 LPN revealed Resident #2 had dementia, occasional agitation and was afraid of bad weather. S5 LPN stated Resident #2 socialized well with others and only had problems with one Resident, Resident #4, in the past. S5 LPN stated Resident #4 would make comments to Resident #2 like what are you looking at?, why are you looking at me? S5 LPN stated the comments would cause Resident #2 to start crying. S5 LPN also stated Resident #2's Responsible Parties often report that other Residents have told them that Resident #4 says mean things to their mother and they (Responsible Parties) do not want Resident #4 in their mother's room.
Interview on 04/05/2023 at 9:30 a.m. with S12 CNA revealed Resident #2's family had made it clear that they didn't like the way Resident #4 spoke to Resident #2 and didn't want Resident #4 near or around Resident #2. S12 CNA revealed she had witnessed Resident #4 telling Resident #2 to get up and move to another chair. S12 CNA stated if Resident #2 was crying, because she was confused and didn't know where she was, Resident #4 would tell her to go in her room because nobody wants to hear that.
Review of a facility grievance dated 03/27/2023 revealed Resident #2's RP reported that Resident #4 had gone into Resident #2's room last night (03/26/2023). S9 HHC (Household Coordinator) and S2 DON began reviewing camera footage from Saturday (03/25/2023) evening. During the review of camera footage, it was noted that Resident #4 did enter into Resident #2's room at 6:10 p.m. and stayed for approximately 10 minutes. Staff seated in the dayroom in view of the Resident #2's room at the time of incident.
Interview on 04/03/2023 at 3:07 p.m. with S6 LPN revealed Resident #2's baseline was confused, generally friendly and social, depending on level of anxiety that day, as opposed to being fidgety and wandering. S6 LPN stated on 03/25/2023 she witnessed Resident #4 escorted Resident #2 into her room when Resident #2 was experiencing increased anxiety and confusion. S6 LPN stated she monitored but did not intervene because Resident #4 was exhibiting positive behavior. S6 LPN confirmed she was aware Resident #2's family did not want Resident #4 in her room due to past issues with Resident #4 being mean to Resident #2.
Interview on 04/04/2023 at 2:55 p.m. with S6 Household Coordinator revealed Resident #2's daughter/RP reported to her on 03/27/2023 that Resident #4 had gone into Resident #2's room over the weekend. S6 HHC stated she reported this to S2 DON and S6 HHC and S2 DON viewed camera footage and confirmed the RP's allegation. S6 HHC stated camera footage revealed Resident #4 was in Resident #2's room with the door open for about 10 minutes. S6 HHC revealed no other staff entered the room during that time. S6 HHC stated she was pretty sure Resident #2's family had mentioned and made everyone aware that they did not want Resident #4 in their mother's room.
Interview on 04/04/2023 at 11:30 a.m. with S2 DON and S1 Administrator confirmed that Resident #4 did enter Resident #2's room on the evening of 03/25/2023. S2 DON revealed Resident #2's Responsible Party had stated she did not want Resident #4 in her mother's room and that nursing staff were aware. Both S2 DON and S1 Administrator confirmed staff were present at the time Resident #4 entered Resident #2's room with Resident #2. S2 DON and S1 Administrator confirmed that Resident #2's RP had made complaints about Resident #4 saying mean things to Resident #2. Both S2 DON and S1 Admin confirmed staff should have prevented Resident #4 from entering Resident #2's room as requested by Resident #2's responsible party and did not.
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 observation, interview, and record review, the Facility failed to provide services with reasonable accommodation of needs for 1 Resident (R4) out of 11 (Resident #1, Resident #2, Resident #3,...
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Based on observation, interview, and record review, the Facility failed to provide services with reasonable accommodation of needs for 1 Resident (R4) out of 11 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 Resident #6, R1, R2, R3, R4, and R5) sampled Residents. The facility failed to ensure the call light was within reach for R4 to call for assistance when needed.
Findings:
Review of R4's Quarterly MDS with an ARD of 02/15/2023 revealed a BIMS of 12 (moderately impaired cognition).
Observation on 04/04/2023 at 4:05 p.m. revealed R4 in her room positioned in a recliner with the leg rest reclined. R4's legs were crossed over the left armrest and the call light cord was clipped to the wall with the padded call light on the floor underneath the bed. The call light was out of the R4's reach.
Interview with R4 revealed R4 was requesting to be placed in bed. R4 stated she didn't know where her call light was to call the CNA.
Interview on 04/05/2023 at 4:15 p.m. with S2 DON confirmed that R4's call light was out of reach and should have been available for R4's use to call for 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
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review and interview the Facility failed to develop and implement a baseline care plan or comprehensive care plan within 48 hours for each resident that includes the instructions neede...
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Based on record review and interview the Facility failed to develop and implement a baseline care plan or comprehensive care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #6) of 11 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6, R1, R2, R3, R4, and R5) sampled residents. Findings:
Review of Resident #6's Electronic Health Record revealed an admit date of 03/24/2023. Resident #6 had the following diagnoses including: Acute Respiratory Failure with Hypoxia; Pneumonia, unspecified organism; COPD; recurrent unspecified; SOB; and Emphysema.
Review of Resident #6's 04/2023 MD Orders revealed the following in part .
03/24/2023 - Oxygen @ 3L per nasal cannula continuous. May remove for brief periods, bathing/showers and transport
03/27/2023 - Clean filter, change date and initial tubing q week every evening shift every Saturday
03/30/2023 - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3 ml 1 application inhale orally BID
03/31/2023 - Post Nebulizer Treatment Monitor - Breath Sounds, record the total minutes received tx, toleration and pulse as needed BID for monitoring
Review of Resident #6's baseline Care Plan revealed no information pertaining to Resident #6 receiving oxygen therapy.
Interview on 04/04/2023 at 9:53 a.m. with S2 DON confirmed there was no information in Resident #6's Baseline Care Plan concerning the Resident receiving oxygen and it should be.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation interview and record review the Facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for ...
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Based on observation interview and record review the Facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #6) of 11 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, R1, R2, R3, R4 and R5) sampled residents by failing to label oxygen tubing with date when changed. Findings:
Observation on 04/03/2023 at 11:41 a.m. revealed Resident #6 sitting on the side of his bed in his room. Resident #6 had oxygen on at 3L/min per nasal cannula. There was no labeled date on the oxygen tubing or on the concentrator bottle.
Review of Resident #6's Electronic Health Record revealed an admit date of 03/24/2023. Resident #6 had the following diagnoses that included: Acute Respiratory Failure with Hypoxia; Pneumonia, unspecified organism; COPD; SOB; and Emphysema.
Review of Resident #6's 04/2023 MD Orders revealed the following in part .
03/24/2023 - Oxygen @ 3L per nasal cannula continuous. May remove for brief periods, bathing/showers and transport
03/27/2023 - Clean filter, change date and initial tubing q week every evening shift every Saturday
03/30/2023 - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg/3 ml 1 application inhale orally BID
Review of Resident #6's baseline Care Plan had no information concerning the Resident receiving oxygen therapy.
Review of the Facility Policy titled Departmental (Respiratory Therapy) - Prevention of Infection revealed no information concerning labeling of oxygen tubing.
Interview on 04/03/2023 at 11:47 a.m. with S7 LPN confirmed that Resident #6's oxygen tubing and concentrator bottle was not dated and should have been.
Observation on 04/03/2023 at 11:50 a.m. revealed S7 LPN came into Resident #6's room and changed the tubing and concentrator bottle. Both were dated with today's date.
Interview on 04/04/2023 at 9:13 a.m. with S2 DON revealed that oxygen tubing was changed every 7 days. S2 DON stated that it was not in the Facility's policy to label the oxygen tubing with the date it was changed. S2 DON stated documentation was required on the eMAR only.
Interview on 04/04/2023 at 9:53 a.m. with S2 DON confirmed there was an MD order for Resident #6 to label the oxygen tubing when changed on a weekly basis. S2 DON stated this order should have been followed and was not.
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 F0557
(Tag F0557)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a resident was treated with respect and dignity for 1(Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a resident was treated with respect and dignity for 1(Resident #5) of 11 ((Resident#1, Resident #2, Resident #3, Resident #4, Resident #5 Resident #6, R1, R2, R3, R4, and R5) sampled Residents. The Facility failed to ensure that Resident #5's room was free of odor, soiled bed linens, and a dirty bedside commode.
Findings:
Review of Resident #5's EHR revealed she was readmitted to the facility on [DATE] with admitting Diagnosis of Acute and Chronic Respiratory Failure with Hypoxia, Pulmonary HTN, Type 2 DM, Retinopathy with Macular Edema, Chronic Kidney Disease, Essential (Primary) HTN, Paroxysmal Atrial Fibrillation, Chronic Systolic (Congestive Heart Failure), Myocardial Infarction, Peripheral Vascular Disease, Generalize muscle weakness, Hx. of Falls, Major Depressive Disorder, Morbid (Severe), and Osteoarthritis.
Review of Resident #5's 5 day MDS with an ARD of 03/17/2023 revealed a BIMS of 15 (cognitively intact). Resident #5 was able to feed herself, required supervision with set-up help to walk in her room, locomotion on the unit, dressing, toilet use, and requires limited one person assistance with bed mobility, transfer, walk in corridor, and locomotion off the unit.
Review of Resident #5's Care Plan revealed Resident #5 had a self-care deficit and required extensive assistance by 1 staff for bathing/shower and personal hygiene. Limited physical mobility- used a wheelchair walker.
Observation on 04/03/2023 at 11:07 a.m. revealed Resident #5 sitting in a recliner in her room fully dressed. Resident #1's bathroom had a very strong smell of urine in the area near the vanity and behind the toilet.
Interview with Resident #5 on 04/03/2023 at 11:15 a.m. revealed that on 03/26/2023, she was feeling bad and had problems with holding her bowels. Resident #5 stated she used her bedside commode, soiled 2 gowns, a pair of underwear and had bowel movements on her bed sheets. Resident #5 stated she was embarrassed because she was feeling so bad and was not able to clean up behind herself. Resident #5 stated she gone to the Emergency Room. Resident #5 stated that she returned back the Facility around lunch only to find her room the same way that she left it. Resident #5 stated her daughter had to cover the bed and move the bedside commode to the side. Resident #5 stated her daughter had to ask the nurse to send a CNA to clean the room. Resident #5 stated she waited and no CNA came. Resident #5 stated she was so upset, she could have cried because people treat dogs better than that. Resident stated that was a dirty shame and was so disrespectful. Resident #5 stated she tried to eat her lunch but she just couldn't because of the odor, unmade soiled bed, and dirty bedside commode. Resident stated her room was only cleaned when S10 Homemaker was working.
Interview on 04/03/2023 at 11:56 a.m. with S10 Homemaker stated 03/26/2023 was her scheduled off day. S10 Homemaker stated there were no other homemaker scheduled on the home. S10 Homemaker stated her duties were to sweep/mop, and clean bathrooms every day; serve the Residents' meals; and clean the kitchen after each meal. S10 Homemaker stated on her days off, the CNAs have to perform her job duties.
Interview on 04/03/2023 at 12:03 p.m. with S5 LPN revealed Resident #5 returned from the emergency room on [DATE] at 12:35 p.m. S5 LPN stated it was not until Resident #5's daughter reported to her that the room had not been cleaned. S5 LPN stated upon entering Resident #5's room, the Resident was sitting next to the bed eating her lunch in the uncleaned room with the heavy smell of feces. S5 LPN stated she asked S15 Care Partner to go and clean Resident #5's room. S5 LPN stated that S10 Homemaker had the day off therefore no Homemaker was scheduled to the home. S5 LPN stated in the absence of a homemaker it's the responsibility of the CNA to clean the Residents' rooms. S5 LPN stated she had reported to S13 CNA Homemaker Supervisor that Residents' rooms are not being cleaned when there is no Homemaker scheduled on the home. S5 LPN confirmed that Resident #5's room had a foul smell of feces, feces on the side of the fitted sheet, soiled gowns and underwear in the corner of the shower and a dirty bedside commode. S5 LPN confirmed that Resident #5's room should had been cleaned while she was at the emergency room and wasn't.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide housekeeping and maintenance services necessa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, comfortable, and homelike environment by failing to ensure:
1. Resident rooms/bathrooms were maintained for 3 ( Resident #5, R2, and R3) of 11 (Resident#1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, R1, R2, R3, R4, and R5) sampled Residents
2. Residents' assistive devices were maintained for 4 (R2, R3, R4, and R5) of 11 (Resident#1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, R1, R2, R3, R4, and R5) sampled Residents.
Findings:
1.
Resident #5
A review of Resident #5's EHR revealed she was readmitted to the facility on [DATE] with diagnoses that included in part . Acute and Chronic Respiratory Failure with Hypoxia, Pulmonary HTN, Type 2 DM, Essential (Primary) HTN, Congestive Heart Failure, Peripheral Vascular Disease, Major Depressive Disorder, and Osteoarthritis.
Review of Resident #5's 5 day MDS with an ARD of 03/17/2023 revealed a BIMS score of 15, indicating Resident #5 was cognitively intact.
Observation on 04/03/2023 at 11:07 a.m. revealed Resident #5 sitting in a recliner in her room.
Review of photographs, provided by Resident #5's RP, with a date and time stamp of 03/26/2023 12:26 p.m., 12:28 p.m. and 12:41 p.m. revealed feces on the side of bed sheets, a closed bedside commode with a small white face towel which was covered with dark black/grayish matter, red and blue pattern clothing on the floor in the corner on top of a clear shower mat and gowns were noted in the photographs to be entangled in a large white towel with large amounts of smeared dark colored substance.
Interview on 04/03/2023 at 12:50 p.m. with Resident #5 and Resident #5's RP revealed on 03/26/2023, Resident #5 left the facility at 5:00 a.m. and returned at approximately 12:30 p.m. Resident #5's RP provided photographs which were taken by the RP on 03/26/2023 after Resident #5 returned from an emergency room visit. Resident #5's RP stated she reported the conditions of Resident #5's room to S5 LPN on 03/26/2023 at approximately 12:45 p.m. Resident #5's RP stated a CNA came in and moved the bedside commode into the bathroom after the room's condition was reported to S5 LPN. Resident #5's stated lunch was purchased by her RP and she wanted to visit and eat in the privacy of her room, so she had to eat in the uncleaned, unsanitary conditions of her room. Resident #5's RP stated when she returned to the facility on [DATE] at 6:00 p.m., the bed had been made; however, the bathroom and shower had not been cleaned, soiled clothing were still on the shower floor, and the room reeked of the odor of bowel movement. Resident #5's RP stated she again reported to S5 LPN that Resident #5's room still needed to be cleaned.
An interview was conducted on 04/05/2023 at 1:00 p.m. with S5 LPN at which time the photographs of Resident #5's room/shower, provided by Resident #5's RP, were identified by S5 LPN as Resident #5's room and shower. S5 LPN confirmed the photographs showed the condition that Resident #5's room/shower were in on 03/26/2023 when Resident #5 returned from an emergency room visit.
An interview was conducted on 04/05/2023 at 2:05 p.m. with S13 CNA Homemaker Supervisor confirmed Resident #5's room should have been checked and cleaned while Resident #5 was out to the Emergency Room, and not left for Resident #5 to return to an uncleaned room/bathroom.
R2
A review of R2's EHR revealed he was readmitted to the facility on [DATE] with diagnoses that included in part . Type 2 DM, Essential (Primary) Hypertension, Congestive Heart Failure, and Osteoarthritis.
A review of R2's Annual MDS with an ARD of 02/08/2023 revealed a BIMS score of 15, indicating R2 was cognitively intact.
Observation on 04/04/2023 at 3:45 p.m. revealed R2 in his room in his wheelchair. Observation of R2's bathroom revealed a thick film of dried tan colored substance with dark flakes on the floor behind the toilet. The bolts on the toilet had a dried yellowish substance on them. A dried brownish substance was smeared on the shower curtain.
Interview on 04/04/2023 at 3:45 p.m. with R2 revealed his room/bathroom were cleaned once a week and sometimes twice weekly. R2 stated he shared a bathroom with R3 who misses the toilet all the time, and urinates on the toilet seat and/or the floor. R2 stated last week (unable to recall exact date) the bathroom stayed dirty for three days because R3 missed the toilet, urinated on the toilet seat/floor. R2 reported fecal matter was on the toilet ring, rim and outside on the bowl. R2 stated he reported it to the day shift CNA (unable to recall her name) for 2 days and nothing was done. R2 stated finally on the third day, a day shift CNA came in and finally cleaned the toilet and the bathroom. R2 stated during those 3 days, no one came in to clean his room, sweep/mop and or empty the trash. R2 stated he used his shower every day and had to use a dirty bathroom for 3 days. R2 stated since he had reported it to the day shift CNA, he felt there was no need to tell the nurse so he didn't.
Observation of R2's bathroom on 04/04/2023 at 4:20 p.m. accompanied by S2 DON confirmed the areas around the toilet were not cleaned, and S2 DON identified the dried brown smeared substance as fecal matter. S2 DON stated the rooms/bathrooms should be cleaned daily by the Homemaker, and confirmed the bathroom that was shared by R2 and R3 bathroom was not cleaned but should have been.
R3
A review of R3's EHR revealed he was readmitted to the facility on [DATE] with diagnoses that included in part . Essential (Primary) Hypertension, Peripheral Vascular Disease, Seizure Disease and Chronic Obstructive Disease.
Review of R3's Quarterly MDS with an ARD of 01/02/2023 revealed a BIMS score of 05, indicating (severely impaired cognitively).
Observation on 04/04/2023 at 4:00 p.m. revealed R3 lying in bed. The bedroom floor was observed with small pieces of debris scattered throughout the floor. There was dust in the corner of the room behind the door, behind the bed, and underneath the bed/vanity. The trash can was overflowing with trash. Observation of R3's bathroom revealed a thick film of dried tan colored substance with dark flakes on the floor behind the toilet. The bolts on the toilet had a dried yellowish substance on them. A dried brownish substance smeared on the shower curtain.
Interview with R3 4:00 p.m. revealed he was able to answer all questions with appropriate response. R3 stated that he shared the bathroom with R2. R3 stated his room was not cleaned today (04/04/2023) or yesterday (04/03/2023). R3 stated one morning last week (unable to recall the date), he had an accident in the bathroom where he messed on the toilet. R3 stated when he told the day shift CNA (not sure of her name and day), she stated They were busy and would get to it later. R3 stated, later never came until maybe 2 days later.
During an observation on 04/04/2023 at 4:25 p.m. accompanied by S2 DON, S2 DON asked R3 what can I do for you? R3 replied you can have my room cleaned. S2 DON confirmed R3's room/bathroom needed to be cleaned and should have been cleaned daily, but had not been.
2.
Observation on 04/04/2023 at 3:45 p.m. revealed R2 sitting in a wheelchair with multiple tears on both arm rests. Interview with R2, at the time of the observation, revealed he used the wheelchair to move around the facility.
Observation on 04/04/2023 at 4:00 p.m. revealed R3 lying in bed with a wheelchair positioned at the foot of his bed. The wheelchair was noted to have multiple tears on both armrests and a tear on the seat cushion.
Observation on 04/04/2023 at 4:05 p.m. revealed R4 sitting in a recliner with a wheelchair positioned in front of the bathroom door. The wheelchair was noted to have a tear on the right armrest with a long strip of neon green tape, taped on top of the tear.
Interview conducted on 04/04/2023 at 4:15 p.m. with S2 DON after she inspected R2, R3 and R4's wheelchairs; confirmed the wheelchairs were in need of repair or replacement.
Observation on 04/05/2023 at 8:10 a.m. revealed R5 sitting in a wheelchair. The left armrest of the wheelchair did not have a cushion under the vinyl covering. The vinyl cover was secured in place with neon green tape. The armrest of the wheelchair was secured with neon green tape which was raveled and coming off.
Interview conducted on 04/05/2023 at 8:17 a.m. with S4 ADON revealed R5 had a customized wheelchair on order. S4 ADON stated R5's wheelchair was ordered by Therapy Services.
Interview conducted on 04/05/2023 at 9:00 a.m. with S14 Rehabilitation Director revealed a customized wheelchair was ordered per R5 family's request in 12/2022. Rehabilitation Director stated R5 was measured for the wheelchair in 01/2023 by an outsource representative. S14 Rehabilitation Director confirmed she had no estimated date of delivery.
Interview conducted on 04/05/2023 at 9:10 a.m. with S4 ADON confirmed another wheelchair should have been issued to R5 until the delivery of his customized wheelchair
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the Facility failed to ensure their grievance policy and procedure was followed. The Facility failed to resolve Resident's/Responsible Parties complai...
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Based on observation, interview and record review the Facility failed to ensure their grievance policy and procedure was followed. The Facility failed to resolve Resident's/Responsible Parties complaints/grievances for 1 (Resident #2) of 11(Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, R1, R2, R3, R4, and R5) sampled residents. Findings:
Review of the Facility's policy titled Resident Care Grievance Policy revealed in part . The Resident or person filing the grievance or complaint on behalf of the Resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems.
Review of the Facility's grievance log revealed in part .
Grievance opened 03/06/2023 on behalf of Resident #2 by the responsible party. Grievance concern noted as patient safety. Resolution noted as investigation initiated, supervision of both residents. The date complainant notified documented as 03/08/2023.
Grievance opened 03/27/2023 on behalf of Resident #2 by the responsible party. Grievance concern noted as customer service. Resolution noted as, staff reviewed cameras, investigation initiated etc. The date complainant notified was left blank.
Review of a facility electronic grievance report dated 03/06/2023 documented by S2 DON (Director of Nursing) revealed in part . Received a complaint from Resident #2's RP (Responsible Party) alleging Resident #2 is being verbally abused by Resident #4, with the last incident occurring on Mardi-Gras (02/21/2023). RP stated on Mardi Gras, Resident #4 got in Resident #2's face and told her to brush her hair because she looked like an old hag. Resident #2's RP stated she has also seen Resident #4 yell at her mother telling her to get out of her chair in the dining room.
Immediate action taken revealed in part .Resident #2 assessed with no abnormalities noted. Investigation initiated. Safe surveys completed with interviewable Residents. Accused resident counseled. Resident #4 willing to go to inpatient behavioral hospital.
Review of attached notes revealed no documented resolution of the grievance logged on 03/06/2023.
Review of a facility electronic grievance report dated 03/27/2023 revealed Resident #2's RP reported that Resident #4 had gone into Resident #2's room last night (03/26/2023). S9 HHC (Household Coordinator) and S2 DON (Director of Nursing) began reviewing camera footage from Saturday (03/25/2023) evening. During the review of camera footage, it was noted that Resident #4 did enter into Resident #2's room at 6:10 p.m. and stayed for approximately 10 minutes. Staff seated in the dayroom in view of the Resident #2's room at the time of incident.
Immediate action taken documented as: Investigation initiated into event.
Review of attached notes revealed no documented resolution of the grievance logged on 03/27/2023.
Interview on 04/04/2023 at 8:36 a.m. with S2 DON and S1 Administrator confirmed there was no documented evidence that grievances opened on 03/06/2023 and 03/27/2023 on behalf of Resident #2 had been resolved. S2 DON and S1 Administrator confirmed that investigating grievances and assessing Residents were not considered resolutions.
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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $92,470 in fines, Payment denial on record. Review inspection reports carefully.
- • 32 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $92,470 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • 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 Riviere De Soleil Community's CMS Rating?
CMS assigns RIVIERE DE SOLEIL COMMUNITY CARE CENTER an overall rating of 2 out of 5 stars, which is considered 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 Riviere De Soleil Community Staffed?
CMS rates RIVIERE DE SOLEIL COMMUNITY CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 46%, compared to the Louisiana average of 46%.
What Have Inspectors Found at Riviere De Soleil Community?
State health inspectors documented 32 deficiencies at RIVIERE DE SOLEIL COMMUNITY CARE CENTER during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 29 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Riviere De Soleil Community?
RIVIERE DE SOLEIL COMMUNITY CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by COMMCARE CORPORATION, a chain that manages multiple nursing homes. With 130 certified beds and approximately 107 residents (about 82% occupancy), it is a mid-sized facility located in MANSURA, Louisiana.
How Does Riviere De Soleil Community Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, RIVIERE DE SOLEIL COMMUNITY CARE CENTER's overall rating (2 stars) is below the state average of 2.4, staff turnover (46%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Riviere De Soleil Community?
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 I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Riviere De Soleil Community Safe?
Based on CMS inspection data, RIVIERE DE SOLEIL COMMUNITY CARE CENTER 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 2-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 Riviere De Soleil Community Stick Around?
RIVIERE DE SOLEIL COMMUNITY CARE CENTER has a staff turnover rate of 46%, 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 Riviere De Soleil Community Ever Fined?
RIVIERE DE SOLEIL COMMUNITY CARE CENTER has been fined $92,470 across 2 penalty actions. This is above the Louisiana average of $34,004. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Riviere De Soleil Community on Any Federal Watch List?
RIVIERE DE SOLEIL COMMUNITY CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.