Many Healthcare and Rehabilitation Center
For profit - Corporation
162 Beds
NEXION HEALTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
18/100
#143 of 264 in LA
Photo by Many Healthcare & Rehabilitation Center
Photo by Many Healthcare & Rehabilitation Center
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Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Many Healthcare and Rehabilitation Center currently holds a Trust Grade of F, indicating significant concerns about its care quality. Ranking #143 out of 264 in Louisiana places it in the bottom half of the state's facilities, and it is the second of only two options in Sabine County. The facility's performance is worsening, with issues increasing from 8 to 10 between 2024 and 2025, and it has a concerning total of $112,959 in fines, higher than 77% of Louisiana facilities. While staffing is a relative strength with a turnover rate of 24%, which is well below the state average, the quality of care is troubling, as shown by serious incidents where residents were harmed, including a resident suffering a fractured femur due to improper transfer and another resident experiencing physical abuse by a fellow resident. Overall, while there are some positive aspects like staffing stability, the critical safety issues and low trust grade raise significant red flags for families considering this facility.
- Trust Score
- F
- In Louisiana
- #143/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 24% annual turnover. Excellent stability, 24 points below Louisiana's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- $112,959 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
18/100
Bottom 46%
Review needed
8 → 10 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 10 issues
The Good
-
Low Staff Turnover (24%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (24%)
24 points below Louisiana average of 48%
Facility shows strength in staff retention, fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Federal Fines: $112,959
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: NEXION HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 34 deficiencies on record
1 life-threatening 2 actual harm
Jan 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (#71) out of 1 resident reviewed for discharge. The total sample size w...
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Based on record review and interview the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (#71) out of 1 resident reviewed for discharge. The total sample size was 29.
Findings:
Review of the facility's policy titled Transfer or Discharge Notice with a review date of 01/2023 read in part . Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. 6. A copy of the notice is sent to the Office of the State Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.
Record Review of Resident #71's Electronic Health Record (EHR) revealed an admission date of 11/06/2024 and a discharge date of 12/10/2024. Resident #71 had diagnoses that included in part .Displaced Comminuted Fracture of Shaft of Right Femur; Subsequent encounter for Closed Fracture with routine healing; Muscle Weakness; Primary Osteoarthritis other specified site; Unilateral Primary Osteoarthritis, Right Knee; Cognitive Communication Deficit; Age-Related Osteoporosis without current pathological fracture; Anxiety Disorder.
Record Review of Resident #71's Discharge MDS with an ARD of 12/10/2024 revealed a discharge date of 12/10/2024.
Record Review of Resident #71's EHR revealed no documentation that the Ombudsman had been notified of Resident #71's discharge to another facility on 12/10/2024.
Interview on 01/14/2025 at 2:26 p.m. with S5 Social Services Director (SSD) revealed Resident #71 was discharged to a behavioral hospital due to an increase in behaviors. S5 SSD stated S6 Business Office Manager was responsible for sending notification of transfers and discharges to the Ombudsman.
Interview on 01/14/2025 at 2:29 p.m. with S6 Business Office Manager confirmed she did not submit in writing to the Ombudsmen a notification of Resident #71's discharge.
Interview on 01/14/2025 at 2:49 p.m. with S3 Corporate RN confirmed the facility should submit a notification in writing to the Ombudsmen of resident transfers and discharges, but did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#5) of 1 residents investigated for PASARR in a final sample of 29 residents.
Findings:
Record Review of Resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part .Major Depressive Disorder, Anxiety Disorder, Cerebral Infarction without residual deficits, Vascular Dementia Unspecified Severity without Behavioral Disturbance. Further review revealed he was diagnosed with Schizoaffective Disorder on 10/10/2023.
Record Review of Resident #5's Quarterly MDS with an ARD of 01/30/2025 revealed a BIMS summary score of 99, indicating BIMS was unable to be completed.
Record Review of the Resident #5's Care Plan with a Target Date of 01/22/2025 revealed in part .The resident had the potential to be verbally aggressive, yelling at staff, cursing at staff (initiated 10/09/2023). Interventions: Psychiatric/Psychogeriatric consult as indicated. Administer medications as ordered. Monitor/document for side effects and effectiveness.
The resident uses psychotropic medications (initiated 10/09/2023). Interventions: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness. Monitor/record occurrence of for target behavior symptoms and document per facility protocol.
Further review of Resident #5's record revealed there was no evidence that a new review or a Level II PASARR had been submitted to the appropriate state-designated authority after the new diagnosis of Schizoaffective Disorder on 10/10/2023.
Interview on 01/13/2025 at 12:40 p.m. with S5 Social Services Director revealed she was responsible for sending referrals to the appropriate state-agencies for Level II PASARR evaluations. After review of Office of Behavioral Health (OBH) PASRR Level II Resident Review Form, S5 Social Services Director stated Resident #5 didn't meet criteria for a Level II PASARR evaluation.
Interview on 01/13/2025 at 2:37 p.m. with S5 Social Services Director reviewed Resident #5's diagnoses list and confirmed Resident #5 had a diagnosis of Schizoaffective Disorder on 10/10/2023. S5 Social Services Director confirmed the OBH PASRR Level II Resident Review Form that was submitted for Resident #5 was incorrect, and a Level II PASARR evaluation should have been submitted, but was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the implementation of a comprehensive person cen...
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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 the implementation of a comprehensive person centered care plan for 1 (Resident #44) of 29 sampled residents. The facility failed to ensure Resident #44's NPO status was implemented.
Findings:
Review of Resident #44's clinical record revealed an admit date of 03/28/2024, with diagnoses which included dysphagia-oropharyngeal phase; hemiplegia and hemiparesis following cerebral infarction protein-calorie malnutrition; dysphasia following other cerebrovascular disease; dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; adult failure to thrive and age-related physical debility.
Review of Resident #44's Quarterly MDS with an ARD of 11/12/2024, revealed a BIMS score of 4. Resident had severe cognitive impairment. Resident had impairment on both sides for upper and lower extremities. Resident was dependent for eating, oral hygiene, toileting, showering/bathing; lower/upper body dressing and personal hygiene.
Review of Resident #44's physician's order with a start date of 11/06/2024, read in part NPO diet, NPO texture, NPO consistency.
Review of Resident #44's Care Plan revealed in part The resident requires tube feeding, NPO. Interventions to include: *****NPO**.
Review of Resident #44's Tasks revealed a [NAME] that read in part . Level of Staff assistance during care: Resident is nothing by mouth for swallowing. Eating/Nutrition: *****NPO**.
Observation of Resident #44 on 01/13/2025 at 10:28 a.m. revealed Resident #44 in bed; Grey water pitcher with a straw noted on Resident #44's bedside table.
Interview with S10 LPN on 01/13/2025 at 10:36 a.m. revealed that if Resident #44 requested anything by mouth; she would explain to Resident #44 that she was NPO.
Interview with S9 CNA on 01/13/2025 at 10:41 a.m. revealed S9 CNA provided Resident #44 with small swallows of water when she goes in to check on Resident #44. S9 CNA stated that the water pitcher in Resident 44's room is used for sips of water. S9 CNA stated that she would ask the nurse if a resident was not able to have anything by mouth.
Observation and Interview with S10 LPN on 01/13/2025 at 2:29 p.m. revealed that S9 CNA was aware that she should not have been giving Resident #44 anything by mouth to include water. S10 LPN stated that she was unsure of why the grey pitcher with a straw was in Resident #44's room.
Interview with S2 DON on 01/13/2025 at 2:50 p.m. confirmed that Resident #44 should not have been given sips of water since she was NPO and that there should not have been a water pitcher with a straw on her bedside table. S2 DON also stated that CNA's are aware of resident status by checking the Kiosk.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to document a Discharge Summary when a resident was discharged from the facility for 1 (#71) out of 1 residents reviewed for discharge. The tot...
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Based on interview and record review the facility failed to document a Discharge Summary when a resident was discharged from the facility for 1 (#71) out of 1 residents reviewed for discharge. The total sample size was 29.
Findings:
Review of the facility's policy titled Transfer or Discharge Documentation and Notice with a review date of 01/2023 read in part . When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.
Record Review of Resident #71's Electronic Health Record (EHR) revealed an admission date of 11/06/2024 and a discharge date of 12/10/2024. Resident #71 had diagnoses that included in part .Displaced Comminuted Fracture of Shaft of Right Femur; Subsequent encounter for Closed Fracture with routine healing; Muscle Weakness; Primary Osteoarthritis other specified site; Unilateral Primary Osteoarthritis, Right Knee; Cognitive Communication Deficit; Age-Related Osteoporosis without current pathological fracture; Anxiety Disorder.
Record Review of Resident #71's Discharge MDS with an ARD of 12/10/2024 revealed a discharge date of 12/10/2024.
Record Review of Resident #71's departmental progress notes read in part .
12/10/2024 4:50 pm General Nurses Note: Resident accepted by facility . S2 DON notified, notified Resident #71's responsible party (RP), and Physician . awaiting pick up from ambulance service.
12/10/2024 6:25 p.m. General Nurses Note: Resident #71 left out of facility via ambulance, Resident #71 left in stable condition via stretcher. Gave report to LPN, and notified Resident #71's RP and S2 DON of resident departure from facility.
12/10/2024 8:23 p.m. Social Services Note: Resident #71 discharged .
Record Review of Resident #71's EHR and paper medical record revealed no documentation of a discharge summary completed.
Interview on 01/14/2025 at 2:42 p.m. with S2 DON accompanied with S3 Corporate RN confirmed a discharge summary should have been completed for Resident #71, but was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infecti...
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Based on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent possible cross contamination for 1 (#44) of 29 sampled residents by failing to use enhanced barrier precautions, when needed. Findings:
Review on 01/14/2025 of the facility's policy and procedure dated 04/01/2024, and titled Enhanced Barrier Precautions read in part . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following:
Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies.
Resident Activity/Assistance for Residents on EBP
[NAME] Gloves and Gown
Administer medications enterally:
Yes
Device care or use: central line, urinary catheter, feeding tube .
Yes
Any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device
Yes
Review of Resident #44's clinical record revealed an admit date of 03/28/2024, with diagnoses which included dysphagia-oropharyngeal phase; hemiplegia and hemiparesis following cerebral infarction protein-calorie malnutrition; dysphasia following other cerebrovascular disease; dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; adult failure to thrive and age-related physical debility.
Review of Resident #44's Quarterly MDS with an ARD of 11/12/2024, revealed a BIMS score of 4. Resident had severe cognitive impairment. Resident had impairment on both sides for upper and lower extremities. Resident was dependent for eating, oral hygiene, toileting, showering/bathing; lower/upper body dressing and personal hygiene.
Review of Resident #44's Care Plan revealed in part The resident requires tube feeding; NPO. Interventions to include . Promote enhanced barrier precaution when providing care or having physical contact with resident.
Observation of Resident #44 in room on 01/12/2025 at 2:57 p.m. revealed an Enhanced Barrier Precaution (EBP) sign on the outside of the room but no PPE noted on door or in room.
Observation of Resident #44 in bed on 01/13/2025 at 10:28 a.m. revealed an Enhanced Barrier Precaution sign by Resident #44's door but no PPE hanging on door or in Resident #44's room.
Observation of Resident #44's Medication administration via PEG tube on 01/13/2025 at 1:59 p.m. revealed S10 LPN did not wear a gown while in contact with Resident #44's PEG tube. S10 LPN confirmed that she should have worn a gown while flushing and administering medications via Resident #44's PEG tube.
Interview with S2 DON on 01/13/2025 at 2:50 p.m. confirmed that a gown and gloves should have been worn by S10 LPN while administering Resident #44's medication and flush via PEG tube.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (Resident #46) of 29 sampled residents. The fac...
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Based on observation, record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (Resident #46) of 29 sampled residents. The facility failed to ensure medications were administered safely and timely by leaving Resident #46's medications at her bedside.
Findings:
Review of the facility's policy titled Medication Administration dated 07/08/2024 revealed in part .Medications are administered in a safe and timely manner, and as prescribed.
Review of Resident #46's medical record revealed an admit date of 07/19/2021 with diagnoses that included in part .Bilateral Primary Osteoarthritis, Morbid (severe) Obesity, Bipolar Disorder, Obstructive Sleep Apnea, Unspecified Myalgia, Repeated Falls, Chest Pain and Edema.
Review of Resident #46's Quarterly MDS with an ARD of 10/22/2024 revealed a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #46 required supervision for: Bed mobility, Transfer, Eating and Toilet use.
Review of Resident #46's care plan with a target date of 04/09/2025 revealed the resident has frequent health complaints with interventions that included administer medications as ordered.
Observation and interview on 01/12/2025 at 9:41 a.m. revealed Resident #46 lying in bed. Resident #46 noted to have a cup of medicine sitting on her bed side table. Resident #46 revealed the medications in the cup were her morning medications that the nurse had left for her to take. Resident #46 revealed she had fallen back asleep before she could take her medications.
Observation and interview on 01/12/2025 at 9:48 a.m. with S8 LPN in Resident #46's room confirmed the medications left on Resident #46's bed side table in a medicine cup were her morning medications. S8 LPN confirmed she did not ensure Resident #46 had swallowed her medications before she left Resident #4's room, but she should have.
Review of Resident #46's January 2025 Medication Administration Record with S8 LPN revealed the following medications were left at Resident #46's bedside:
1. Cranberry Oral Tablet 450 MG PO-8:00 a.m.
2. Effexor XR 75 MG (antidepressant) PO-8:00 a.m.
3. Ezetimibe 10 MG (cholesterol lowering) PO-8:00 a.m.
4. Loratadine 10 MG (antihistamine) PO-8:00 a.m.
5. Eliquis 2.5 MG (anticoagulant) PO-8:00 a.m.
6. Lasix 40 MG (diuretic) PO-8:00 a.m.
7. Lyrica 100 MG (anticonvulsant) PO-8:00 a.m.
8. Preservision AREDS 2 Capsules (vitamin and mineral) PO-8:00 a.m.
Interview on 01/13/2025 at 10:25 a.m. with S2 DON confirmed it was the expectation of nurses and nursing standards, that nurses ensure residents swallow their medications and not leave them at the resident's bedside.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 4 (S11 CNA, S12 CNA, S13 CNA, a...
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Based on record review and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 4 (S11 CNA, S12 CNA, S13 CNA, and S14 CNA) of 5 (S11 CNA, S12 CNA, S13 CNA, S14 CNA, and S15 CNA) CNA personnel records reviewed. Findings:
Review of CNA personnel records revealed the following:
S11 CNA- date of hire was on 09/15/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months.
S12 CNA-date of hire was on 11/21/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months.
S13 CNA-date of hire was on 02/01/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months.
S14 CNA-date of hire was on 04/26/2023. Further review failed to reveal evidence that an annual performance review had been completed and/or signed off by department head in the past 12 months.
Interview on 01/14/2025 at 12:00 p.m. with S1 Administrator revealed all employees should have yearly performance evaluations completed.
Telephone interview on 01/14/2025 at 12:06 p.m. with S4 Corporate HR confirmed all employees should have performance evaluations completed yearly.
Interview on 01/14/2025 at 2:12 p.m. with S1 Administrator confirmed the performance evaluations were not completed for S11 CNA, S12 CNA, S13 CNA, and S14 CNA as required, but should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and ...
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Based on observation and interview the facility failed to post nurse staffing information on a daily basis that included the resident census, and total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 70. Findings:
Observation on 01/12/2025 at 8:40 a.m. revealed a form for daily staffing dated 01/10/2025 was posted on a bulletin board near the nurse's station. Complete daily staffing information including census, and total number and actual hours worked by nursing staff were not posted for 01/10/2025, 01/11/2025, and 01/12/2025.
Observation on 01/12/2025 at 9:06 a.m. revealed the posted daily staffing forms remained not updated for 01/10/2025, 01/11/2025, and 01/12/2025. Interview with S16 RN and S17 LPN at time of observation revealed they were unsure who was responsible for completing and posting the daily staffing hours over the weekend. S16 RN and S17 LPN confirmed the facility had not posted daily nurse staffing information on a daily basis, but should have.
Interview on 01/12/2025 at 9:33 a.m. with S1 Administrator confirmed nurse staff information including daily required and provided hours should have been posted daily over the weekend, but had not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The facility failed to follow the m...
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Based on observation, interview and record review the facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The facility failed to follow the menu in regards to recipe and portion size to ensure nutritional adequacy of the meal for 6 (#57, #41, #4, #1, #36 and #23) of 6 residents (#57, #41, #4, #1, #36 and #23), who received pureed diets.
Review of the facility's recipe book located in the kitchen for pureed diets revealed in part . P/PU4 (coded for pureed foods-no lumps, require no chewing). Beef Meatballs f/Frz (fresh/frozen) w/mushroom gravy. [NAME] Method: Puree; Serving Utensil: #8 scoop; Serving Size: ½ Cup. Preparation Step: IDDSI (International Dysphagia Diet Standardization Initiative) Pureed foods: The number of portions served should equal the same number of portions pureed. Use Fork-Drip and Spoon-tilt test to ensure proper PU4 consistency is reached. Potato Mashed f (fresh)/ Inst (instant) Mix (Mashed Potatoes). Serving Utensil: #8 scoop; serving size: ½ cup. Ingredients: Water, Tap (Boiled) and Potato, Mashed Flake Dry. Preparation Step: Prepare mashed potatoes according to package instructions.
1.Observation of preparation of the pureed lunch meal, and interview of S18 [NAME] on 01/12/2025 at 10:35 a.m., revealed the following: The pureed meal preparation consisted of Meatballs, Mashed Potatoes and [NAME] Gravy. S18 [NAME] stated that she was told to just make it look like baby food. S18 [NAME] was observed to add an unmeasured amount of cold tap water from the sink, and an unmeasured amount of the meatballs, in the food processor. S18 [NAME] paused the food processor to check the consistency of the meatballs, and then added more meatballs. S18 [NAME] stated that she was unaware of the amount of meatballs that had been added. S18 [NAME] did not follow a recipe to prepare the food items, and stated that she was unaware of a recipe binder for pureed food preparation. S18 [NAME] stated that she was told to just make it look like baby food. S18 [NAME] stated that there were 6 residents who received a pureed diet. Observation of S18 [NAME] prepare the mashed potatoes revealed there were preparation instructions on the bag; however, S18 [NAME] added an unmeasured amount of instant mashed potatoes to boiling water until the potatoes reached the consistency she preferred and S18 [NAME] used the same process for preparing the brown gravy mix.
Interview on 01/12/2025 at 10:50 a.m. with S7 Dietary Manager, confirmed that S18 [NAME] did not refer to the recipe for the P/PU4 diet prior to preparing the food, and confirmed that S18 [NAME] did not prepare the pureed items correctly.
2. Observation of the lunch meal service on 01/12/2025 at 12:10 p.m., revealed the P/PU4 diet of beef meatballs were not served with a #8 scoop (1/2 cup or 4 ounces). S18 [NAME] used a yellow scoop that measured 1 and 5/8 oz., served one meal tray that was to have 2oz of meat per the resident's meal card and changed to a green scoop that measured 2 and 2/3 oz. after S7 Dietary manager informed her of the incorrect utensil size.
Interview on 01/12/2025 at 12:26 p.m. with S7 Dietary Manager confirmed that the pureed meal item was served using the incorrect serving size utensil, and that they should have used the utensil designated on the posted print out titled NSF Certified Dishers, that contained color coded utensil serving measurements.
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 and prepare food under sanitary conditions in accordance with professional standards of food service safety, as evidenced by failing to:...
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Based on observation and interview the facility failed to store and prepare food under sanitary conditions in accordance with professional standards of food service safety, as evidenced by failing to:
1. Properly store food items located in the facility's refrigerator, freezer, resident dining area, and kitchen area.
2.Store clean dishes in an area that would remain free of food debris.
3. Monitor and record the temperatures of a refrigerator that was used to store prepared meal items for residents, from 12/01/2024 to current (01/12/2025).
4.Test and document the dishwasher's sanitizing solution concentration for dinner dishes on 01/10/2025 and 01/11/2025, and breakfast dishes on 01/12/2025.
5.Ensure dietary staff wore proper hair covering.
Findings:
Review of the facility's policy dated 10/2022, and titled Refrigerators and Freezers, read in part .
Policy Statement:
This facility will ensure safe refrigerator temperatures, and sanitation, and will observe food expiration guidelines.
Policy Interpretation and Implementation:
2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.
4. Food Service Supervisors, or designated employees will check and record refrigerator and freezer temperatures daily with first opening, and at closing in the evening.
7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.
8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired, or past perish dates.
Review of the facility's policy dated 10/2022, and titled Food Receiving and Storage read in part .
Policy Statement:
Food shall be received and stored in a manner that complies with safe food handling practices.
Policy Interpretation and Implementation:
1. Food Services, or other designated staff, will maintain clean food storage areas at all times.
7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date).
12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee, and documented according to state - specific requirements.
c. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines.
Review of the facility's policy dated 10/2022, and titled Food Preparation and Service read in part .
Policy Statement:
Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices.
Policy Interpretation and Implementation:
Food Preparation Area
6. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.
Review of the facility's policy dated 01/2023, and titled Dry Storage read in part .
4. If a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated.
11. Bags of bread products should be closed and dated with the date that it was opened.
12. All bins for storage must be emptied and cleaned before new food can be added. After the bin has been cleaned and dried, it should be dated with the date that it is filled.
Review of the facility's policy dated 01/2024, and titled Sanitization read in part .
Policy Statement:
The food service area shall be maintained in a clean and sanitary manner.
Policy Interpretation and Implementation:
1. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary .
Review of the facility's policy dated 10/2022, and titled Dishwashing Machine Use read in part .
Policy Statement:
Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation.
Policy Interpretation and Implementation:
5. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine, and once a week thereafter. Concentrations will be recorded in a facility approved log.
Observation of refrigerated items, and interview with S18 [NAME] during the initial tour of the kitchen that began on 01/12/2025 at 8:58 a.m., revealed 3 sticks of butter that had been removed from the packaging, and was not dated; 1 stick of butter opened, and undated; sausage links unsealed; a gallon size jar of Italian dressing open and undated; 1 pack of turkey sandwich meat, undated; a clear liquid substance in the bottom a silver container that contained the opened turkey sandwich meat and other unopened sandwich meats; and a bottle of liquid garlic opened and undated.
Observation of the Freezer during the initial tour of the kitchen that began on 01/12/2025 at 8:58 a.m., revealed 4 bags of frozen spinach that had been removed from the box and was undated; 6 bags of frozen red potatoes that had been removed from the box, and was undated; 7 packages of whipped topping that had been removed from the box and was undated; 1 bag of frozen chicken wings opened and undated; 1 package of Shrimp opened and undated; 1 box of frozen pie dough unsealed and undated with a Best By date of 03/15/2024; 1 box of frozen pie dough undated with a Best By date of 10/8/2024; 1 box of cookie dough unsealed and undated; 5 bags of frozen cauliflower that had been removed from the box and was undated; 6 bags of frozen vegetable blend that had been removed from the box and was undated.
Observation in the kitchen area on 01/12/2025 at 9:30 a.m. with S7 Dietary Manager revealed hamburger buns on the prep area table, opened and undated; pan lids located under the steam table, dirtied with food particles; a box of bananas stored under the kitchen mixer right next to a trash can; and an apple juice dispensing carton opened and uncovered.
Observation of the resident dining area on 01/12/2025 at 9:45 a.m., revealed a black refrigerator with no thermometer in the freezer area that held ice cream used for resident consumption, and prepared meal items in the refrigerated area to include puddings, and a red juice for today's lunch meal, with no temperature log observed at that time. Observation revealed 4 loaves of sandwich bread and 2 bags of rolls that were located on the shelving unit, and had been removed from the original container and was undated; a box of Kellogg's cereal that was opened, unsealed and undated.
Interview with S7 Dietary Manager on 01/12/2025 at 10:00 a.m. confirmed that in the refrigerator there were 3 sticks of butter that had been removed from the packaging, and were undated; 1 stick of butter that had been opened, and was undated; 1 package of sausage links were unsealed; a big jar of Italian dressing was opened and undated; 1 pack of turkey sandwich meat, was undated; and that there was a clear liquid substance in the bottom of the silver container that contained the undated turkey sandwich meat and other unopened sandwich meats; and that a bottle of liquid garlic was opened and undated. S7 Dietary Manager confirmed that in the freezer, there were 4 bags of frozen spinach that had been removed from the box and was undated; 6 bags of frozen red potatoes that had been removed from the box, and was undated; 7 packages of whipped topping that had been removed from the box and was undated; 1 bag of frozen chicken wings opened and undated; 1 package of Shrimp opened and undated; 1 box of frozen pie dough unsealed and undated with a Best By date of 03/15/2024; 1 box of frozen pie dough undated with a Best By date of 10/8/2024; 1 box of cookie dough unsealed and undated; 5 bags of frozen cauliflower that had been removed from the box and was undated; 6 bags of frozen vegetable blend that had been removed from the box and was undated. S7 Dietary Manager stated that the frozen pie dough should have been thrown out. S7 Dietary Manager confirmed that in the Dining area, there was no thermometer in the black refrigerator's freezer area, and that there were 4 loaves of sandwich bread and 2 bags of rolls that were located on the shelving unit, that had been removed from the original container and was undated; a box of Kellogg's cereal that was opened, unsealed and undated.
Interview with S20 Kitchen Aide on 01/12/2025 at 10:13 a.m., revealed that she was unaware of how or where to document the dishwasher's sanitizer solution concentration results, and had already used the dishwasher for the breakfast dishes without the sanitizer concentration being checked.
Review of the 01/2025 dishwasher's sanitizing solution concentration log, revealed that the dinner log had not been completed for 01/10/2025 and 01/11/2025, and the breakfast log had not been completed for 01/12/2025.
Interview and review of the Kitchen's freezer/refrigerator logs with S7 Dietary Manager on 01/12/2025 at 10:29 a.m., confirmed that the temperature log for the black refrigerator located in the dining area, had not been completed the entire month of 12/2024, and from 01/01/2025 to current (01/12/2025), and it should have been.
Observation of the lunch meal service on 01/12/2025 at 12:10 p.m., which consisted of Corndogs, French fries and creamed corn, revealed hair was observed in the corndogs. S18 [NAME] who served the corn dogs wore a green bandana as a hair covering. S7 Dietary Manager observed the corn dogs at that time, and confirmed that hair was in the corn dogs.
Sept 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse for 1 (#6)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse for 1 (#6) of 8 (#1, #2, #3, #4, #5, #6, #7 and #8) residents reviewed for abuse. The facility failed to protect Resident #6 from physical abuse by Resident #8.
The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
Review of the facility policy on 09/17/2024, with a revision date of 05/17/2024 titled Abuse Prohibition Policy, read in part . Each resident has the right to be free from abuse, mistreatment neglect, corporal punishment, involuntary seclusion and financial abuse.
Resident #6
Review of Resident #6's medical records revealed an admission date of 12/07/2022, with diagnoses that included: Heart Failure, Major Depressive Disorder, Osteoarthritis, Congestive Heart Failure, Hypertension, and Atrial Fibrillation.
Review of Resident #6's Quarterly MDS with an ARD of 07/09/2024 revealed a BIMS score of 07, indicating severe cognition impairment.
Resident #8
Review of Resident #8's medical record revealed an admit date of 02/20/2024, with diagnoses that included: Delusional Disorder, Generalized Anxiety Disorder, Schizoaffective Disorder, Bipolar type; Unspecified Dementia, Unspecified Severity with Agitation, Psychotic Disorder with Delusions due to known Physiological Condition, and Major Depressive Disorder, recurrent, severe with psychotic symptoms.
Review of Resident #8's MDS with an ARD of 05/17/2024 revealed a BIMS of 3, indicating severe cognitive impairment.
Review of Resident #8's Comprehensive Person Centered Care Plan with a target date of 06/07/2024, read in part Resident #8 has a behavior problem: throwing items, restless, agitation. Resident #8 has the potential to be physically aggressive towards staff and residents.
Review of a facility Incident Report dated 06/11/2024, revealed Resident #6, Resident #8 and other fellow residents, were sitting in Hall X common area on 06/11/2024 at 6:00 p.m. Resident #8 began speaking to Resident #6 but she did not respond. Resident #8 rolled his wheelchair to Resident #6, and grabbed the back of her hair and left ear. Staff then entered Hall X's common area, took Resident #8 to his room, and began 1:1 monitoring. S1 Administrator, S2 DON, and responsible party were notified. Resident #8 remained on 1:1 monitoring until he was admitted to an inpatient psychiatric hospital on [DATE].
Interview on 09/10/2024 at 12:25 p.m. with Resident R1, revealed she was on Hall X 's common area visiting with other residents, when she heard Resident #8 making a fuss. Resident R1 stated she heard Resident #6 ask Resident #8 to stop screaming. Resident R1 stated Resident #8 then went to Resident #6 and grabbed her by her hair and ear. Resident R1 stated she then began yelling for help and a staff member showed up and removed Resident #8 from the Hall X common area.
Interview on 09/16/2024 at 2:22 p.m. with S5 CNA, revealed she heard hollering from Hall X's common area, walked up, observed Resident #8 holding onto Resident #6's wheelchair, and would not let go. S5 CNA stated Resident R1 notified her that Resident #8 had pulled Resident #6's hair and ear. S5 CNA stated she separated Resident #6 and Resident #8, and redirected Resident #8 to his room and began 1:1 supervision.
Interview on 09/16/2024 at 2:30 p.m. with S6 CNA, revealed she was on Hall X making rounds, and heard yelling from Hall X's common area. S6 CNA stated she ran to Hall X's common area, and observed S5 CNA separating Resident #6 and Resident #8. S6 CNA stated after the incident, Resident #6 complained of ear pain, and she observed a red mark to Resident #6's left ear. S6 CNA stated Resident #8 became 1:1 supervision until he was sent out to Psychiatric Hospital.
The facility has implemented the following actions to correct the deficient practice:
1. Resident #6 and Resident #8 were separated and Resident #8 was placed on 1:1 monitoring immediately.
2. Resident #6 had a bruise observed to left ear after the incident, and has had no further injuries.
3. Each resident's physician and responsible party were notified regarding the incident.
4. New orders from Resident #8's physician for a psychiatric evaluation. Resident #8 continued 1:1 supervision until he was admitted to an inpatient psychiatric hospital on [DATE] at 12:15 p.m.
5. Life satisfaction rounds were made on all cognitive residents who utilized Hall X's common area, with no issues noted.
6. On 06/11/2024, S2 DON initiated an In-services/training reviewing the facility's abuse policy, and educated staff in aggressive behaviors in residents. All in services/training completed for facility staff as of 06/12/2024.
7. QA committed met on 06/11/2024 to discuss the resident to resident altercation that occurred between Resident #6 and Resident #8. Abuse QA is ongoing at this time.
Facility correction date of 06/12/2024.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure an allegation of resident to resident sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours aft...
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Based on interview and record review the facility failed to ensure an allegation of resident to resident sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the resident to resident sexual abuse was discovered for 2 (Resident #5 and Resident #7) of 8 residents reviewed for abuse. Findings:
Review of the facility's policy titled, Abuse Prohibition Policy read in part .
1.
Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination.
2.
The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within 2 hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation.
Review of the SIMS (Statewide Incident Management System) report dated 07/15/2024 revealed the allegation of sexual abuse for Resident #5 and Resident #7. Documentation on the SIMS report reflected the date of sexual abuse for Resident #5 and Resident #7 occurred on 07/12/2024 and 07/13/2024 but unable to validate/verify. The SIMS entry time was noted as 07/15/2024 at 9:05 a.m.
Interview on 09/16/2024 at 4:50 p.m. with S3 LPN revealed she had witnessed resident involved in 2 incidents over the weekend on Friday, 7/12/2024 and Saturday, 7/13/2024 but was not aware on needing to write an incident report immediately. S3 LPN reported she should have written the incident reports written within 2 hours after each incident but was not done.
Interview on 09/17/2024 at 9:00 a.m. with S2 DON revealed it wasn't until the daily morning meeting on Monday, 07/15/2024 when she and the administrator were informed of the incidents over the weekend when she initiated the Sims report immediately after made aware. S2 DON verified that S3 LPN should have initiated the incident report immediately and did not.
Interview on 09/17/2024 at 11:00 a.m. with S1 ADM confirmed the allegation of resident to resident sexual abuse was substantiated by the facility but was not notified and aware of the incident until Monday morning of 07/15/2024. S1 ADM confirmed a SIMS report was not entered immediately or within 2 hours after discovery of incident abuse and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to implement the resident's comprehensive plan of care for 1 (#4) of 8 (#1, #2, #3, #4, #5, #6 ,#7 and #8) sampled residents. The...
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Based on observation, record review, and interview the facility failed to implement the resident's comprehensive plan of care for 1 (#4) of 8 (#1, #2, #3, #4, #5, #6 ,#7 and #8) sampled residents. The facility failed to place a fall mat at the bedside for resident #4.
Findings:
Review of Resident #4's clinical record revealed an admit date of 01/04/2022, with diagnoses which included repeated falls; other spondylosis, cervical region; spondylolisthesis, lumbar region; other abnormalities of gait and mobility; displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing; schizoaffective disorder, bipolar type; anxiety disorder, unspecified; and Alzheimer's disease, unspecified.
Review of Resident #4's Quarterly MDS with an ARD/ Target date of 04/19/2024, revealed a BIMS score of 11; Moderate Impairment. Resident #4 requires supervision and one person physical assist with bed mobility; and requires Supervision and set up help only with transfers, eating and toilet use.
Review of Resident #4's clinical record revealed a Morse Fall Scale Evaluation with a Post Fall score of 50 (High Risk for Falling) dated 06/26/2024.
Review of Resident #4's physician's order with a start date of 07/08/2024, read in part .fall mat at bedside.
Review of Resident #4's Care Plan revealed in part The resident is at risk for falls. Falls 2024: 06/26/2024 - fell in room beside bed, therapy screen, c/o right pain, x-ray performed and sent to ER. Interventions included: Fall mat at bedside as ordered, non-slip footwear when ambulating, re-educate on call light, move closer to nurse's station for close observation and aiding with assist post-op.
Observation of Resident #4 on 09/09/2024 at 10:56 a.m., revealed Resident #4 propelling himself in his wheelchair. No fall mat at bedside, or in room.
Interview with Resident #4 on 09/09/2024 at 10:57 a.m., revealed that he broke his right hip over a month ago, when he was getting ready to put his pajamas on (unable to recall the exact date). Resident #4 stated that he turned around too quick, and fell on his hip. Resident #4 stated that he was sent to a local hospital via Helicopter, and had surgery on his hip. He stated that he transfers himself from bed to chair, and chair to bed, and does not need help, so he does not call for help.
Interview and observation on 09/09/24 at 1:02 p.m. with S2 DON, confirmed that there was no fall mat at Resident #4's bedside, or in room at all, and there should have been.
Apr 2024
2 deficiencies
1 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
Based on record review, observation, and interview, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for a...
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Based on record review, observation, and interview, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for accidents. The facility failed to properly secure Resident #3's wheelchair prior to transporting the resident in 1 of the facility's 2 vans.
This deficient practice resulted in an immediate jeopardy situation on 03/20/2024 at 9:50 a.m., when Resident #3 was placed in the facility's van, and her wheelchair was anchored/secured in the facility's van with only three of the four anchors required. While the van was in motion, Resident #3's wheelchair fell backwards, and Resident #3 hit the back of her head on the lift. Resident #3 sustained an abrasion with bleeding noted to the back of her head. The Administrator stated the weekly safety inspections on the transportation van had not been completed by the van driver prior to the accident, as directed by the facility's policy.
The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
Review on 04/11/2024 of the facility policy revised on 03/2023 titled Facility Vehicle Log, A Part of the Driver and Vehicle Safety Policy revealed in part .
Driver's Weekly Vehicle Safety Inspection-
To be completed by the company vehicle driver once each week, and prior to driving a vehicle that has been returned to service after repairs.
If there are safety concerns noted during the inspection, they are to be noted on the Driver's Weekly Vehicle Safety Inspection form, and reported immediately to Maintenance or the Administrator. The vehicle should immediately be taken out of service if the driver or others determine that the vehicle cannot be driven safely.
Maintenance and Repair Invoices-
In addition to the form maintained above, all invoices for maintenance and repairs must be maintained either in the Facility Vehicle Log, or in another secure location so that a complete record of the vehicle's history is available.
Securing Residents in Van - Competency Determination-
Secure two front tie-downs to a solid, structural frame member of the wheelchair.
Secure two back tie-downs to a solid, structural frame member of the wheelchair.
Secure the passenger with shoulder and lap belts.
Review of the Q'straint Installation Instructions - Vehicle Anchorages & Accessories for 4-Point Wheelchair Securement Systems dated September 2009, and reviewed on 04/09/2024 at 4:36 p.m. revealed in part .
WARNINGS
Do not alter or modify the system or components in any way without first consulting Q'Straint.
The system is a complete, integrated system. Do not interchange or substitute any components.
Q'Straint systems and components have been tested in a configuration similar to that recommended in these instructions. Any deviation from these recommendations is the responsibility of the installer.
Systems and components should only be installed by an experienced technician.
Review of Resident #3's medical record revealed an admit date of 09/07/2017, with diagnoses that included in part .Cerebral Infarction, Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus, Contracture of Left Hand, Bipolar Disorder, and Pain.
Review of Resident #3's Quarterly MDS with an ARD of 02/07/2024, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #3 used a manual wheelchair, and required substantial/maximal assistance with sit to stand and chair/bed to chair transferring.
Review of Resident #3's Comprehensive Plan of Care, with a target date of 05/14/2024, revealed Resident #3 was care planned for the following problems:
1. Resident has an ADL self-care performance deficit due to left sided weakness. Interventions included: extensive assistance by two person assist with bed mobility, transfers, and toileting; and set up assist with eating.
2. Resident #3 is at risk for falls. Interventions included: anticipate and meet resident's needs. On 03/20/2024 - fall in van-wheelchair tipped backward/abrasion to back of head.
Review of the facility's Incident/Accident report completed by S5 RN on 03/20/2024 at 10:07 a.m., revealed in part .This nurse was called by S4 CNA, who stated Resident #3 fell back and hit her head while on van. Resident was brought in wheelchair by S3 CNA/Transportation, who stated her chair flipped over backwards in van, and she hit her head. Blood noted to back of head. Resident brought to nurses' station and area to head cleaned and assessed by S5 RN, and small abrasion noted, no active bleeding. Abrasion also noted to base of neck between shoulders, no bleeding noted to area. Neuro checks started. Resident complained of headache, Tylenol offered.
Resident Description: We hit a bump, and I tipped over in my wheelchair. Pain rated at 4, on a pain scale of 1 - 10.
During an interview on 04/08/2024 at 2:30 p.m., Resident #3 stated she was coming back from a doctor's appointment with S3 Transportation and another employee the day the accident occurred on the van. Resident #3 stated they hit a bump, her wheelchair flipped backwards, and she hit her head on the back door. Resident #3 stated she felt the back of her head with her hand, and there was blood. Resident #3 stated she was sitting in her wheelchair which was buckled to the floor, and didn't know how she tipped over backwards. Resident #3 stated it did hurt, and she kept a headache for some days.
During an interview on 04/09/2024 at 8:00 a.m., with S3 Transportation, she stated on the day of the accident, S4 CNA anchored Resident #3's wheelchair down in the van using 3 of the 4 required anchors. S3 Transportation stated the front right anchor was already broken prior to the accident, and had been replaced with a type of ratchet strap. She stated she didn't know how long the anchor had been broken. S3 Transportation stated while driving on 03/20/2024, she heard a click, looked back, and saw Resident #3 falling backwards, so she pulled the van over. S3 Transportation stated the wheelchair was tilted back, and once stopped, they repositioned the resident back into the wheelchair and secured the wheelchair again. S3 Transportation stated she saw a small amount of blood, and a small gash to the back of Resident #3's head. S3 Transportation stated she called the nursing home to report it, and S5 RN came out to check on the resident when they arrived. S3 Transportation stated the anchor was fixed now. Observation of the van at that time, 04/09/2024 at 8:00 a.m., revealed 4 silver anchors secured to the floor of the van.
During an interview on 04/09/2024 at 8:12 a.m., S2 Maintenance stated about a month ago he replaced the right front anchor with a manual ratchet strap when one of the drivers told him the front right anchor was not working. S2 Maintenance said the manual ratchet strap was working at the time of the accident with Resident #3 on 03/20/2024, but it was harder to use. S2 Maintenance stated he didn't know if S3 Transportation and S4 CNA knew how to use the ratchet strap. S2 Maintenance stated since Resident #3's accident, he replaced the manual ratchet strap with the silver automatic one that was observed in place now.
During an interview on 04/09/2024 at 8:20 a.m., S4 CNA stated on the day of Resident #3's accident, she strapped down Resident #3 into the van in her wheelchair. S4 CNA stated while they were traveling, the brakes were hit hard, she heard the wheelchair locks make a sound, and Resident #3 screamed. S4 CNA stated she looked and saw Resident #3 falling backwards in her wheelchair, and they pulled over. S4 CNA stated the wheelchair was tilted back, and they unstrapped Resident #3, fixed the wheelchair, put Resident #3 back in the wheelchair, and secured it down again. S4 CNA stated Resident #3 reached for the back of her head with her hand, and said it was bleeding. S4 CNA stated Resident #3 said My head hurts. S4 CNA stated she had strapped Resident #3's wheelchair down using the two back anchors and the front left one. S4 CNA stated the front right one was different, it was a tow strap that didn't work. S4 CNA described the tow strap as the kind that was used to tow cars. S4 CNA stated she didn't know how long the front right anchor had been broken. S4 CNA stated she had never been trained on how to secure residents' wheelchairs in the van, and didn't know she wasn't supposed to do it, or she wouldn't have. S4 CNA stated she secured Resident #3's wheelchair because S3 Transportation just got in the driver's seat, and it had to be done. S4 CNA stated she went on transports often, but had never used the tow strap before, and didn't know how long it had been in use.
During a telephone interview on 04/09/2024 at 2:10 p.m., S2 Maintenance stated a driver reported the front right anchor wasn't working around the first week of 03/2024 (could not remember the exact date). S2 Maintenance stated he fixed it immediately by replacing the silver automatic anchor with the manual ratchet strap, and the van was not taken out of service. S2 Maintenance stated he did not report to the Administrator when he made the repairs and switched out the anchor to the ratchet strap. S2 Maintenance stated he switched the ratchet strap back to a silver automatic anchor on 03/20/2024 while inspecting the van after the incident. S2 Maintenance stated he did not document any of the repairs on the inspection form, or an invoice of any type, but should have. S2 Maintenance stated he had not received any special training or certification on how to repair the van. S2 Maintenance stated he swapped out the anchors when needed, but took the van to a business who repaired wheelchair accessible vehicles for all other repairs.
During a telephone interview on 04/11/2024 at 8:38 a.m., S4 CNA stated on the day of the accident with Resident #3, she told S3 Transportation the tow strap wasn't working. S4 CNA stated S3 Transportation stated she had informed S2 Maintenance that the tow strap was not working; however, he said it was.
During a telephone interview at 8:41 a.m. on 04/11/2024, S3 Transportation stated S4 CNA secured Resident #3's wheelchair into the van the day of the incident because We do team work. S3 Transportation stated she knew there were only 3 anchors working, and they had reported it to S2 Maintenance in the past, but maybe he forgot. S3 Transportation stated they had been using the van with only 3 working anchors for a while, (unable to remember how long), and this was not the first time a resident had been transported with only three anchors in use. S3 Transportation stated she wasn't aware that the CNA riding along shouldn't be securing residents' wheelchairs into the van.
During an interview on 04/09/2024 at 10:11 a.m., S1 Administrator confirmed S4 CNA was not trained to secure residents' wheelchairs in the van. S1 Administrator stated S4 CNA was riding along on the transport because the resident required 2 person assistance. S1 Administrator stated S3 Transportation had been trained on securing residents' wheelchairs prior to the accident on 03/20/2024, and should have been the one to secure Resident #3's wheelchair into the van. S1 Administrator stated they only train the drivers to secure residents' wheelchairs. S1 Administrator was unable to provide the Driver's Weekly Safety Inspections for 02/2024 and 03/2024, as requested. S1 Administrator confirmed the drivers were not completing the Driver's Weekly Safety inspection of the van each week prior to the accident on 03/20/2024, and should have been.
During an interview on 04/11/2024 at 12:00 p.m., S1 Administrator confirmed Resident #3's wheelchair had not been properly secured in the van on the day of the accident, because the wheelchair was secured with three anchors instead of the four that were required. S1 Administrator stated S2 Maintenance said the ratchet strap was working when checked immediately after Resident #3's accident. S1 Administrator acknowledged the CNAs and Drivers may not have known how to use the ratchet strap. S1 Administrator stated when S2 Maintenance replaced the silver automatic anchor with the ratchet strap, it was not reported to her. S1 Administrator stated it was her understanding that the manual ratchet straps were okay to use in place of the silver automatic anchor. S1 Administrator stated she did not have any manuals on the van, because the van was there when she was hired. S1 Administrator stated she obtained the Q'straint Installation Instructions from Corporate after the surveyor inquired about it.
The facility has implemented the following actions to correct the deficient practice:
Plan of Correction Date 03/23/2024
The monthly Healthstream topic for April is Driver and Vehicle Safety. This course, which includes videos and Driver and Vehicle Safety Policy, will be completed by all Nexion staff by April 30, 2024.
Inservice on Driver and Vehicle Safety Policy was initiated by the Maintenance Director to all current company authorized drivers on March 20, 2024.
Securing Resident in Van - Competency Demonstration for all drivers according to Driver and Vehicle Safety Policy initiated March 21, 2024 through present.
Monitor each driver that is scheduled for transport once daily by Maintenance Director, Administrator, or DON. Monitored by Securing Residents in Van - Competency Demonstration. Began March 22, 2024 through present.
All van Q'Straints are working properly. Inspected by Maintenance Director March 20, 2024 and monthly.
Weekly van inspection log being completed by driver per policy and procedure.
The Maintenance Director continues to complete the monthly van inspection log.
The Maintenance Director was trained by Regional Maintenance Director.
The facility was in compliance on March 23, 2024. Ongoing training will continue to be provided as determined by the QA team.
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 F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview the facility failed to ensure a Certified Nursing Assistant (CNA) was competent in skills and techniques necessary to assure resident safety for 1 (#...
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Based on record review, observation, and interview the facility failed to ensure a Certified Nursing Assistant (CNA) was competent in skills and techniques necessary to assure resident safety for 1 (#3) of 4 (#1, #2, #3, & #4) residents reviewed for accidents. The facility failed to ensure that an untrained CNA (S4) was not allowed to secure Resident #3, who was wheelchair bound, in a facility van prior to transportation.
Findings:
Review on 04/11/2024 of the facility policy revised on 03/2023 titled Facility Vehicle Log, A Part of the Driver and Vehicle Safety Policy revealed in part .
Driver's Weekly Vehicle Safety Inspection-
To be completed by the company vehicle driver once each week and prior to driving a vehicle that has been returned to service after repairs.
If there are safety concerns noted during the inspection, they are to be noted on the Driver's Weekly Vehicle Safety Inspection form and reported immediately to Maintenance or the Administrator. The vehicle should immediately be taken out of service if the driver or others determine that the vehicle cannot be driven safely.
Securing Residents in Van-Competency Determination-
Secure two front tie-downs to a solid, structural frame member of the wheelchair.
Secure two back tie-downs to a solid, structural frame member of the wheelchair.
Review of Resident #3's medical record revealed an admit date of 09/07/2017, with diagnoses that included in part .Cerebral Infarction, Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus, Contracture of Left Hand, Bipolar Disorder, and Pain.
Review of Resident #3's Quarterly MDS with an ARD of 02/07/2024, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #3 used a manual wheelchair, and required substantial/maximal assistance with sit to stand and chair/bed to chair transferring.
Review of Resident #3's Comprehensive Plan of Care, with a target date of 05/14/2024, revealed Resident #3 was care planned for the following problems:
1. Resident has an ADL self-care performance deficit due to left sided weakness. Interventions included: extensive assistance by two person assist with bed mobility, transfers, and toileting; and set up assist with eating.
2. Resident #3 is at risk for falls. Interventions included: anticipate and meet resident's needs. On 03/20/2024 - fall in van-wheelchair tipped backward/abrasion to back of head.
Review of the facility's Incident/Accident report completed by S5 RN on 03/20/2024 at 10:07 a.m. revealed in part .This nurse was called by S4 CNA who states Resident #3 fell back and hit her head on van. Resident was brought in in wheelchair by S3 CNA/Transportation stating her chair flipped over backwards in van and she hit her head. Abrasion also noted to base of neck between shoulders, no bleeding noted to area. Neuro checks started. Resident complained of headache, Tylenol offered.
Resident Description: We hit a bump, and I tipped over in my wheelchair. Pain rated at 4, on a pain scale of 1 - 10.
During an interview on 04/08/2024 at 2:30 p.m., Resident #3 stated she was coming back from a doctor's appointment with S3 Transportation and another employee the day the accident occurred on the van. Resident #3 stated they hit a bump, her wheelchair flipped backwards, and she hit her head on the back door. Resident #3 stated she felt the back of her head with her hand, and there was blood. Resident #3 stated she was sitting in her wheelchair which was buckled to the floor, and didn't know how she tipped over backwards. Resident #3 stated it did hurt, and she kept a headache for some days.
During an interview on 04/09/2024 at 8:00 a.m., with S3 CNA/Transportation, she stated on the day of the accident, S4 CNA anchored Resident #3's wheelchair down in the van using 3 of the 4 required anchors. S3 CNA/Transportation stated the front right anchor was already broken prior to the accident, and had been replaced with a type of ratchet strap. She stated she didn't know how long it had been broken. S3 CNA/Transportation stated while driving on 03/20/2024, she heard a click, looked back, and saw Resident #3 falling backwards, so she pulled the van over. S3 CNA/Transportation stated the wheelchair was tilted back, and once stopped, they repositioned the resident back into the wheelchair and secured the wheelchair again. S3 CNA/Transportation stated she saw a small amount of blood, and a small gash to the back of Resident #3's head. S3 CNA/Transportation stated she called the nursing home to report it, and S5 RN came out to check on the resident when they arrived.
During an interview on 04/09/2024 at 8:20 a.m., S4 CNA stated on the day of Resident #3's accident, she strapped down Resident #3 into the van in her wheelchair. S4 CNA stated while they were traveling, the brakes were hit hard, she heard the wheelchair locks make a sound, and Resident #3 screamed. S4 CNA stated she looked and saw Resident #3 falling backwards in her wheelchair and they pulled over. S4 CNA stated she and CNA/Transportation unstrapped Resident #3, fixed the wheelchair, put Resident #3 back in the wheelchair and secured it down again. S4 CNA stated Resident #3 reached for the back of her head with her hand and said it was bleeding. S4 CNA stated Resident #3 said My head hurts. S4 CNA stated she had strapped Resident #3's wheelchair down using the two back anchors and the front left one. S4 CNA stated the front right one was different, it was a tow strap that didn't work. S4 CNA stated she didn't know how long the front right anchor had been broken. S4 CNA stated she had never been trained on how to secure residents' wheelchairs in the van and didn't know she wasn't supposed to do it or she wouldn't have. S4 CNA stated she secured Resident #3's wheelchair because S3 Transportation just got in the driver's seat and it had to be done.
During a telephone interview at 8:41 a.m. on 04/11/2024, S3 CNA/Transportation stated S4 CNA secured Resident #3's wheelchair into the van the day of the incident because We do team work. S3 Transportation stated she knew there were only 3 anchors working, and they had reported it to S2 Maintenance in the past but maybe he forgot. S3 CNA/Transportation stated they had been using the van with only 3 working anchors for a while, and this was not the first time a resident had been transported with only three anchors in use. S3 CNA/Transportation stated she wasn't aware the CNA riding along shouldn't be securing the residents' wheelchairs into the van.
Review of S3 CNA/Transportation's training records revealed competency checks were conducted on 08/03/2022 (Securing Residents in Van), and 01/17/2024 (Vehicle Safety Inspection).
During an interview on 04/09/2024 at 10:11 a.m. S1 Administrator confirmed S4 CNA was not trained to secure residents' wheelchairs in the van. S1 Administrator stated S4 CNA was riding along on the transport because the resident required 2-person assistance. S1 Administrator stated S3 Transportation had been trained on securing residents' wheelchairs prior to the accident and should have been the one to secure Resident #3's wheelchair into the van. S1 Administrator stated they only train the drivers to do the securing of residents' wheelchairs. S1 Administrator confirmed the drivers were not completing the Driver's Weekly Safety inspection each week prior to the accident on 03/20/2024, and should have been.
During an interview on 04/11/2024 at 12:00 p.m., S1 Administrator confirmed Resident #3's wheelchair had not been properly secured in the van on the day of the accident.
Jan 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's right to be free from physical and sexual abuse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's right to be free from physical and sexual abuse, and psychosocial harm by another resident, for (#1) of 3 (#1, #2, and #3) residents investigated for abuse.
This failed practice resulted in an actual harm situation on 12/27/2023 at 3:40 p.m., when Resident #2 put his hands under Resident #1's shirt, and on her breast. On 11/19/2023, Resident #2 tried to throw a coffee cup at Resident #1; however, staff intervened. On 12/26/2023, Resident #2 lurched towards Resident #1 when staff tried to take Resident #1 to provide care, and a CNA had to step between the residents. On 12/27/2023, Resident #2 put his hand under Resident #1's shirt and on her breast, became angry when he was redirected, and grabbed and pinched Resident #1 on her back, and through her clothes, leaving a reddened area on her back. On 12/29/2023, Resident #2 grabbed Resident #1's hand squeezing it, and she yelled out Ouch! with a facial grimace.
A reasonable person in Resident #1's situation would have experienced severe psychosocial harm and humiliation, as a result of this inappropriate, unwanted sexual contact/abuse.
Findings:
Review of the facility's Abuse Prohibition Policy revealed in part .
Physical abuse includes hitting, slapping, kicking, shoving, pinching, and controlling behavior through corporal punishment.
Sexual abuse includes, but is not limited to, rape, sexual harassment, sexual coercion, or sexual assault.
13. If the incident involves sexual behavior, the following will occur:
-Determine if both victim and perpetrator are able to make decisions.
A resident's consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent, or if consent was obtained through intimidation, fear or coercion.
Sexual abuse is non-consensual sexual contact of any type with a resident as defined at 42 CFR 483.5. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area.
Resident #1
Review of Resident #1's medical record revealed an admit date of 11/14/2022, with diagnoses that included in part .Alzheimer's disease with early onset; Sjogren's syndrome; Anxiety disorder; and Muscle wasting.
Review of Resident #1's Quarterly MDS with an ARD of 11/21/2023 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required partial/moderate assistance with toilet hygiene and was always incontinent of bowel and bladder.
Review of Resident #1's care plan revealed a problem of impaired cognitive function with dementia related to Alzheimer's. Interventions included administer medications as ordered, ask yes or no questions in order to determine resident's needs and cue, reorient, and supervise as needed. Review of the interventions revealed the resident needs extensive assistance with all decision making.
Review of Resident #1's nurses' notes documented by S10 LPN revealed the following:
12/27/2023 at 3:39 p.m. - Resident (Resident #1) in day room observed with male friend (Resident #2), and his hand was inside resident's shirt. When this nurse approached the male resident to remove his hand from under her shirt, he got angry and started grabbing the resident on the back, telling her not to get up. Treatment nurse (S9 LPN) redirected male resident to dining room, and this nurse redirected resident (#1) to Wing X lobby to separate the two residents. Will continue to monitor.
12/29/2023 at 1:09 p.m. - CNA attempting to assist Resident #1 to the dining room when Resident #2 grabbed her hand squeezing it. She yelled out Ouch! with facial grimace. CNA asked him to let go of her hand. He started yelling, placed hands on chest pushing CNA into Christmas tree. Redirected Resident #2 to another room, and CNA assisted Resident #1 to dining room. No injuries noted. Notified Administrator and DON, MD, S11 NP, and RP. New order to send to behavioral health and collect CBC/CMP/UA per S11 NP. Referral sent and awaiting response. Documented by S7 LPN.
In an interview on 01/23/2024 at 12:30 p.m., Resident #1 stated she had been residing at the facility for two days, and her parents lived there too. Resident #1 denied ever being abused physically or sexually by a staff member, or another resident. Resident #1 denied ever being touched inappropriately by another resident.
Resident #2
Review of Resident #2's medical record revealed an admit date of 10/04/2023, with diagnoses that included in part .Unspecified Dementia, moderate with agitation; Hypertension; Major Depressive Disorder; Schizoaffective Disorder, Depressive type; Emphysema; and Cognitive Communication Deficit.
Review of Resident #2's Quarterly MDS with an ARD of 12/13/2023 revealed the resident had a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #2 had no impairment of the upper or lower extremities, was independent with walking 150 feet, independent with toilet transferring, independent with sitting to lying or lying to sitting, and required set up or clean up assistance with eating.
Resident #2's Care Plan revealed a problem of The resident is at risk for impaired cognitive function/dementia. Interventions included: Aricept as ordered; cue, reorient and supervise as needed; monitor/document/report prn any changes in cognitive function, changes in decision making ability, memory, recall and general awareness, difficulty expressing self or understanding others, level of consciousness, or mental status.
Review of an 11/09/2023 progress note documented by S12 NP, revealed Resident #2 was seen for ongoing behaviors including agitation and combativeness. Patient is agitated and combative when staff attempts to redirect him and perform tasks separate from his female friend (Resident #1), who also resides in facility.
Review of S15 Psychiatric NP's progress note dated 12/04/2023 revealed the following in part .
Psych Impression: Pt has hypersexual thoughts .
Review of Resident #2's nurses' notes revealed the following in part .
11/05/2023 at 6:59 p.m. - CNA assisting another resident (Resident #1) to her room so that she could be changed. This resident (Resident #2) became agitated and yelled at staff, You let her be, I'll take care of her. Writer explained to resident that staff had to care of this resident. Administered prn Vistaril for agitation. Documented by S5 LPN.
11/05/2023 at 8:29 p.m. - A female resident (Resident #1) was falling asleep on the couch and writer asked if she were ready to lie down and she stated yes. When writer went to assist resident (Resident #1) to her room, this resident (Resident #2) stated to female, No you come with me! Writer explained to Resident #2 that the resident was wanting to go lie down and he bowed his shoulders to writer and yelled, No! She can go with me over there pointing to the other day room. CNA then escorted female to her room to assist with her getting ready for bed and Resident #2 stormed off cursing. MD notified of resident's behaviors this shift. Documented by S5 LPN.
11/09/2023 at 2:19 p.m. - Attempting to provide care to another resident (Resident #1), when Resident #2 became verbally aggressive with staff. Redirection unsuccessful. PRN Vistaril given. S12 NP made rounds, new orders to increase Paxil from 10mg to 20mg daily. Continue to monitor. Documented by S7 LPN.
11/12/2023 at 4:04 p.m.: Resident became disrespectful and aggressive towards staff when staff attempted to remove Resident #1 from day room. Staff explained to Resident #2 that Resident #1 needed to go to her room for some female care, and Resident #2 said, That's a damn lie, I know when I have to go to the bathroom, and y'all just trying to control me standing between staff and Resident #1. I explained to Resident #2 that Resident #1 does not always know when she needs to go to the restroom, and that we are here to help her stay clean and safe. Resident #2 continued being rude and did not want us to take Resident #1 to her room. While nurse was explaining again to Resident #2 that Resident #1 needed help, CNAs were able to sneak Resident #1 to her room to assist her. Documented by S7 LPN.
11/19/2023 at 11:21 a.m. - Resident refused to let staff care for another resident (Resident #1). When the resident (Resident #1) went with staff he (Resident #2) told her (Resident #1), I said come on here. She continued to walk with staff, and he tried to throw a coffee cup at her (Resident #1). I got the cup out of resident's hand and redirected him to the lobby area in front of nursing home. He walked off telling the resident (Resident #1), You better be ready when I get back and I mean it. Documented by S10 LPN.
12/10/2023 at 1:55 p.m. - Resident #2 observed by this nurse pulling another resident (Resident #1) away from staff while (staff) were trying to take the resident for care. When staff directed the lady resident away from this resident, he got mad and said, Y'all full of shit over here. He walked away and threw his coffee all over the floor. Documented by S10 LPN.
12/14/2023 at 3:40 p.m. - Resident in lobby with female resident (Resident #1). When staff went to direct female resident to room to do routine care, he got angry and started yelling at CNA. He states, That is my wife and you going to let her go. Redirected successful. Will monitor. Documented by S10 LPN.
12/15/2023 at 12:20 p.m. - CNA was assisting Resident #1 up from couch in dayroom A, to take her to the bathroom. CNA stated , I asked Resident #1 to get up and let's go to the restroom, and Resident #2 stated, no she doesn't need to go. I said yes she does, and he kicked me in my leg. Documented by S8 LPN.
12/15/2023 at 4:19 p.m. - Resident #2 transferred to inpatient psychiatric facility.
12/21/2023 at 2:46 p.m. - Resident #2 returned to facility by transporter from Behavioral Hospital. Documented by S10 LPN.
12/26/2023 at 4:26 p.m. - Patient agitated when attempting to provide care to another resident (his girlfriend) (Resident #1), multiple times throughout the day. S12 NP made rounds, new order to start Vistaril 25mg po q 6 hours prn agitated/behaviors/combativeness/anxiety. Documented by S7 LPN.
12/26/2023 at 7:45 p.m. - When staff attempted to provide care to a female resident (Resident #1), who this resident identifies as his girlfriend, he became aggressive with staff. When CNAs went to assist female resident to her room he then lurched towards female resident, and CNA stepped in between them. Writer got between resident and CNA, and he grabbed writer by the shoulders from behind attempting to move writer. He then shoved writer. Female resident taken to her room for care. Documented by S5 LPN.
12/27/2023 at 3:40 p.m. - Resident in dayroom observed with his hand inside a female resident (Resident #1) shirt. When this nurse approached resident to remove his hand from under her shirt, he got angry and started grabbing the female on her back telling her not to get up. S9 LPN redirected resident to dining room. MD and RP notified. Documented by S10 LPN.
12/29/2023 at 1:09 p.m. - CNA attempting to assist Resident #1 to dining room when Resident #2 grabbed Resident #1's hand squeezing it. She yelled out Ouch! with facial grimace. CNA asked him to let go of her hand. He started yelling, placed his hands on (CNA's) chest, pushing CNA into Christmas tree. Redirected him to another room, and CNA assisted Resident #1 to the dining room. No injuries noted. Notified S1 Administrator, S2 DON, S11 NP and RP. New order to send to behavioral health Referral sent and awaiting response. Documented by S7 LPN.
12/29/2023 at 3:44 p.m. - Resident transferred to Behavioral hospital.
During a telephone interview on 01/23/2024 at 11:35 a.m., S13 CNA stated she observed Resident #2's hand under Resident #1's shirt and on her breast, while they were in the day room. S13 CNA stated she reported it to S9 LPN and S10 LPN, who went immediately to the day room. S13 CNA stated they separated the residents and took Resident #1 to her room. S13 CNA stated Resident #2 once grabbed Resident #1 by the hands when they were trying to change her, and Resident #1 said it hurt her hand.
In a telephone interview on 01/23/2024 at 11:51 a.m., S10 LPN revealed on 12/27/2023, S13 CNA told her Residents #1 and #2 were sitting in the dayroom, and Resident #2 had his hand under her shirt, rubbing her breast. She said she and S9 LPN went in and tried to separate them. She said she told Resident #1 to come with her to go change her clothes. S10 LPN said when Resident #1 tried to get up off the couch, Resident #2 grabbed her and pinched her on the back to try to keep her from getting up. S10 LPN stated she told Resident #2 to let go of her and Resident #2 said she, Resident #1, couldn't go with us. S10 LPN said she told him yes she can, but she can come right back. S10 LPN said they then separated the two residents, and took Resident #1 into her room. S10 LPN said Resident #1 had a spot on her back that was red for a little while where Resident #2 had pinched her. S10 LPN stated Resident #2 pinched her skin through her clothes and her clothes were twisted. S10 LPN said Resident #1 said Ouch when he pinched her. S10 LPN stated we told Resident #2 to let her go and he did, so it just lasted for a second. S10 LPN stated the next day they (Resident #1 and Resident #2) were back walking together and eating lunch together like nothing ever happened.
During a telephone interview on 01/23/2024 at 12:20 p.m., S9 LPN stated on 12/27/2023, Resident #2 put his hand under Resident #1's shirt and pinched her skin on her back, and told her not to get up. S9 LPN stated they separated the residents, and she examined Resident #1, who had a red pinch mark on her back. S9 LPN stated the redness was gone within an hour, and didn't bruise.
In an interview on 01/23/2024 at approximately 3:30 p.m., S2 DON said Resident #2 started obsessing over Resident #1 not too long after he was admitted to the facility. S2 DON said it was sweet at first, they would just sit together and hold hands. S2 DON said around the end of November 2023, Resident #2 started getting more aggressive with staff, possessive over Resident #1, and didn't want staff to change her. S2 DON said when he continued to get more aggressive with staff, he was sent to a behavioral hospital. S2 DON said when he returned to the facility, it was the same thing all over again, with the possessiveness of Resident #1. S2 DON stated they were trying to adjust his medications. S2 DON confirmed on 12/27/2023, Resident #2 put his hand up Resident #1's shirt on her breast, and pinched her back. S2 DON stated she thought staff were trying to keep the residents separated. S2 DON said she hated to send Resident #2 back out to a behavioral hospital, and was hoping his medications would start working. S2 DON stated from 12/26/2023 through 12/29/2023, staff were trying to redirect Resident #2, and giving him Vistaril as needed.
In an interview on 01/24/2024 at 9:00 a.m., S2 DON stated she had to send Resident #2 out to a psychiatric hospital after it happened again on 12/29/2023, when he squeezed Resident #1's hand, and pushed a CNA into the Christmas tree. S2 DON acknowledged that Resident #2 and Resident #1 were not kept separated and allowed to spend time together after the incident on 12/27/2023, when Resident #2 touched Resident #1's breast, and pinched her back.
In a telephone interview on 01/24/2024 at 10:00 a.m., S12 NP stated the NF called her often about Resident #2's behaviors, but was unsure of exact dates. S12 NP stated she understood the incident on 12/27/2023 to be that Resident #2 had his hand under Resident #1's shirt, but didn't know it was on her breast. S12 NP stated that was not told to her, and said she was told it was under her shirt, so it could've been on her back or anywhere. S12 NP said Resident #2 was possessive of Resident #1 like a jealous boyfriend. When asked if Resident #2 should have been sent out after the sexual abuse, S12 NP said she didn't consider it to be sexual abuse, and she would have to investigate that further. S12 NP confirmed if Resident #2's hand was on Resident #1's breast, the residents should have been kept separate after that had occurred. S12 NP stated that would be hard to do unless they put Resident #2 on 1:1 supervision. S12 NP stated she didn't have the authority to PEC him, but the Psychiatric NP did. S12 NP stated she considered Resident #2's behaviors as combativeness, and she wouldn't label it sexual abuse.
In an interview on 01/24/2024 at 10:25 a.m., S10 LPN confirmed S13 CNA informed that Resident #2 had his hand on Resident #1's breast. S10 LPN stated she walked over to the dayroom couch where the residents were sitting, and observed Resident #2's hand under the front of Resident #1's shirt, which Resident #2 removed as she was walking in. S10 LPN stated she called S12 NP and told her Resident #2's hands were on Resident #1's breast. S10 LPN stated S12 NP instructed to get a mental health consult because they were the only ones who could do a PEC. S10 LPN stated she did pass on the need for the mental health consult, but couldn't remember who she told.
During a telephone interview on 01/24/2024 at 12:00 p.m., Resident #1's responsible party stated this would have never happened to her mother before she had dementia. Resident #1's RP explained her mother would never have held hands in public. Resident #1's daughter stated Resident #1 was a very [NAME] and proper lady, and the incident with his hand under her shirt would have absolutely upset her. Resident #1's daughter stated her mother would have been devastated and horrified.
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 record review and interview, the facility failed to develop a comprehensive care plan for 1 (#2) of 3 (#1, #2, & #3) sampled residents that addressed his possessiveness over another resident ...
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Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 (#2) of 3 (#1, #2, & #3) sampled residents that addressed his possessiveness over another resident and his combative behaviors with staff related to this resident. Findings:
Resident #2
Review of Resident #2's medical record revealed an admit date of 10/04/2023 with diagnoses that included in part .Unspecified Dementia, moderate with agitation, Hypertension, Major Depressive Disorder, Schizoaffective Disorder, depressive type, Emphysema, and Cognitive Communication Deficit.
Review of Resident #2's Quarterly MDS with an ARD of 12/13/2023 revealed the resident had a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #2 had no impairment of the upper or lower extremities, was independent with walking 150 feet, independent with toilet transferring, independent with sitting to lying or lying to sitting, and required set up or clean up assistance with eating.
Review of Resident #2's nurses' notes revealed in part the following:
11/05/2023-6:59p.m.: CNA assisting another resident (Resident #1) to her room so that she could be changed. This resident became agitated and yelled at staff, You let her be, I'll take care of her Writer explained to resident that staff had to care for this resident and then he bowed shoulders up to staff. Writer redirected resident at this time. He is sitting in day room watching television. Administered prn Vistaril for agitation. By S5 LPN
11/5/23 at 8:29 p.m.: A female resident (Resident #1) was falling asleep on the couch and writer asked if she were ready to lie down and she stated yes. When writer went to assist res to her room, this resident stated to female, No you come with me! Writer explained to Resident #2 that the resident was wanting to go lie down and he bowed his shoulders to writer and yelled, No! She can go with me over there pointing to the other day room. What are you gonna do about it?! CNA then escorted female to her room to assist with her getting ready for bed and Resident #2 stormed off cursing. Writer unable to understand all that he said. He is currently pacing up and down from dining area to B wing day room. Unable to redirect resident at this time. MD notified of resident's behaviors this shift. By S5 LPN.
11/09/2023 at 2:19 p.m.: Attempting to provide care to another resident (Resident #1) when Resident #2 became verbally aggressive with staff. Redirection unsuccessful. PRN Vistaril given. S6 NP made rounds new orders to increase Paxil from 10mg to 20mg daily. Attempted to notify RP but no answer. Continue to monitor. By S7 LPN
11/12/2023 at 4:04 p.m.: Resident became disrespectful and aggressive towards staff when attempted to remove (Resident #1) from day room. Staff explained to Resident #2 that Resident #1 needed to go to her room for some female care, and he said, That's a damn lie, I know when I have to go to the bathroom, and y'all are just trying to control me standing between staff and Resident #1. I explained to Resident #2 that Resident #1 doesn't always know when she needs to go to the restroom, and that we are here to help her stay clean and safe. He continued being rude and did not want us to take Resident #1 to her room. While nurse explaining again to Resident #2 that Resident #1 needed help, CNAs were able to sneak Resident #1 off to her room to assist her. By S8 LPN
Review of the nurses' notes revealed this type of behavior occurred again on 11/19/2023, 12/10/2023, 12/14/2023, 12/15/2023, 12/26/2023 at 4:26 p.m. and 7:45 p.m., 12/27/2023, and 12/29/2023 and involved Resident #1 each time.
Review of Resident #2's care plan failed to reveal any evidence of care planning for Resident #2's possessiveness with Resident #1 or his combativeness with staff when attempting to take her away from him to provide her care.
In an interview and review of Resident #2's care plan on 01/24/2024 at 12:20 p.m., S3 MDS and S4 MDS confirmed Resident #2's care plan did not address his combative behaviors related to Resident #1 and should have.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #2 was adequately supervised to protect Resident #1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #2 was adequately supervised to protect Resident #1 and prevent physical and sexual abuse of Resident #1, for 1 (#2) of 3 (#1, #2, and #3) sampled residents.
Findings:
Resident #2
Review of Resident #2's medical record revealed an admit date of 10/04/2023, with diagnoses that included in part .Unspecified Dementia, moderate with agitation; Hypertension; Major Depressive Disorder; Schizoaffective Disorder, Depressive type; Emphysema; and Cognitive Communication Deficit.
Review of Resident #2's Quarterly MDS with an ARD of 12/13/2023 revealed the resident had a BIMS score of 3, which indicated severely impaired cognition. Review of the MDS revealed Resident #2 had no impairment of the upper or lower extremities, was independent with walking 150 feet, independent with toilet transferring, independent with sitting to lying or lying to sitting, and required set up or clean up assistance with eating.
Resident #2's Care Plan revealed a problem of The resident is at risk for impaired cognitive function/dementia. Interventions included in part . Aricept as ordered; cue, reorient and supervise as needed.
Review of an 11/09/2023 progress note documented by S12 NP, revealed Resident #2 was seen for ongoing behaviors including agitation and combativeness. Patient is agitated and combative when staff attempts to redirect him and perform tasks separate from his female friend, (Resident #1), who also resides in facility.
Review of S15 Psychiatric NP's progress note dated 12/04/2023 revealed the following:
Psych Impression: Pt has hypersexual thoughts .
Review of Resident #2's nurses' notes revealed between 11/05/2023 through 12/15/2023, Resident #2 interfered with staff while they were attempting to provide care to Resident #1 on 8 different occasions. Resident #2 had become increasingly more possessive of Resident #1 (a female resident), physically abusive, and verbally abusive with staff and was sent to a behavioral hospital on [DATE]. Upon Resident #2's return to the facility on [DATE], the facility failed to realize the level of supervision required for Resident #2 in order to protect Resident #1 from abuse.
12/26/2023 at 4:26 p.m. - Patient agitated when attempting to provide care to another resident (his girlfriend) (Resident #1), multiple times throughout the day. S12 NP made rounds, new order to start Vistaril 25mg po q 6 hours prn agitated/behaviors/combativeness/anxiety. Documented by S7 LPN.
12/26/2023 at 7:45 p.m. - When staff attempted to provide care to a female resident (Resident #1), who this resident identifies as his girlfriend, he became aggressive with staff. When CNAs went to assist female resident to her room, he then lurched towards female resident, and CNA stepped in between them. Writer got between Resident #1 and CNA, and he grabbed writer by the shoulders from behind attempting to move writer. Documented by S5 LPN.
12/27/2023 at 3:40 p.m. - Resident in dayroom observed with his hand inside a female resident's (Resident #1) shirt. When this nurse approached resident to remove his hand from under her shirt, he got angry and started grabbing the female on her back telling her not to get up. S9 LPN redirected Resident #2 to dining room, and this nurse redirected resident (#1) to Wing X lobby to separate the two residents. Will continue to monitor. MD and RP notified. Documented by S10 LPN.
12/29/2023 at 1:09 p.m. - CNA attempting to assist Resident #1 to dining room when Resident #2 grabbed Resident #1's hand squeezing it. She yelled out Ouch! with facial grimace. CNA asked him to let go of her hand. He started yelling, placed hands on (CNA's) chest, pushing CNA into Christmas tree. Redirected him to another room, and CNA assisted Resident #1 to the dining room. No injuries noted. Notified S1 Administrator, S2 DON, S11 NP and RP. New order to send to behavioral health Referral sent and awaiting response. Documented by S7 LPN.
12/29/2023 at 3:44 p.m. - Resident transferred to Behavioral hospital.
During a telephone interview on 01/23/2024 at 11:35 a.m., S13 CNA stated she observed Resident #2's hand under Resident #1's shirt and on her breast, while they were in the day room. S13 CNA stated she reported it to S9 LPN and S10 LPN, who went immediately to the day room. S13 CNA stated they separated the residents and took Resident #1 to her room. S13 CNA stated Resident #1 seemed okay with being his girlfriend until he became very possessive, and would tell us we couldn't change her. S13 CNA stated Resident #2 once grabbed Resident #1 by the hands when they were trying to change her, and Resident #1 said it hurt her hand. S13 CNA stated the nurses were responsible for documenting the every 30 minute monitoring, but the aides would assist the nurses with locating the resident when needed.
In a telephone interview on 01/23/2024 at 11:51 a.m., S10 LPN revealed on 12/27/2023, S13 CNA told her Residents #1 and #2 were sitting in the dayroom, and Resident #2 had his hand under her shirt, rubbing her breast. She said she and S9 LPN went in and tried to separate them. She said she told Resident #1 to come with her to go change her clothes. S10 LPN said when Resident #1 tried to get up off the couch, Resident #2 grabbed her and pinched her on the back to try to keep her from getting up. S10 LPN stated she told Resident #2 to let go of her, and Resident #2 said she couldn't go with us. S10 LPN said she told him yes she can, but she can come right back. S10 LPN said they then separated the two residents and took Resident #1 into her room. S10 LPN stated the next day, they (Resident #1 and Resident #2) were back walking together, and eating lunch together like nothing ever happened. S10 LPN stated Resident #2 was on every 30 minute watches when this incident occurred.
In an interview on 01/23/2024 at approximately 3:30 p.m., S2 DON said Resident #2 started obsessing over Resident #1 not too long after he was admitted to the facility. S2 DON said it was sweet at first, they would just sit together and hold hands. S2 DON said around the end of November 2023, Resident #2 started getting more aggressive with staff, possessive over Resident #1, and didn't want staff to change her. S2 DON said when he continued to get more aggressive with staff, he was sent to a behavioral hospital. S2 DON said when he returned to the facility, it was the same thing all over again with the possessiveness of Resident #1. S2 DON stated they were trying to adjust his medications. S2 DON said he was put on every 30 minute monitoring on 12/26/2023 at 7:45 p.m. S2 DON confirmed on the next day, 12/27/2023, Resident #2 put his hand up Resident #1's shirt and on her breast, and pinched her back. S2 DON stated she thought staff were trying to keep the residents separated. S2 DON said she hated to send Resident #2 back out to a behavioral hospital, and was hoping his medications would start working. S2 DON stated from 12/26/2023 through 12/29/2023, staff were trying to redirect Resident #2, and giving him Vistaril as needed.
In a telephone interview on 01/24/2024 at 10:00 a.m., S12 NP stated the NF called her often about Resident #2's behaviors, but was unsure of the exact dates. S12 NP stated she understood the incident on 12/27/2023 to be that Resident #2 had his hand under Resident #1's shirt, but didn't know it was on her breast. S12 NP stated that was not told to her, and said she was told it was under her shirt, so it could've been on her back or anywhere. S12 NP said Resident #2 was possessive of Resident #1 like a jealous boyfriend. When asked if Resident #2 should have been sent out after the sexual abuse, S12 NP said she didn't consider it to be sexual abuse, and she would have to investigate that further. S12 NP confirmed if Resident #2's hand was on Resident #1's breast, the residents should have been kept separate after that had occurred. S12 NP stated that would be hard to do unless they put Resident #2 on 1:1 supervision.
In an interview on 01/24/2024 at 10:25 a.m., S10 LPN confirmed S13 CNA informed her that Resident #2 had his hand on Resident #1's breast. S10 LPN stated she walked over to the dayroom couch where the residents were sitting, and observed Resident #2's hand under the front of Resident #1's shirt, which Resident #2 removed as she was walking in. S10 LPN stated she called S12 NP and told her Resident #2's hands were on Resident #1's breast. S10 LPN stated S12 NP instructed to get a mental health consult because they were the only ones who could do a PEC. S10 LPN stated she did pass on the need for the mental health consult, but couldn't remember who she told.
In an interview on 01/24/2024 at 9:00 a.m., S2 DON stated she felt like staff were providing adequate supervision of Resident #2 at the time of the incident on 12/27/2023, because Resident #2 was already being monitored every 30 minutes since the incident that occurred on 12/26/2023. S2 DON acknowledged this monitoring included a short note by the nurses every 30 minutes to document the Resident #2's whereabouts, and what he was doing at that time. S2 DON stated they had already sent him out to a psychiatric hospital, and didn't want to send him out again. S2 DON stated she didn't think she needed to send Resident #2 out because it was the first time he had been aggressive with a resident, and had only been aggressive with staff previously. S2 DON stated she had to send Resident #2 out to a psychiatric hospital after it happened again on 12/29/2023, when he squeezed Resident #1's hand, and pushed a CNA into the Christmas tree. S2 DON acknowledged that Resident #2 and Resident #1 were not kept separated after the incident on 12/27/2023, when Resident #2 touched Resident #1's breast, and pinched her back.
Dec 2023
6 deficiencies
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 services were provided to meet professional sta...
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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 services were provided to meet professional standards of practice as evidenced by failing to obtain an order for oxygen therapy for 1 (Resident #17) of 2 (#17 and #69) residents reviewed for respiratory care.
Findings:
Review of the facility's policy titled, Oxygen Administration read in part .
The purpose of this procedure is to provide guidelines for safe oxygen administration.
Preparation:
1.
Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
Review of Resident #17's medical record revealed an admit date of 02/27/2023 with diagnoses that included Gastrostomy status, Cerebral Infarction due to Embolism of Unspecified Middle Cerebral Artery, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Osteomyelitis of Vertebra, Sacral-coccygeal region, Type 2 DM with Hyperglycemia, Functional Quadriplegia and Personal History of Covid-19.
Review of Resident #17's Hospital Discharge summary dated [DATE] revealed no orders or discharge instructions for oxygen therapy administration.
Review of Resident #17's Physician's Active Orders for 12/11/2023 revealed no documentation for oxygen therapy administration.
Review of Resident #17's EMAR for 12/2023 in part . revealed the following orders: 12/12/2023 at 2:05 p.m. - Check O2 saturation every shift.
12/12/2023 at 2:18 p.m. - O2 at 2 liters/ nasal cannula prn to maintain O2 saturation of 92%.
Review of Resident #17's Progress Note per S5 LPN dated 12/06/2023 at 6:00 p.m. revealed in part . Resident arrived at facility via ambulance. Resident vitals upon arrival 177/89, HR87, Oxygen 97 via nasal cannula, Respiration 18 and Temperature 97.6.
Review of Resident #17's Progress Note per S12 LPN dated 12/07/2023 at 9:41 p.m. revealed in part . Oxygen saturation on room air tonight 89%. Placed back on O2 at 2liters/minute per nasal cannula. O2 saturation up to 97%.
Observation on 12/11/2023 at 12:45 p.m. of Resident #17 revealed oxygen in progress via nasal cannula at 1.5 liters per minute per oxygen concentrator at resident's bedside. Oxygen tubing labeled with date 12/11/2023.
Interview on 12/11/2023 at 1:18 p.m. with S5 LPN revealed Resident #17 had returned from the hospital last week with oxygen in use. S5 LPN revealed Resident #17 received oxygen and continue oxygen saturation checks.
Observation on 12/11/2023 at 1:25 p.m. in Resident #17's room accompanied by S9 RN Unit Manager in Resident #17's room revealed oxygen in progress at 1.5 liters per minute via nasal cannula.
Observation on 12/12/2023 at 7:50 a.m. revealed Resident #17 awake lying in bed with head of bed elevated with oxygen in progress at 1.5 liters per minute via nasal cannula per oxygen concentrator. Oxygen tubing labeled with date 12/12/2023.
Interview on 12/12/2023 at 3:40 p.m. with S9 RN Unit Manager revealed Resident #17 did not have a physician's order for receiving oxygen since he had returned from the hospital via ambulance on 12/06/2023.
Telephone interview on 12/12/2023 at 4:10 p.m. with S12 LPN revealed she had worked the night when Resident #17 had returned from the hospital on [DATE] just before shift change. S12 LPN stated resident had oxygen in progress at the beginning of her shift and had weaned resident off of oxygen after his oxygen saturation was at 96% on room air during the night. S12 LPN revealed Resident #17's oxygen saturation had dropped down to 89% on 12/07/2023 when she placed resident back on oxygen at 2 liters per minute via nasal cannula. S12 LPN revealed she had not notified NP/MD due to she thought there was an order for oxygen in place because resident had returned from the hospital with oxygen in progress. S12 LPN revealed she was not aware that Resident #17 did not have an order for oxygen in place. S12 LPN revealed she should have notified NP/MD to obtain physician's orders for oxygen therapy for Resident #17, but did not.
Interview on 12/13/2023 at 09:11 a.m. with S2 RN DON confirmed that S12 LPN should have clarified Resident #17's hospital discharge orders with NP/MD regarding his oxygen therapy, but did not. S2 RN DON confirmed S12 LPN should have notified NP/MD to obtain physician's orders for oxygen therapy for Resident #17, but did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maint...
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Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (#13) of 4 (#6, #13, #26, and #64) residents reviewed for ADL care.
Findings:
Review of the Facility's Fingernail/Toenail Care policy read in part .
Policy: The Purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections.
General Guidelines:
1.Nail care includes daily cleaning and regular trimming.
Review of Resident #13's Care plan with a target completion date of 12/06/2023 revealed in part
Resident #13 requires assistance with ADLS.
Personal hygiene- requires substantial/maximum assistance.
An observation and interview on 12/11/2023 at 11:58 a.m. revealed Resident #13 with long and jagged fingernails. Resident #13 stated he has asked staff to cut his nails but he has been told they are unable to clip his nails because he is Type 2 Diabetic. Resident #13 stated he would clip his own nails if he had a pair of clippers.
An interview on 12/12/2033 at 9:40 a.m. with S7 Unit Manager confirmed Resident #13's fingernails are long and should have been cut by nursing staff but had not been. S7 Unit Manager asked Resident #13 if he would like his fingernails cut and Resident #13 responded yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-center...
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Based on interview and record review the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan 1 (Resident #11) of 1 sampled residents for edema. The facility failed to ensure Physician's Orders for an assistive device for support and positioning were implemented.
Findings:
Review of Resident #11's clinical record revealed an admit date of 10/17/2023. Resident #11 was noted to have diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Muscle Wasting and Atrophy, and Osteoarthritis.
Review of Resident #11's MDS Assessment with ARD 11/16/2023 revealed Resident #11 had a BIMS score of 15, cognitively intact, and had functional limitation in range of motion in the upper and lower extremities on one side.
Observation on 12/11/23 at 12:28 p.m. revealed Resident #11 seated in a wheelchair in the facility dining room. Mild edema was noted to Resident #11's left upper arm and hand. No assistive or supportive devices were observed in use. Interview with Resident #11 at the time of observation revealed use of his left arm had been affected by a stroke.
Observation on 12/12/2023 at 11:30 a.m. revealed Resident #11 seated in a wheelchair in the facility dining room with his left arm resting across the front of his body. Mild edema was observed to Resident #11's left hand. No assistive/supportive devices were observed in use.
Review of Resident #11's Physicians orders revealed in part .
11/21/2023 Flip half tray to left side of wheelchair for proper positioning. Every shift related to Hemiplegia and Hemiparesis.
Review of Resident #11's CPOC with target date of 01/30/2024 revealed in part .The resident has limited physical mobility related to stroke. Provide supportive care, assistance with mobility as needed. Flip half tray to left side of wheelchair for proper positioning.
Interview on 12/12/2023 at 11:55 a.m. with S5 LPN revealed Resident #11 was supposed to have a flip tray to support his left arm while in his wheelchair but he did not.
Interview on 12/12/2023 at 3:00 p.m. with S4 COTA stated Resident #11 had a flip tray ordered to support his left arm. S4 COTA presented Resident #11's flip tray, stating it had been in the therapy department for at-least one week.
Interview on 12/12/2023 at 3:15 p.m. with S2 DON revealed she was not aware Resident #11 did not have his flip tray on his wheelchair to support his left arm and he should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to...
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Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by:
1. Failing to ensure staff performed hand hygiene after touching contaminated areas during wound care for 1 (#56) of 1 residents observed for wound care.
2. Failing to ensure catheter tubing was kept off the floor for 1 (#17) of 1 resident reviewed for urinary catheter.
Findings:
Review of the Facility's Handwashing- Hand Hygiene policy read in part .
Applying and removing gloves:
1. Perform hand hygiene before and after applying non sterile gloves.
Resident #56
Review of Resident #56's medical records revealed an admit date of 12/16/2021 with diagnoses that included: Pressure Ulcer to Sacral Region Stage 4, Stemi Myocardial Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction, Unspecified Dementia, Obstructive Sleep Apnea, Heart Failure, and Essential Hypertension.
Review of Resident #56's 12/2023 Physician's Order read in part .
Cleanse healing Stage 4 Pressure Ulcer to sacrum with wound cleanser, pat dry, apply collagen powder, cover with foam dressing on Monday, Wednesday, Fridays and as needed until healed.
An observation of wound care for Resident #56 on 12/12/2023 at 2:00 p.m. revealed S6 LPN cleansed Resident #56 sacrum wound with 4x4 and wound cleanser, removed soiled gloves, then put on a new set of gloves without cleaning/sanitizing hands. S6 LPN cleansed the sacrum wound for a second time, removed gloves and put on a new pair of gloves without cleaning/sanitizing hand.
An interview on 12/12/2023 at 2:05 p.m., S6 LPN was notified by this surveyor that she failed to sanitize hands prior to applying new gloves to cleanse the sacrum wound and apply new dressing. S6 LPN confirmed that she does not sanitize her hands once she has removed her gloves after cleaning a resident's wound unless her gloves were visibly soiled. S6 LPN stated she thought she was only to sanitize her hands prior to treatment, if her gloves are visibly soiled and after wound care is provided.
An interview on 12/12/2023 at 3:10 p.m. with S2 DON confirmed that hand hygiene must be completed after removing soiled gloves and prior to putting a new pair of gloves on.
Review of the facility's policy titled, Catheter Care, Urinary revealed in part .
Purpose - The purpose of this procedure is to prevent catheter-associated urinary tract infections.
Infection Control - 2. Maintain clean technique when handling or manipulating catheter, tubing, or drainage bag. B. Be sure the catheter tubing and drainage bag are kept off the floor.
Resident #17
Review of Resident #17's medical record revealed an admit date of 02/27/2023 with diagnoses that included: Cerebral Infarction due to Embolism of Unspecified Middle Cerebral Artery, Hemiplegia and Hemiparesis following CVI affecting Right Dominant Side, Osteomyelitis of Vertebra, Sacral-coccygeal Region, Type 2 DM, Functional Quadriplegia and Unspecified Neuromuscular Dysfunction of Bladder.
Review of Resident #17's Quarterly MDS with an ARD of 11/21/2023 revealed a BIMS score of 99, indicating resident was unable to complete the interview, and had moderately impaired skills for daily decision making. Review of the MDS revealed Resident #17 had an indwelling urinary catheter.
Observation on 12/11/2023 at 12:45 p.m. revealed Resident #17's indwelling catheter with amber colored urine in catheter tubing with 500cc of amber colored urine in drainage bag hanging from bed frame. Observation of Resident #17's indwelling catheter tubing was hanging from the bed frame with the tubing touching the floor.
Observation on 12/11/2023 at 1:25 p.m. in Resident #17's room accompanied by S9 RN Unit Manager in Resident #17's room revealed Resident #17's catheter tubing was hanging from the bed frame with tubing touching the floor. Interview at that time with S9 RN Unit Manager confirmed the catheter tubing was touching the floor and should not have been.
Interview on 12/12/2023 at 3:31 p.m. with S8 RN ADON revealed the nursing staff are responsible for ensuring residents catheter bags and tubing are not touching the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Resident #69
A review of Resident #69's medical record revealed an admit date of 09/21/2023 with diagnoses that included: Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction ...
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Resident #69
A review of Resident #69's medical record revealed an admit date of 09/21/2023 with diagnoses that included: Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting left side, Essential Hypertension, and Major Depression Disorder.
A review of Resident #69's Care Plan with a target completion date of 01/04/2024 read in part .
Resident #69 has oxygen therapy: Monitor nebulizer treatment prior to and after treatment, Ipratropium-Albuterol solution as ordered, Monitor for signs and symptoms of respiratory distress and report to medical director as needed.
An observation on 12/11/2023 at 10:34 a.m. revealed Resident #69's nebulizer mask dated 12/5/2023 hanging on the nebulizer machine, left open to air, and uncontained.
An observation on 12/12/2023 at 9:30 a.m. revealed Resident #69's nebulizer mask was observed hanging on the side of the nebulizer machine uncontained.
An interview on 12/12/2023 at 9:40 a.m. with S2 DON confirmed the above findings. S2 DON stated all respiratory tubing should be dated and stored in a zip lock bag when not in use, but it was not.
Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards of practice. The facility failed to ensure respiratory equipment was properly stored for 2 (Resident #17 and Resident #69) of 2 residents reviewed for respiratory care.
Findings:
Review of the facility's policy titled, Departmental (Respiratory Therapy) Prevention of Infection revealed in part . Steps in the Procedure - Infection Control Considerations related to Oxygen Administration.
8. Keep the oxygen cannula and tubing used prn in a plastic bag when not in use.
Resident #17
Review of Resident #17's medical record revealed an admit date of 02/27/2023 with diagnoses that included: Functional Quadriplegia, Cerebral Infarction due to Embolism of Unspecified Middle Cerebral Artery, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Osteomyelitis of Vertebra, Sacral-Coccygeal Region, Type 2 DM with DN and Personal History of Covid-19.
Review of Resident #17's Care plan with target date of 02/13/2024 revealed resident required
Oxygen therapy with interventions that included oxygen as ordered, monitor for signs and symptoms of respiratory distress and report to MD prn.
Observation on 12/11/2023 at 12:45 p.m. with Resident #17's revealed oxygen in progress via nasal cannula at 1.5 liters per minute per oxygen concentrator. Oxygen tubing labeled with date 12/11/2023.
Observation on 12/12/2023 at 7:50 a.m. revealed Resident #17 awake lying in bed with head of bed elevated with oxygen in progress at 1.5 liters per minute via nasal cannula per oxygen concentrator. Oxygen tubing labeled with date 12/12/2023.
Observation on 12/13/2023 at 10:13 a.m. in Resident #17's room accompanied by S11 LPN TX Nurse and S14 CNA revealed oxygen tubing and nasal cannula uncovered and open to air lying on residents bed. Interview with S11 LPN TX Nurse at that time confirmed nasal cannula and oxygen tubing was uncovered and open to air, but should not have been. S11 LPN TX Nurse stated it should have been contained in a plastic bag.
Interview on 12/13/2023 at 10:36 a.m. with S9 RN Unit Manager confirmed Resident #17's oxygen tubing and nasal cannula should have been properly contained in a plastic bag, but was not done.
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 ensure that food was stored in accordance with professional standards for food service. The facility failed to ensure that expired/outdated it...
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Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. The facility failed to ensure that expired/outdated items were not available for resident consumption and failed to ensure frozen food items were properly stored. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. Findings:
Review of the facility policy titled: Food Receiving and Storage revealed in part .
All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by) date.
Observation on 12/11/2023 at 10:00 a.m. of the facility cooler accompanied by S3 Dietary Manger, revealed the following items on the shelf for use:
(1) 5lb container of cottage cheese with an expiration date of 10/28/2023
(1) opened gallon of yellow mustard dated 12/15.
Interview with S3 Dietary Manager at the time of observation confirmed the above findings. S3 Dietary Manager stated she was unsure what year the mustard labeled 12/15 had been opened.
On initial tour of the kitchen on 12/11/2023 at 10:08 a.m. accompanied by S3 Dietary Manager the following items were observed in the facility freezer for use:
(2) opened, undated 5 pound bags of French fries.
(1) opened, undated bag of sausage links.
(1) opened, undated bag of brussel sprouts.
(1) opened, undated 1lb package of sliced sandwich meat.
(2) opened, undated bags of frozen hamburger patties.
(1) opened, undated 5 pound bag of shredded cheddar cheese.
(1) opened, undated bag of frozen meat pies.
Findings confirmed with S3 Dietary Manager at the time of observations.
Sept 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to use a two-person transfer, as determined necessary by the resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to use a two-person transfer, as determined necessary by the resident's person centered plan of care, during a transfer from bed to wheelchair for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Resident #2 fell to the ground, and sustained an Acute Left Femur Fracture.
This failed practice resulted in an actual harm situation for Resident #2 on 09/06/2023 at 9:00 a.m., when S4 CNA transferred the resident from the bed to a wheelchair without assistance of another staff, as indicated on Resident #2's plan of care. During the transfer, Resident #2 fell to the ground. Resident #2 complained of left knee pain with swelling noted, and an x-ray was obtained which revealed an Acute Left Femur Fracture. Resident #2 was sent to the emergency room on [DATE], and had a Retrograde Nailing of the Left Distal Femur performed.
Findings:
Review of the facility's Fall Prevention Program revealed in part .
All residents will be screened for risk for falls utilizing the Fall Risk Assessment. This will be done at the time of admission, quarterly, after each fall and upon significant change in condition. Residents identified as being at risk will have interventions identified in their plan of care to minimize falls.
Review of the facility's Safe Patient Handling and Moving Protocol revealed in part .
It is important to remember that each resident is different; transfer techniques and bed mobility/positioning may need to be modified for the particular resident to meet their individual needs. Please verify level of assistance required prior to initiating transfer or bed mobility/positioning.
Review of Resident #2's medical record revealed an admission date of 01/26/2022, with diagnoses that included Cerebral Infarction, Type 2 Diabetes Mellitus, and Repeated Falls.
Review of Resident #2's Quarterly Fall Scale Evaluation dated 08/15/2023 revealed Resident #2 had a score of 55, which was deemed high risk for falling.
Review of Resident #2's Quarterly MDS with an ARD of 08/15/2023 revealed a BIMS score of 15, indicating the resident was cognitively intact. Review of the MDS revealed Resident #2 required extensive two person physical assistance with transferring, bed mobility, and toilet use.
Review of Resident #2's care plan with a target date of 11/07/2023 revealed in part .
Resident #2 needs assist with activities of daily living.
Interventions included in part .Transfers-extensive assist with assist of two. Bed mobility and toileting-extensive assist with assist of two. Walk in room-did not occur.
Review of an incident report dated 09/06/2023 at 9:00 a.m. read in part .
Nursing Description: CNA was assisting resident with transfer from bed to wheelchair, and when going to pivot and turn, resident states she was about to fall and CNA eased resident to the floor slowly .Wheelchair was placed beside bed and locked for easy transfer. Resident was sitting on her bottom with her legs straight out in upright position. Resident did not hit her head or any extremities on anything.
Resident Description: I just got weak.
Review of a left knee x-ray dated 09/06/2023, revealed an Impression of Acute Fracture of the Distal Femur.
Review of the Operative Procedure Note documented on 09/08/2023, revealed Resident #2's preoperative diagnoses was Displaced Left Distal Third Femur Fracture. The procedure performed was Retrograde Nailing of Left Distal Third Femur Fracture.
In an interview on 09/20/2023 at 8:15 a.m., S3 LPN stated on the morning of the incident, S4 CNA told her she went to get Resident #2 ready to shower. S3 LPN stated S4 CNA told her she was transferring Resident #2 from the bed to the wheelchair when the resident got weak and said she could not do it. S3 LPN stated S4 CNA reported to her that she eased her down to the floor from a standing position. S3 LPN said she assessed Resident #2 and said she complained of left knee pain, which was normal for the resident. S3 LPN said Resident #2's knee was swollen, which was also usual for the resident. S3 LPN stated a portable x-ray was done, and they were notified her leg was fractured. S3 LPN said she notified the physician who came and assessed her later that day, and ordered an orthopedic consult. S3 LPN said there was no orthopedic doctor available for a few days, so Resident #2 was sent to the emergency room the following day.
In a telephone interview on 09/20/2023 at 9:40 a.m., S4 CNA stated on 09/06/2023, she was working as a Shower Aide. S4 CNA stated she went to Resident #2's room, gathered her clothes, and then asked Resident #2 if she was ready to go shower. S4 CNA said Resident #2 sat up on the side of the bed. S4 CNA stated Resident #2 was sitting on the edge of the bed so she counted to 3 and Resident #2 stood up fine. S4 CNA stated she was ready to turn her, and Resident #2 said she was falling. S4 CNA stated she held Resident #2 under her arms and breasts, and eased her to the floor. S4 CNA said Resident #2 said Ouch and complained of back or knee pain. S4 CNA stated she reported it to S3 LPN. S4 CNA stated she only works at the facility prn, and Resident #2 had been more mobile the last time she worked with her. S4 CNA stated after the fall, she was then told Resident #2 only gets bed baths. S4 CNA stated she didn't know Resident #2 didn't get out of bed anymore. S4 CNA confirmed she didn't know Resident #2 required two person assistance to transfer. S4 CNA stated she should have asked someone. S4 CNA confirmed she did know how to look up how much assistance was required by each resident, but did not look it up, and should have.
In an interview on 09/20/2023 at 10:00 a.m., S2 DON stated CNAs should check residents' tasks on their Ipads (portable tablets) to determine how much assistance residents require with ADLs. S2 DON stated at the time of the fall on 09/06/2023, Resident #2 was care planned for 2 person assistance with transfers. S2 DON confirmed S4 CNA should have checked the tasks before the transfer to determine how much assistance Resident #2 required, and found someone to assist her with transferring Resident #2.
Nov 2022
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the Facility failed to treat Residents with respect and dignity by failing to provide a cover for a drainage bag for 1 (Resident #13) of 1 sampled Res...
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Based on observation, interview and record review the Facility failed to treat Residents with respect and dignity by failing to provide a cover for a drainage bag for 1 (Resident #13) of 1 sampled Resident with an indwelling catheter. Findings:
Observation on 11/29/2022 at 12:10 p.m. revealed Resident #13 being assessed by the Hospice Nurse. The Resident's catheter drainage bag was uncovered hanging on the side of the bed. Urine was noted in the drainage bag
Observation on 11/30/2022 at 7:45 a.m. revealed Resident #13 lying in bed uncovered. Her bed was in low position and upper side rails were raised. The Resident's catheter bag was uncovered and sitting on the floor.
Review of Resident #13's EHR revealed an admit date of 08/22/2022. The Resident had the following diagnoses including Unstageable Pressure Ulcer of Sacral Region; UTI not specified; and overactive bladder.
Review of Resident #13's 11/2022 MD Orders revealed the following including:
08/23/2022 - 16Fr, Foley catheter for urinary retention
08/23/2022 - Admit to hospice dx: Alzheimer's Disease
08/29/2022 - Foley Catheter care q shift and prn
08/29/20022 - Privacy bag or covering over urine collection bag for dignity every shift
11/15/2022 - Foley Catheter change every 30 days and prn
Review of Resident #13's Admit MDS with ARD of 08/31/2022 revealed in part:
Section C - Cognitive Pattern - The Resident had a BIMS of 6.
Section H - Bowel and Bladder - The Resident had an indwelling catheter and was frequently incontinent of bowel
Review of the Facility's Dignity Policy Interpretation and Implementation #12. a. revealed the following: Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered;
Interview on 11/30/2022 at 7:45 a.m. with S5 LPN confirmed Resident #13's Catheter bag was uncovered and it should not 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
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure written notices to the resident or his or her legal representative including items and services which are/are not covered under Medi...
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Based on interview and record review, the facility failed to ensure written notices to the resident or his or her legal representative including items and services which are/are not covered under Medicare or by the facility's per diem rate, including the cost of those items and services and the potential liability for payment for the non-covered services. This deficient practice was identified for 2 of 2 (Resident #1 and Resident #14) sampled residents for Advance Beneficiary Notices (ABN). Findings:
Review of the SNF Beneficiary Notification Review forms completed by the facility revealed the following:
Resident #1 - Medicare Part A Skilled Services Episode start date 05/12/2022; last covered day 07/15/2022. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review revealed SNF ABN, Form CMS (Centers for Medicare & Medicaid Services) 10055 was not issued.
Resident #14 - Medicare Part A Skilled Services Episode start date 07/26/2022; last covered day 09/09/2022. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review revealed form CMS 10055 was not issued. NOMNC Form CMS 10123 was issued, but there was no evidence as to when because the form was not dated.
Interview with S7 Business Office Manager on 11/30/2022 at 1:40 p.m., and review of the SNF ABN forms revealed S7 Business Office Manager stated she was responsible for issuing SNF ABN notices to Residents, or the Residents' Representatives. S7 Business Office Manager stated that Residents #1 and #14 were not issued form CMS 10055 at admission, or prior to their benefit days ending. S7 Business Office Manager stated she does not complete SNF ABN notices on any residents at the facility because there is no reason why Medicare A will not cover the Resident's services. S7 Business Office Manager stated she does not believe she has to complete this form, and confirmed she did not complete nor have residents signed the required forms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to follow the Comprehensive Plan of Care and monitor for signs/symptoms of bleeding for a resident who was discovered to have a br...
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Based on observation, interview and record review the facility failed to follow the Comprehensive Plan of Care and monitor for signs/symptoms of bleeding for a resident who was discovered to have a bruise to the right forehead and right arm, for 1 (Resident #8) of 17 Sampled Residents. Findings:
Observation on 11/29/2022 at 11:55 a.m. of Resident #8 revealed the Resident asleep. Resident #8 had a large bruise to her right forehead which covered the right side of her forehead, down into the right orbital area, and a large bruise which covered the entire anterior and posterior arm right arm. Her bed was in low position. There was a protective pad noted on the wall side of the bed. There were no side rails noted.
Observation on 11/30/2022 at 7:32 a.m. of Resident #8 revealed the Resident awake. The Resident's bed was noted in high position and her protective pad was noted below the level of the bed. The Resident was lying on her right side facing the wall. There was a large bruise noted to her right forehead and her right arm as noted above.
Review of Resident #8's EHR revealed an admission date of 05/09/2021, and the following diagnoses: Cerebral Ischemia, Muscle Wasting & Atrophy, Other Abnormalities of Gait and Mobility, Age-Related Physical Debility, Hemiplegia and Hemiparesis following Cerebral Infarction and Long-Term use of Anti-coagulants.
Review of Resident #8's Quarterly MDS with an ARD of 11/11/2022 revealed the following in part:
Section C - Cognitive Pattern - The Resident's BIMS was 99 (unable to complete interview).
Section J - Health Conditions - The Resident had no falls.
Review of Resident #8's Comprehensive Plan of Care with a target date of 11/25/2022, revealed a problem of Anticoagulant Therapy with approaches that included: Monitor for s/s of bleeding
Review of Resident #8's 11/2022 MD Orders revealed the following including:
10/14/2022 - ASA 325 mg po daily
11/02/2022 - Warfarin Sodium 5 mg po every evening for treating/preventing blood clots r/t long term (current) use of anticoagulants
11/16/2022 - Admit to Hospice - DX Alzheimer's, D/C all routine labs, therapy, f/u appts. Continue with PT/INR monthly as Resident is on Coumadin
Review of Resident #8's 08/2022 - 11/2022 Progress Notes revealed the following in part: On 11/25/2022 at 9:00 a.m., Resident #8's family reported that the Resident had a bruise on her head. The nurse assessed the Resident and noted a quarter sized dark brownish bruise to mid-frontal head, faint light bluish-purple bruising to right forehead, and a scratch to her mid-nose. On 11/26/2022, Resident #8 was noted having vaginal bleeding, and Coumadin was held 5 days. A PT/INR was performed on 11/29/2022 with the following result: 11/29/2022 - PT 73.0; INR 7.09.
The progress notes dated 08/2022 to 11/2022 did not indicate that there was a bruise to Resident #8's right arm.
Review of Resident #8's medical record revealed orders to hold Coumadin until 12/07/2022, recheck PT/INR in 1 week, and give vitamin K today.
Interview on 11/30/2022 at 7:35 a.m. with S5 LPN revealed she was the nurse that Resident #8's family had reported the bruise to the forehead to. S5 LPN stated the bruise was much larger now than it was when she first assessed the injury on 11/25/2022. S5 LPN confirmed she was not aware of the bruise on Resident #8's right arm that was first noted by the surveyor on 11/29/2022 at 11:55 a.m.
Interview on 11/30/2022 at 7:40 a.m. with S2 DON revealed she was not sure how Resident #8 received the bruise to her forehead, and why there was no documentation of the increase in the size of the bruise. S2 DON stated this was a s/s of bleeding, and should have been reported. S2 DON stated she was not aware that Resident #8 had a bruise on her arm, and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the Facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections...
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Based on observation, record review and interview the Facility failed to ensure Residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident # 13) of 1 Sampled Resident with a urinary catheter. Findings:
Observation on 11/29/2022 at 12:10 p.m. revealed Resident #13 being assess by the Hospice Nurse. The Resident had a sitter at bedside as well. There was no distress noted. Resident #13's catheter bag was hanging on the side of the bed.
Observation on 11/30/2022 at 7:45 a.m. revealed Resident #13 lying in bed uncovered. Her bed was in low position and upper side rails were raised. She was alert and responded appropriately when questioned. Resident #13's catheter bag was uncovered and sitting on the floor.
Review of the Facility Catheter Care, Urinary Policy revealed in part, Infection Control 2. b. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor.
Review of Resident #13's EHR revealed an admit date of 08/22/2022. The Resident had the following diagnoses including Unstageable Pressure Ulcer of Sacral Region; UTI not specified; and overactive bladder.
Review of Resident #13's 11/2022 MD Orders revealed the following including:
08/23/2022 - 16Fr, Foley catheter for urinary retention
08/23/2022 - Admit to hospice dx: Alzheimer's Disease
08/29/2022 - Foley Catheter care q shift and prn
08/29/20022 - Privacy bag or covering over urine collection bag for dignity every shift
10/10/2022 - Sterile insertion of 16Fr/10cc F/C to be changed q 30 days and prn leakage/occlusion/failure to drain
11/15/2022 - Foley Catheter change every 30 days and prn
11/16/2022 - Macrobid 100 mg q hs for UTI
Review of Resident #13's Admit MDS with ARD of 08/31/2022 revealed in part:
Section C - Cognitive Pattern - The Resident had a BIMS of 6.
Section H - Bowel and Bladder - The Resident had an indwelling catheter and was frequently incontinent of bowel.
Review of Resident #13's 08/2022 - 11/2022 Progress Notes revealed the Resident was placed on antibiotics for UTI.
Interview on 11/30/2022 at 7:45 a.m. with S5 LPN confirmed Resident #13's catheter bag was on the floor, uncovered and it should not 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 provide respiratory care consistent with professional standards for 2 of 2 sampled residents for respiratory care (Resident #6...
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Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 of 2 sampled residents for respiratory care (Resident #65 and Resident #320). The facility failed to ensure respiratory equipment was properly changed, labeled and stored. Findings:
Review of the facility's policy titled: Departmental (Respiratory Therapy) - Prevention of Infection, revealed in part
Review the Residents care plan to assess for any special circumstances or precautions related to the Resident.
Resident #65
Review of Resident #65's Electronic Medical Record revealed an admit date of 05/06/2022, with diagnoses which included: Chronic Obstructive Pulmonary Disease.
Review of Resident #65's Quarterly MDS with ARD/Target date of 09/09/2022 revealed the following: BIMS score of 15 indicating no cognitive impairment - no behaviors present; Functional Status: Bed mobility, Transfers, Toilet Use, Personal Hygiene, Bathing and Walk in room and off unit = Independent with no setup help required; Eating = Independent with setup help only; and Dressing = Independent with 1 person physical assist. ROM = no impairments on both sides for upper and lower extremities; and Resident #65 was coded for Oxygen use
Review of Resident #65's Care Plan with a target date of 03/01/2023 revealed Resident #65 had Chronic Obstructive Pulmonary Disease, with interventions that included: Give aerosol or bronchodilators as ordered and O2 as ordered.
Review of Resident #65's Physician Orders dated 05/06/2022 revealed: O2 at 2L/min via NC continuously. May titrate 3-4 LPN to keep O2 sats >90%. Change/label/date O2 tubing every week.
Observation on 11/28/2022 at 10:58 a.m. revealed Resident #65 was receiving O2 via NC at 3.5L/min. The O2 tubing was not labeled/dated and the humidification bottle was empty with no label/date.
Interview with Resident #65 on 11/28/2022 at 11:00 a.m. revealed she used oxygen continuously.
Observation on 11/29/2022 at 11:59 a.m. revealed Resident #65 was receiving O2 via NC at 3L/min. The O2 tubing was not labeled/dated and the humidification bottle was empty with no label/date.
Interview on 11/29/2022 at 12:30 p.m. with S4 LPN in Resident #65's room confirmed the humidification bottle was empty, but should not have been. S4 LPN stated Resident #65's O2 tubing and humidification bottles are changed weekly, and as needed. S4 LPN confirmed there was no label/date on the O2 tubing or humidification bottle for Resident #65, but there should have been.
Resident #320
Review of Resident #320's Electronic Medical Record revealed an admit date of 11/16/2022, with diagnoses which included: Obstructive Sleep Apnea.
Review of Resident #320's MDS revealed the admission MDS was incomplete as Resident #320 is a new admit.
Review of Resident #320's Care Plan with a target date of 02/14/2023 revealed Resident #320 required oxygen therapy with interventions that included: change/label/date O2 tubing as ordered and O2 via nasal cannula at 3L/min as ordered.
Review of Resident #320's Physician Orders dated 11/16/2022 revealed: O2 at 3L/min via NC continuously. May titrate 3-4 LPN to keep 02 sats >90%. Change/label/date 02 tubing every week.
Observation on 11/28/2022 at 9:45 a.m. revealed Resident #320 was receiving O2 via NC at 3L/min. The humidification bottle connected to the NC was not labeled with a date.
Interview with Resident #320 on 11/28/2022 at 9:46 a.m. revealed she used the oxygen continuously.
Observation on 11/29/2022 at 12:09 p.m. revealed Resident #320 receiving O2 via NC at 3L/min. There was no date on humidification bottle connected to the NC.
Interview on 11/29/2022 at 12:42 p.m. with S4 LPN in Resident #320's room revealed Resident #320's O2 tubing and humidification bottles are changed weekly, and as needed. S4 LPN confirmed there was no date on Resident #320's humidification bottle, and there should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that 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 serve all Residents at a table at the same time, who were seated at the same time, and by failing to utilize non-disposable dishware and cutlery.
Observation on 11/28/2022 at 11:43 a.m. revealed 21 Residents were served their lunch meal on disposable dishware. There was a total of 21 Residents in the dining room. Seven Residents were served metal non-disposable cutlery, and all of the other residents received plastic disposable cutlery. Further observation revealed the Residents sitting at the same table in the dining room were not served at the same time. All of the Residents in the dining room had been served a meal while one Resident had not. The Resident was in the dining room when meal service started. The Resident's table began being served at 11:43 a.m. and the Resident was not served until 11:57 a.m. after asking staff for the meal.
Observation on 11/28/2022 at 12:21 p.m. of the food cart on Hall A revealed all Residents received their lunch meal on disposable dishware with disposable cutlery.
Interview on 11/28/2022 at 11:24 a.m. with S8 Dietary Staff in the dining room revealed she was the only staff member working in the kitchen, so she would have to use disposable dishware/cutlery as there was no one available to wash dishes. She confirmed the Residents' meals should be served on non-disposable dishware with non-disposable cutlery.
Interview on 11/28/2022 at 12:05 p.m. with Resident # 25 revealed he preferred being served on non-disposable plates with non-disposable cutlery as the plastic disposable cutlery was hard to manage.
Interview on 11/28/2022 at 12:06 p.m. with Resident # 43 revealed he preferred being served on non-disposable plates.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure a resident received the treatments necessary to promote wound healing for 1 (#70) of 3 (#13, #50, #70) residents reviewed for pressu...
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Based on record review and interview, the facility failed to ensure a resident received the treatments necessary to promote wound healing for 1 (#70) of 3 (#13, #50, #70) residents reviewed for pressure ulcers.
Review of Resident #70's record revealed an admit date of 10/05/2022 with diagnoses that included, in part, malignant neoplasm of the pancreas and a pressure ulcer of the sacral region, stage 2.
Review of Resident #70's physician's orders revealed an order dated 10/19/2022 to cleanse unstageable pressure ulcer to coccyx with wound cleanser, pat dry, apply Aquacel AG, then cover with Optifoam daily and as needed until healed.
Review of Resident #70's October 2022 TAR revealed the pressure ulcer to the coccyx was not treated on 10/20/2022, 10/26/2022, 10/28/2022, or 10/30/2022.
In an interview on 11/30/2022 at 4:39 p.m., S2 DON and S6 Wound Care Nurse acknowledged the wound care orders were not documented as completed on 10/20/2022, 10/26/2022, 10/28/2022, and 10/30/2022 and should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure the Nurse Staffing Information contained the actual hours worked by licensed and unlicensed nursing staff directly responsible for resi...
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Based on observation and interview the facility failed to ensure the Nurse Staffing Information contained the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The facility census was 68 according to the Resident Census and Condition of Residents form. Findings:
Observation on 11/28/2022 at 2:00 p.m. revealed a staffing schedule hanging on a bulletin board on the wall at the entrance of the Facility. The staffing schedule revealed the following: Date: 11/28/2022, Census - 68, RN - 16, LPN - 32, and CNA - 45. The posted staffing schedule did not include the actual hours worked by the facility's licensed and unlicensed staff per shift.
Observation on 11/29/2022 at 7:30 a.m. revealed a staffing schedule hanging on a bulletin board on the wall at the entrance of the Facility. The staffing schedule revealed the following: Date: 11/29/2022, Census - 68, RN - 16, LPN - 24+8, and CNA - 45. The posted staffing schedule did not include the actual hours worked by the facility's licensed and unlicensed staff per shift.
Observation on 11/30/2022 at 9:10 a.m. revealed the staffing schedule was dated 11/30/2022, and the following information was documented: Census - 69, RN - 16, LPN - 24, and CNA - 60. The posted staffing schedule did not include the actual hours worked by the facility's licensed and unlicensed staff per shift.
Interview on 11/30/2022 at 9:10 a.m. with S9 Corporate Nurse confirmed the staff posting was in totals, and there was no separation of staffing hours per shift.
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
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 by having a dirty ceiling above t...
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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 by having a dirty ceiling above the steam table and food prep area and a dirty vent hood. The deficient practice had the potential to affect any resident who consumed meals served from the facility's kitchen. Findings:
In an observation during the lunch meal at 11:30 a.m. on 11/28/2022, it was noted that the ceiling tiles were covered in black spots with a fuzzy, dark substance hanging down over the steam table and food prep area. Further observation revealed ceiling tiles all over the kitchen were dirty with dark brown and black substances on them. An observation of the top of the vent hood revealed a fuzzy brown substance all over it.
In an interview with S1 Administrator on 11/28/2022 at 12:25 p.m. during the kitchen observation, S1 Administrator acknowledged the ceiling tiles and hood vent were dirty and needed to be cleaned.
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
- • 24% annual turnover. Excellent stability, 24 points below Louisiana's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $112,959 in fines. Review inspection reports carefully.
- • 34 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $112,959 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (18/100). Below average facility with significant concerns.
Bottom line: Trust Score of 18/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Many Healthcare And Rehabilitation Center's CMS Rating?
CMS assigns Many Healthcare and Rehabilitation 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 Many Healthcare And Rehabilitation Center Staffed?
CMS rates Many Healthcare and Rehabilitation Center's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 24%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Many Healthcare And Rehabilitation Center?
State health inspectors documented 34 deficiencies at Many Healthcare and Rehabilitation Center during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 31 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 Many Healthcare And Rehabilitation Center?
Many Healthcare and Rehabilitation Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NEXION HEALTH, a chain that manages multiple nursing homes. With 162 certified beds and approximately 77 residents (about 48% occupancy), it is a mid-sized facility located in Many, Louisiana.
How Does Many Healthcare And Rehabilitation Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Many Healthcare and Rehabilitation Center's overall rating (2 stars) is below the state average of 2.4, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Many Healthcare And Rehabilitation Center?
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 Many Healthcare And Rehabilitation Center Safe?
Based on CMS inspection data, Many Healthcare and Rehabilitation Center has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (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 Many Healthcare And Rehabilitation Center Stick Around?
Staff at Many Healthcare and Rehabilitation Center tend to stick around. With a turnover rate of 24%, the facility is 22 percentage points below the Louisiana average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 20%, meaning experienced RNs are available to handle complex medical needs.
Was Many Healthcare And Rehabilitation Center Ever Fined?
Many Healthcare and Rehabilitation Center has been fined $112,959 across 3 penalty actions. This is 3.3x the Louisiana average of $34,208. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Many Healthcare And Rehabilitation Center on Any Federal Watch List?
Many Healthcare and Rehabilitation 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.