Colonial Nursing and Rehabilitation Center
For profit - Limited Liability company
64 Beds
RIGHTCARE HEALTH SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
41/100
#122 of 264 in LA
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Colonial Nursing and Rehabilitation Center has a Trust Grade of D, indicating below-average performance with some concerns. It ranks #122 out of 264 facilities in Louisiana, placing it in the top half, and #4 out of 8 in Avoyelles County, meaning only three local options are better. The facility's performance trend is stable, with the same number of issues reported in both 2024 and 2025. Staffing is rated as adequate, with a 2/5 star rating and a turnover rate of 53%, which is average compared to the state. However, the center has faced significant issues, including a critical incident where a cognitively impaired resident was able to exit the building unsupervised and was later arrested, indicating serious safety concerns. Additionally, there were failures in monitoring residents' hydration and nutrition needs, and food storage practices did not meet safety standards, which could impact all residents. Despite some good RN coverage, families should weigh these strengths against the notable weaknesses when considering this facility.
- Trust Score
- D
- In Louisiana
- #122/264
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $19,145 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Louisiana. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 18 deficiencies on record. Higher than average. Multiple issues found across inspections.
41/100
Top 46%
Review needed
7 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 53%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $19,145
Below median ($33,413)
Minor penalties assessed
Chain: RIGHTCARE HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 18 deficiencies on record
1 life-threatening
May 2025
7 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place for a cogniti...
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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 adequate supervision was in place for a cognitively impaired resident who was identified as being at high risk for elopement, exhibited exit seeking behaviors, and voiced a desire to leave the facility did not exit the building for 1 (#156) of 11 (#2, #3, #23,#24, #25, #38, #44, #47, #48, #156 and #157) residents at risk for elopement.
Findings:
This deficient practice resulted in an immediate jeopardy situation for Resident #156 on 05/16/2025 at 8:15 a.m., when Resident #156, who had a BIMS of 4, was cognitively impaired, and exhibited exit seeking behaviors went out of a bathroom window. Resident #156 then walked to a nearby neighborhood approximately 0.5 miles away. At approximately 10:30 a.m., the local police department notified the facility that Resident #156 was in custody after being arrested for theft of a motor vehicle. On 05/16/2025 at 1:00 p.m., Resident #156 returned to the facility.
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 05/27/2025 with a review date of 05/16/2025, and titled Elopements and Wandering Residents, read in part .This facility ensures that residents who exhibit exit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so.
1. The facility is equipped with door locks/alarms to help avoid elopements.
3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.
4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering
a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team.
d. Adequate supervision will be provided to help prevent accidents or elopements.
Review of Resident #156's medical record revealed an admit date of 04/30/2025, with diagnoses that included, in part .Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Cocaine Abuse with Cocaine-Induced Mood Disorder/Sleep Disorder, and Anxiety Disorder.
Review of Resident #156's admission MDS with an ARD of 05/02/2025, revealed a BIMS score of 04, which indicated severe cognitive impairment. Resident #156 was independent for transfers and used a walker for mobility.
Review of Resident #156's 05/2025 Physician's Orders revealed in part .
05/01/2025 -Elopement precautions: Census checks every 1 hour each shift related to history of Delirium and wandering.
05/16/2025- Elopement precautions: 1 on 1 staff supervision each shift.
Review of Resident #156's Care plan with a target completion date of 08/11/2025, read in part .Elopement risk related to reported history of Altered Mental Status, Status post history of CVA (Cerebral Vascular Accident), Cocaine use with wandering attempts to leave hospital noted. 05/15/2025-Elopement attempt noted: Willfully attempted to leave facility without notifying staff, wanted to be discharged back home. Interventions included in part .Elopement precautions: Census checks every 1 hour each shift related to history of delirium and wandering. (initiated on 05/02/2025). Supervision increased to 1:1 for safety. (initiated on 05/15/2025).
Review of Resident #156's Risk of Elopement Evaluation dated 05/01/2025, revealed Resident #156 had verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. Resident #156 scored 1.0 on the evaluation which indicated he was at risk for elopement.
Review of Resident #156's facility progress notes dated 05/15/2025 at 4:28 p.m., written by S2 DON read as follows: Resident #156 came outside of facility with facility staff & other residents to eat crawfish. Resident #156 noted very calm & cooperative during activity. Later resident noted agitated, uncooperative, & telling staff that he was leaving because he stayed here long enough, and it was time for him to go. Resident #156 noted pushing staff away & attempting to leave facility. S2 DON and S1 Administrator intervened. Resident #156 remained agitated (refused to go inside of building, pushed staff away, & continued to walk off attempting to leave facility). Resident #156 was questioned about where he was going & he stated that he was going back to his home in New [NAME]. Resident #156 requested to call the police to assist him with getting back home. S2 DON informed him that staff could assist him with calling his family to help him. After much encouragement, resident finally agreed to come back inside facility to call his sister. Resident #156 became more agitated after speaking with sister & stated that his sister was always against him. Emotional support provided with very little effectiveness noted. Increased anxiety & agitation with complaints of SOB (shortness of breath) noted. Resident #156's supervision increased to 1:1 at this time for safety.
Review of Resident #156's facility progress notes dated 05/16/2025 at 1:00 p.m., written by S2 DON read as follows: Resident #156 left facility (exited hallway bathroom window) after eating breakfast this morning. Resident #156 was located and transported back to the facility in stable condition. Upon questioning, resident was noted alert & oriented x 4 with appropriate verbal responses. Resident #156 stated that he left facility to try to find a ride back to his home in New [NAME]. A follow up assessment was done with no complaints of discomfort & no s/s (signs and symptoms) of injury noted. S/S of frustration/agitation was noted from resident with expressions of dissatisfaction towards having to return to the facility. Resident #156 repeatedly stated, I'm a mechanic & I need to get back to my business. Resident #156 was reassured that staff was aware of his desire for discharge and was trying to ensure a safe discharge plan for him. Designated staff assigned 1:1 supervision for safety. Resident's primary MD and S14 NP were informed of resident leaving facility & of his current status.
Review of a police department report revealed in part ., on 05/16/2025 at approximately 9:29 a.m., this officer was dispatched in reference to a vehicle being in the ditch. The vehicle in question was the same vehicle that was observed in the ditch. Police officers went back to the person who stole the vehicle. While speaking, Resident #156 stated he was trying to get to New [NAME], La. Resident #156 was transported to be booked on the following charges theft of a motor vehicle, criminal damage to property, and illegal possession of stolen things. While in police custody it was learned that Resident #156 was missing person from a local nursing home.
Interview with S14 NP on 05/28/2025 at 9:17 a.m. revealed she came to visit Resident #156 on 05/16/2025 at 6:30 a.m. after being notified on 05/15/2025 of Resident #156 trying to leave the facility. S14 NP stated she ordered an injection of Hydroxyzine (Antihistamine) and placed him on 1:1 supervision on 05/15/2025. S14 NP stated that during her visit with Resident #156 on 05/16/2025 he continued to voice to her that he wanted to go home. S14 NP stated she discussed with him that it wasn't a good idea to leave the facility against medical advice and Resident #156 agreed to remain in the facility. S14 NP stated Resident #156 was cooperative and calm during her visit on 05/16/2025. S14 NP stated Resident #156 didn't exhibit any active exit seeking behaviors at the time of her visit but was adamant about going home. S14 NP stated once Resident #156 agreed to remain in the facility, she notified staff of his mood, and lifted his 1:1 supervision.
Interview with S15 CNA on 05/28/2025 at 12:06 p.m. revealed she worked on 05/16/2025 during the 6:00 a.m.-2:00 p.m., shift when Resident #156 eloped. S15 CNA revealed she had last seen Resident #156 during breakfast that morning. S15 CNA stated during her observation of Resident #156 during breakfast, Resident #156 was calm with no abnormal behaviors. S15 CNA stated on 05/16/2025 at approximately 8:45 a.m., S2 DON approached her outside on the front porch to inquire if Resident #156 was outside. S15 CNA stated she notified S2 DON that Resident #156 did not go outside on the front porch after breakfast. S15 CNA was made aware by S2 DON that Resident #156 could not be located. S15 CNA stated she, S2 DON, and another CNA began looking throughout the entire facility, checking all resident rooms, laundry room, kitchen, and all exits.
Interview with S1 Administrator on 05/29/2025 at 8:56 a.m., revealed on 05/16/2025 at 8:15 a.m. she realized Resident #156 was missing. S1 Administrator stated she went down to check on Resident #156 and noticed he wasn't in bed or in the dining room. S1 Administrator stated she alerted staff to begin searching for Resident #156 throughout the facility. S1 Administrator stated she went back to her office to review surveillance footage which showed Resident #156 entered the X-Hall bathroom, but never exited the bathroom. S1 Administrator stated she immediately increased census checks to every 30 minutes for all residents at high risk of elopement. S1 Administrator stated she initiated an in-service for all staff on 05/16/2025 that was completed on 05/20/2025 for Elopement and Wandering Residents as well as Facility Protocol for 1:1 Staff Supervision.
Interview with S11 LPN on 05/29/2025 at 11:58 a.m., revealed she observed Resident #156 eating breakfast in the dining room on 05/16/2025 around 8:00 a.m. S11 LPN stated Resident #156 walked past her going towards his room in a good mood. S11 LPN stated Resident #156 had no complaints or any exit-seeking behaviors that morning. S11 LPN stated about 10 minutes later S1 Administrator approached her and asked where Resident #156 was. S11 LPN stated she and S1 Administrator immediately began to look in every room and could not locate him. S11 LPN stated Resident #156 was on 1:1 supervision during the night shift (05/15/2025) but it had been lifted on 05/16/2025 by S14 NP.
The facility has implemented the following actions to correct the deficient practice:
1. All staff in-serviced on 05/16/2025 on elopement, wandering residents, and facility protocol for 1:1 supervision. The elopement policy was reviewed with all staff on Elopement and Wandering Residents.
2. Resident #156 was immediately assessed with no complaints of discomfort and no signs and symptoms of injuries noted upon return to the facility on [DATE] at 1:00 p.m. Designated staff were assigned to Resident #156 for 1:1 supervision for safety. S14 NP notified of Resident #156's return status, and a new order for Klonopin 0.5 mg was given to Resident #156 for anxiety.
3. Daily Elopement Risk Monitoring tool was started on 05/16/2025 for resident's identified as high risk for elopement in the facility. Monitoring tool reads as follows: S2 DON or designee will monitor residents at risk for elopement daily for 8 weeks then randomly to identify any issues with safety and/or plan of care for safety.
4. Residents identified as high elopement risk were ordered with increased visual checks every 30 minutes every shift which started on 05/16/2025, to be continued indefinitely.
5. A window audit was conducted on 05/16/2025 by S3 Maintenance Director on all resident bedroom windows, bathroom windows in facility, living area, and dining area.
Facility completion date 05/23/2025.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #156
Review of Resident #156's medical record revealed an admit date of 04/30/2025, with diagnoses that included, in pa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #156
Review of Resident #156's medical record revealed an admit date of 04/30/2025, with diagnoses that included, in part .Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Cocaine Abuse with Cocaine-Induced Mood Disorder/Sleep Disorder, and Anxiety Disorder.
Review of Resident #156's admission MDS with an ARD of 05/02/2025, revealed a BIMS score of 04, which indicated severe cognitive impairment. The MDS revealed Resident #156 was independent for transfers and used a walker for mobility.
Review of Resident #156's Care plan with a target completion date of 08/11/2025, read in part .Elopement risk related to reported history of Altered Mental Status, Cocaine use with wandering attempts to leave hospital noted. 05/15/2025-Elopement attempt noted: willfully attempted to leave facility without notifying staff, wanted to be discharged back home. Interventions included in part; Elopement precautions: Census checks every 1 hour, each shift related to history of Delirium and wandering (initiated on 05/02/2025). Supervision increased to 1:1 for safety. Vistaril injection IM (intramuscular)1 time as ordered per S14 NP for anxiety. (initiated on 05/15/2025).
Review of Resident #156's facility progress notes dated 05/16/2025 at 1:00 p.m., written by S2 DON read in part: Resident #156 left facility (exited X-hall bathroom window) after eating breakfast this morning. He was located & transported back to the facility in stable condition. Upon questioning, resident was noted alert & oriented x 4 with appropriate verbal responses. Resident #156 stated that he left facility to try to find a ride back to his home in New [NAME].
Review of a SIMS report completed by the facility revealed on 05/16/2025 at approximately 8:15 a.m. Resident #156 eloped from the facility. The facility was made aware of the elopement on 05/16/2025 at 8:30 a.m. The facility entered the allegation into SIMS reporting system on 05/16/2025 at 6:18 p.m.
Interview with S1 Administrator on 05/29/2025 at 8:56 a.m., revealed on 05/16/2025 at approximately 8:15 a.m. Resident #156 eloped from the facility. S1 Administrator revealed she was made aware of the elopement on 05/16/2025 at approximately 8:30 a.m. S1 Administrator confirmed she did not report Resident #156's elopement out of the facility within the 2 hour required timeframe, but should have.
Based on record review and interview the facility failed to ensure an allegation of physical abuse and allegation of neglect was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (#6 and #156) of 30 Sampled Residents. Findings:
Review of the facility's undated policy on 05/28/2025 at 08:30 a.m. titled Abuse Prevention and Investigation read in part . The facility defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes deprivation of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Physical abuse includes hitting, slapping, pinching, and kicking. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Reporting: All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately, but not later than 2 hours after the allegation is made if the alleged violation involves abuse or results in serious bodily injury OR within 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury to the administrator of the facility and to other officials including the state survey agency and adult protective services in accordance with state law through established procedures.
Resident #6
Review of the medical record for Resident # 6 revealed he was admitted to the facility on [DATE]. Resident #6 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Major Depressive Disorder, Memory Deficit following CVA, and Dysphagia.
Review of Resident #6's Quarterly MDS with an ARD of 03/25/2025 revealed a BIMS score of 13, which indicated cognition was intact.
Review of a SIMS report completed by the facility revealed on 03/21/2025 at approximately 5:50 a.m. Resident #6 alleged S5 CNA had slapped him on his face. The facility was made aware of the allegation on 03/21/2025 at 8:30 a.m. The facility entered the allegation into SIMS reporting system on 03/21/2025 at 1:29 p.m.
Interview on 05/29/2025 1:25 p.m. with S1 Administrator revealed she was responsible for SIMS reporting for the facility. S1 Administrator revealed the alleged staff to resident physical abuse occurred on 03/21/2025 at approximately 5:50 a.m., and she was made aware of the allegation on 03/21/2025 at 8:30 a.m. S1 Administrator revealed she entered the incident into SIMS on 03/21/2025 at 1:29 p.m. S1 Administrator confirmed that the incident of alleged staff to resident abuse was not entered into the SIMS within the required timeframe, but should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 provide the necessary care and services to provide a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to provide a necessary communication aid for 1 (#35) of 1 Resident reviewed for communication. The total sample size was 30. Findings:
Review of Resident #35's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . Type 2 Diabetes Mellitus, Major Depressive Disorder, Unspecified Dementia, and Generalized Anxiety Disorder.
Review of Resident #35's Quarterly MDS with an ARD date of 05/21/2025 revealed Resident #35 had BIMS of 8 (Moderate Cognitive Impairment). Resident #35's ability to understand others was documented as- sometimes.
Review of Resident #35's Comprehensive Person Centered Care Plan revealed resident had difficulty communicating related to language barrier. Interventions included: Provide a communication board.
Interview and observation on 05/27/2025 at 12:14 p.m. with Resident #35 revealed he had difficulty understanding English, and did not speak English. Resident #35 shook his head no, when asked if he could understand English. Observation of Resident #35's room at that time revealed there was no communication aid/board to assist in communication with resident.
Interview on 05/28/2025 at 8:40 a.m. with S7 CNA revealed she was assigned care of Resident #35. S7 CNA stated Resident #35 did not speak English and understood very little English. S7 CNA stated she determined Resident #35's needs by pointing and guessing at things until resident would shake his head yes or no. S7 CNA stated she never used a communication aid or picture board with Resident #35 because he did not have one.
Observation on 05/28/2025 at 8:50 a.m. of Resident #35's room revealed there was no communication aid to assist in communication with resident.
Interview on 05/28/2025 at 8:54 a.m. with S4 LPN revealed Resident #35 had difficulty with communication as he could not speak English. S4 LPN stated she communicated with Resident #35 by using gestures. S4 LPN confirmed Resident #35 did not have a communication board, or any type of communication aid in his room to assist with communication. S4 LPN revealed Resident #35 would benefit from a communication board to assist in communication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #25
Based on observation, interview, and record review, the facility failed to implement and monitor interventions to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #25
Based on observation, interview, and record review, the facility failed to implement and monitor interventions to maintain proper hydration and nutrition for 2 (Resident #25 and Resident #8) of 2 residents reviewed for nutrition. The facility failed to:
1.
Implement and monitor hydration consistent with Resident #25's assessed needs; and
2.
Notify the Registered Dietician of Resident #8's change in nutritional needs.
Findings:
Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Intake and Output, Monitoring Fluids revealed the following in part .4. For residents with a physician's order for fluid encouragement, fluids will be encouraged as per the resident's care plan. 6. The following residents require measurement and documentation of intake and output. A. Residents with a physician's order for intake and output measurement.
Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Hydration Program revealed the following in part .to provide all residents with sufficient fluid intake to maintain good hydration status.
Resident #25
Review of Resident #25 medical record revealed an admission date of 02/28/2022 with diagnoses that included . Anorexia, Type 2 Diabetes Mellitus with Hypoglycemia without Coma, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, and Acute Kidney Failure.
Review of Resident #25's 05/2025 physician's orders revealed in part .
(02/23/2023) order date: Monitor I&O Qshift (daily estimate fluid needs equals 1500cc/ml).
Review of Resident #25's care plan revealed the following in part .
Initial date (03/04/2022) Focus: Potential for dehydration. Interventions: Monitor I&O Qshift, daily estimate fluid needs as ordered.
Initial date (04/07/2025) Focus: The resident has dehydration or potential for fluid deficit. Interventions: Monitor and document intake and output as per facility policy.
Review of Resident #25's medical record tasks charting revealed the nurses and CNAs were required to document in the clinical record the resident's total amount of oral fluid intake after every shift measured in cc/ml. Further review of the previous 30 days of oral fluid intake documentation revealed the following in part .
-Nurse Documentation for 04/30/2025-05/29/2025: 8 days where the nurse did not document every shift and 10 days where the nurse and CNA documentation did not meet the minimum fluid intake requirement of 1500mls, as ordered.
-CNA Documentation for 04/30/2025-05/29/2025: 17 days where the CNA did not document every shift, 9 days where the CNA and nurse documentation did not meet the minimum fluid intake requirement of 1500mls, as ordered, and 1 day where no documentation was found.
In an interview and record review on 05/29/2025 at 4:10 p.m., S2 DON confirmed Resident #25 had active physician's orders to monitor intake and output every shift with a minimum daily fluid intake of 1500cc/ml. Further review of Resident #25's medical record for oral fluid intake in the last 30 days, S2 DON confirmed (the above findings) that the nursing staff and CNAs failed to document fluid intake every shift as ordered and that the daily fluid intake documented failed to meet the minimum requirement of 1500cc/ml as ordered, but should have.
Resident #8
Findings:
Review of the facility's undated policy titled Enteral Nutrition revealed in part . Adequate nutritional support through enteral feeding will be provided to all residents as ordered. Role of Dietitian: 3. The Dietitian, with input from the Physician and Nurse will: Determine whether the resident's current intake is adequate to meet his or her nutritional needs. Dietitian monitoring: 5. The Dietitian will monitor residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings.
Review of the facility's undated policy titled Registered Dietician-Consultant revealed in part .3. In general the Consultant Registered Dietician (RD) will visit the facility at least monthly to provide nutritional status assessments, review food service operation, and provide guidance and direction for the Dietary Manager (DM). 4. All residents will be assessed upon initial admission and at least annually thereafter. Residents meeting the following criteria will be assessed monthly unless otherwise agreed upon and documented by the RD and physician: d. Residents who have had enteral tube placement since the last RD assessment. 5. The RD will provide the Administrator and DM with written, dated, and signed reports of each consultation visit. The report will contain the RD's significant findings, recommendations, and plans for implementation of the recommendations as applicable. 6. The DM is responsible to prepare a list of residents to be seen by the RD at each scheduled visit as well as provide the RD with access to resident information that will facilitate the RD's assessment in addition to the medical record. 7. The DM is responsible for maintaining a record of RD consultant assessments in a manner that provides easy identification of which residents are due for reassessment such as annual RD visit logs. 8. The Director of Nursing (DON) or DM should consult with the RD via telephone or fax if services are required prior to the next scheduled visit. The discussion and recommendations will be documented in the resident's medical record. 9. The DON or designee is responsible for the implementation of the RD's recommendations to the nursing department and the Dietary Manager is responsible for implementation of the recommendations to the Dietary Department. 10. The DON or designee will promptly notify the physician of any recommendations for order changes.
Review of the facility's undated policy titled Weight Monitoring revealed in part .Weight loss: 4. A weight loss of 5% in 30 days or less, 7.5% in 90 days or less, or 10% in 6 months or less will be considered significant regardless of resident's ideal body weight. 11. The DM will request and RD consult at next scheduled visit or request a telephone consult if indicated. Documentation: 21. Documentation of weight change review, physician notification, and responsible party notification will be documented in the medical record. Standardized assessment entitled Weight Change Evaluation may be used.
Review of Resident #8's medical record revealed an admit date of 01/08/2018 with diagnoses that included in part .Acute and Chronic Respiratory Failure with Hypoxia, Pneumonitis due to Inhalation of Food and Vomit, Encounter for attention to Gastrostomy, Severe Protein-Calorie Malnutrition, and Abnormal Weight loss.
Review of Resident #8's Quarterly MDS with an ARD of 08/02/2025 revealed a BIMs score of 5, which indicated severe cognitive impairment. The MDS revealed Resident #8 required parenteral feeding via Peg tube.
Review of Resident #8's 05/2025 Physicians orders revealed:
04/22/25-enteral feed: every shift enteral: flush feeding tube with (50 cc) of water every 1 hour per volumetric feeding pump
04/22/25-enteral feed: every shift- Diabetisource 1.2 AT 50cc/hour per. Continuous volumetric feeding pump.
Review of Resident #8's care plan with a review date of 08/11/2025 revealed:
Risk for malnutrition. 04/22/2025-Resident is NPO (nothing by mouth)/Peg tube status related to diagnosis of Dysphagia with aspiration noted. 04/30/2025-returned from hospital with significant weight loss noted over past month (19 pounds)
. Intervention included in part .04/30/2025 Refer to RD for evaluation as indicated, significant weight loss noted.
Review of Resident #8's weights revealed:
05/20/2025 - 158.0 lbs. (pounds)
04/30/2025 - 162.0 lbs.
04/21/2025 - 175.0 lbs.
04/08/2025 - 181.0 lbs.
03/17/2025 - 179.0 lbs.
03/11/2025 - 181.0 lbs.
Review of Resident #8's Dietary admission Assessments revealed in part .
04/21/2025-weight in pounds: 181, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager.
04/30/2025-weight in pounds: 175, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager.
05/19/2025-weight in pounds: 162, current diet: Diabetisource 1.50 at 50 cc/hr (mils per hour). Risk for malnutrition due to need for feeding tube, Recommended continue with same plan of care. Electronically signed by S8 Dietary Manager.
Review of Resident #8's weight change evaluation form completed by S2 DON revealed in part .Resident #8 had a weight loss of 19 pounds in 1 month. Notes: total 19 pound weight loss in past month noted on return from hospital on [DATE] status post recent history of aspiration pneumonia with NPO status and new peg tube placement noted. Plan: continue tube feeding, refer to RD for evaluation. Other: referral to RD for review, care plan updated.
On 05/29/2025 after further review of Resident #8's medical record there was no evidence of documentation of the RD's evaluation or referral sent for Resident #8's significant weight loss.
Telephone interview on 05/29/2025 at 12:46 p.m., with S10 Registered Dietician (RD) revealed she came to the facility once or twice a month to assess residents. S10 RD revealed that the facility would email her names of residents needing to be seen by her during her visit. S10 RD stated she reviewed residents' weights on a monthly basis. S10 RD stated Resident #8's significant weight loss was due to his multiple hospitalizations. S10 RD confirmed that she did not receive any evaluation request or referrals regarding Resident #8's significant weight loss from the facility upon his return from the hospital.
Interview on 05/29/2025 at 2:03 p.m. with S2 DON revealed she was responsible for notifying S2 RD of changes in resident's weights via a referral or request for an evaluation. S2 DON stated she sent out a referral and requested an evaluation from S10 RD concerning Resident #8's significant weight loss. S2 DON could not provide documentation of an evaluation or referral sent to S10 RD concerning Resident #8's significant weight loss.
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 food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the r...
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Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 55 residents who resided in the facility.
The facility failed to ensure:
1. Food items in pantry were stored in a sealed container;
2. Opened food items in refrigerator and freezer were labeled with an open date and stored in a sealed container; and
3. Snacks considered potentially hazardous food were stored appropriately.
Findings:
A review of the facility's undated policy titled, Storage: Freezer revealed in part . Keep all frozen foods tightly wrapped or packaged to prevent freezer burn . Label and date all items.
A review of the facility's undated policy titled, Storage: Refrigerator revealed in part . Keep refrigerated foods wrapped or covered and in sanitary containers.
A review of the facility's undated policy titled, Storage: Dry Food revealed in part .Keep all containers tightly closed from insects, rodents, and dust. Dry foods can be contaminated, even if they don't need refrigeration.
1. During the initial tour of kitchen performed on 05/27/2025 from 08:30 a.m. to 09:25 a.m., observation of the indoor pantry revealed (1) 20 pound box of spaghetti noodles opened. S8 Dietary manger confirmed spaghetti noodles should have been labeled with an open date and stored in a sealed container and was not.
2. During the initial tour of kitchen performed on 05/27/2025 from 08:30 a.m. to 09:25 a.m., observation of freezer # 3 revealed (1) two gallon zip lock bag of waffles not labeled with an open date, observation of cooler # 2 revealed (1) 15 pound box of bacon open to air, and observation of cooler #1 revealed (1) bag of liquid eggs opened and not labeled with an open date.
On 05/27/2025 at 10:25 a.m. interview with S8 Dietary manger was conducted. S8 Dietary manager confirmed the following:
(1) two gallon zip lock bag of waffles located in freezer #3 was not labeled with an open date and should have been.
(1) 15 pound box of bacon in cooler #2 was left open to air and should not have been.
(1) bag of liquid eggs located in cooler #1 was not labeled with an open date or stored in a sealed container and should have been.
3. Interview with S8 Dietary Manager on 05/29/2025 at 09:07 a.m. revealed the facility did not have separate snack refrigerators. S8 Dietary Manager revealed snacks are stored and served from hydration carts at 09:30 a.m., 02:30 p.m., and 07:00 p.m. daily.
S8 Dietary Manager revealed the hydration cart prepared at 07:00 p.m. daily included all snacks that were readily available to the residents till 5:00 a.m. the next day. S8 Dietary Manager revealed content of the 07:00 p.m. hydration cart consisted of juice, water, graham crackers, peanut butter crackers, and premade sandwiches that were stored in an ice cooler. S8 Dietary Manager revealed types of sandwiches stored in ice cooler on 07:00 p.m. hydration cart included peanut butter and jelly, turkey, bologna, and pimento cheese sandwiches. S8 Dietary Manager stated (2) two gallon zip lock bags were filled with ice and placed in ice cooler to keep sandwiches cool until sandwiches were discarded at 05:00 a.m. the next day.
On 05/29/2025 at 09:18 a.m. observation of snack ice cooler revealed a 25 quart portable ice cooler that was not temperature regulated.
On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed temperatures were not being monitored for ice cooler that stored sandwiches between 07:00 p.m. and 5:00 a.m. daily. S8 Dietary Manager confirmed turkey and pimiento cheese sandwiches were considered potentially hazardous food and should be stored in a monitored temperature regulated refrigerator and they were not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
3.
Resident #11
A review of Resident # 11's medical record revealed an initial admission date of 12/08/2023 and re-admission date of 01/23/2025 with diagnoses that included Type 2 Diabetes Mellitus w...
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3.
Resident #11
A review of Resident # 11's medical record revealed an initial admission date of 12/08/2023 and re-admission date of 01/23/2025 with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Atherosclerosis of native arteries of extremities with intermittent claudication of bilateral legs, Phantom Limb Syndrome with pain, Peripheral Vascular Disease, acquired absence of right leg above knee, unspecified open wound of left great toe with damage to nail, subsequent encounter, cellulitis of left lower limb.
On 05/28/2025 at 10:00 a.m. review of Resident #11's annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 02/24/2025, revealed Resident #11 had a BIMS score of 10, which indicated moderate cognitive impairment and had an open lesion on the foot.
On 05/28/2025 at 11:04 a.m. review of Resident # 11's care plan with initiation date of 09/06/2024 revealed Resident #11 had actual skin impairment to the left great toe. Interventions included in part . Clean left foot great toe wound with NS/WC (normal saline/wound cleanser), apply iodine, let air dry, cover with dry dressing daily until healed.
On 05/28/2025 at 09:46 a.m. observation revealed S9 Treatment Nurse preparing Resident #11's wound care supplies on the wound care cart outside of Resident #11's room. Observation revealed the following in part . S9 Treatment Nurse removed a 4x4 gauze from the clean packaging and placed the 4x4 gauze directly on the computer keyboard on the wound care cart (contaminating the 4x4 gauze). Further observation revealed S9 Treatment Nurse continue to take the contaminated 4x4 gauze, soak it with normal saline, and then place the soaked, contaminated 4x4 gauze on top of other clean wound care supplies, which would be used for Resident #11's treatment.
On 05/28/2025 at 09:55 a.m. observation of Resident #11's wound care performed by S9 Treatment Nurse revealed Resident #11's left great toe wound was cleansed with the contaminated 4x4 normal saline soaked gauze.
On 05/28/2025 at 10:07 a.m. interview with S9 Treatment Nurse confirmed she contaminated Resident #11's 4x4 gauze during wound care preparation when she placed it directly on the computer keyboard. S9 Treatment Nurse confirmed she then used the contaminated wound care supplies to complete Resident #11's wound care to his left great toe. S9 Treatment Nurse confirmed she should have placed the 4x4 gauze on a clean barrier during wound care preparation to prevent contamination, but did not. S9 Treatment Nurse confirmed she should have discarded the contaminated 4x4 gauze before providing wound care to Resident #11, but did not.
Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to effect the 55 residents who resided in the facility. The facility failed to:
1.
Ensure Enhanced Barrier Precautions (EBP) were utilized for 1 (Resident #19) of 1 residents reviewed for infection control;
2.
Ensure the facility laundry department was free of lint and dust; and
3.
Ensure S9 Treatment Nurse followed proper hand hygiene practices during wound care for 1 (Resident #11) of 1 residents review for pressure ulcers.
Findings:
Review of a facility policy on 05/29/2025 at 7:12 p.m. titled, Enhanced Barrier Precautions with a revision date of 01/2025 revealed the following part .It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 46. Enhanced Barrier Precautions- a. nursing staff will place residents with any applicable conditions or device on EBP. Applicable devices: i. Wounds and/or indwelling devices (feeding tubes) even if the resident is not known to be infected or colonized with MDRO. 48. High contact resident care activities included: transferring.
1.
Resident #19
Review of Resident #19's medical record revealed and admission date of 01/28/2016, with diagnoses that included in part .Alzheimer's Disease with Late Onset, Gastrostomy Malfunction, Major Depressive Disorder, and Gastrostomy Status.
Review of Resident #19's 05/2025 physician's orders revealed an order for Enhanced Barrier Precautions related to peg tube device with an order date of 08/04/2022.
Review of Resident #19's care plan revealed in part .Start date (02/16/2024) Focus: Remains free from skin breakdown. Intervention: (08/02/2022) Enhanced Barrier precautions related to peg tube device.
Observation on 05/27/2025 at 10:05 a.m., revealed Resident #19 transported via geri-chair to his room by S13 CNA. S12 CNA was observed exiting Resident #19's room, retrieving the facility's mechanical lift and reentering the resident's room accompanied by S13 CNA to transfer the resident from geri-chair to bed. Observation revealed no evidence of gown usage by S12 CNA at this time. Observation of the exterior of Resident #19's room door revealed EBP signage posted and PPE (gowns and gloves) available for use.
In an interview on 05/27/2025 at 10:25 a.m., S12 CNA revealed that she and S13 transferred Resident #19 from geri-chair to bed via mechanical lift. S12 CNA confirmed she only wore gloves during the transfer and should have worn a gown also, but did not.
In an interview on 05/29/2025 at 5:00 p.m., S2 DON revealed she expected all staff to wear gown and gloves for any resident on Enhanced Barrier Precautions during direct care, such as a transfer. S2 DON confirmed Resident #19 had a peg tube and required EBP during direct care. S2 DON confirmed S12 CNA should have worn both gown and gloves during Resident #19's transfer, but did not.
2.
Observation on 05/27/2025 at 5:10 p.m. of the facility laundry department accompanied by S1 Administrator. Observation revealed two laundry dryers with an excessive amount of lint within the lint traps. There was excessive lint on the inside of the dryer walls and excessive lint in the surrounding areas of the lint traps. Observation revealed there was excessive lint and dust on the laundry department walls entirely, and excessive lint and dust hanging from the ceilings. S1 Administrator confirmed the findings did not provide a safe, clean, and sanitary environment, and the laundry staff should have cleaned the laundry/dryer area, but did not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
On 05/27/2025 at 11:30 a.m. observation of the facility kitchen revealed one live fly flying throughout the food preparation area.
On 05/29/2025 at 09:08 a.m. observation of the facility kitchen reve...
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On 05/27/2025 at 11:30 a.m. observation of the facility kitchen revealed one live fly flying throughout the food preparation area.
On 05/29/2025 at 09:08 a.m. observation of the facility kitchen revealed one live fly flying throughout the kitchen area.
On 05/29/2025 at 10:52 a.m. interview with S8 Dietary Manager revealed the facility recently began having issues with live flies. S8 Dietary Manager confirmed she has observed live flies in kitchen area and the kitchen should always be free of flies or any other insects/pest, but was not.
Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests. The facility failed to provide an environment free of flies throughout the facility. This deficient practice had the potential to effect all 55 residents who resided in the facility.
Findings:
Review of an undated facility policy on 05/29/2025 at 7:12 p.m. titled, Pest Control Program revealed the following part .Facility will maintain an effective pest control program that eradicates and contains common household pests. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, example flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.
In an interview on 05/27/2025 at 10:47 a.m., Resident #21 revealed he had seen flies and gnats in his room and in the dining area often. Resident #21 stated he reported the flies and gnats to staff previously, but nothing was done.
Dining observation on 05/27/2025 at 11:48 a.m., revealed two flies flying throughout in the dining room. Observation revealed Resident #17 swat his bowl of chicken noodle soup because there was a fly crawling on the ledge of his soup bowl.
In an interview on 05/27/2025 at 12:05 p.m., Resident #39 revealed he bought a fly swatter because he had flies and gnats in his room, and he often had to kill them. Resident #39 stated he always killed flies and gnats throughout the facility, thus the reason he bought a fly swatter. Resident #39 was observed with a fly swatter he carried with him.
Review of Resident #39's Quarterly MDS with an ARD of 04/30/2025 revealed a BIMS score of 15, which indicated intact cognition.
Dining observation on 05/28/2025 at 8:00 a.m., revealed two flies flying throughout in the dining room while multiple residents were eating breakfast. Observation revealed one fly crawling on the dining room table while a resident ate her breakfast, near her plate of food.
In an interview on 05/28/2025 at 12:30 p.m., S3 Maintenance Director revealed he was aware the facility had flying insects inside the building, such as flies and gnats. S3 Maintenance Director stated that during the summer months, the flies and gnats were worse and he tried to deter the flying insects by using a hanging sticky trap/tray. S3 Maintenance Director confirmed there was a flying insect issue throughout the facility, but there should not have been.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nurs...
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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 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) out of 8 (S2Licensed Practical Nurse (LPN), S3LPN, S4Certified Nursing Assistant (CNA), S5CNA, S6CNA, S7CNA, S8CNA, S9CNA,) nursing/direct care staff records reviewed, were re-trained on their policy & procedure for abuse, after an incident of staff to resident verbal abuse occurred for 1 (#1) of 3 (#1, #2, and #3) sampled residents. This deficient practice had the potential to affect all 59 residents residing in the facility.
Findings:
A review of the facility's Policy & Procedure on Abuse revealed in part the following:
Residents have the right to be free from abuse
Training: Employees shall be trained in orientation, annually and as needed on the following topics which include:
Prevention of Abuse, Neglect, and Exploitation
Identifying what constitutes abuse
Recognizing signs of abuse
Review of Resident #1's medical record revealed he was admitted [DATE], with Diagnoses to include Schizoaffective Disorder, Essential Hypertension, Transient Cerebral Ischemic Attack, Cerebral Vascular Accident, and Depression. Review of Resident #1's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/08/2024, revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact.
Review of the facility's Investigation report revealed:
Occurred: 04/28/2024 at 1:30 p.m.
Discovered: 04/28/2024 at 1:30 p.m.
S13RN (Registered Nurse) reported that around 1:30 p.m. she was down the hall by the activities room and heard Resident#1 and S12Ward Clerk exchanging words regarding cigarettes, as she got closer she could hear foul language being exchanged as Resident #1 and S12Ward Clerk were arguing about the cigarette schedule. S13RN intervened and instructed S12Ward Clerk to clock out and go home until further notice from S1Administrator. On 05/02/2024, after interviewing all the residents who smoked, I have concluded my investigation. The incident in question was an isolated incident and unfortunately, S12Ward Clerk acted impulsively and failed to conduct herself in a professional manner.
Review of Resident #1's Nurses Note revealed, on 04/28/2024-the RN was down the hall near activity office when S12Ward Clerk and Resident #1 began arguing over the smoking schedule. S12Ward Clerk was in the nurse's station at the ward clerk area and Resident #1 was right outside the door of the station. Both were cursing and screaming at each other regarding the smoking schedule. S12Ward Clerk stood up screaming, F . you, I will hit you, you m .ther fu .er while lunging toward Resident #1. The resident then began to scream at S12Ward Clerk, what time you get off work? Meet me outside. S4CNA was present in the station and was standing between the two, after minutes of screaming and cursing at each other S4CNA got the two separated, and staff was able to calm Resident #1 down and take him out to smoke.
Review of the facility's In-service training revealed on 04/29/2024 staff received training on abuse policy and smoking policy; however there was no documented evidence that S2LPN, S3LPN, S4CNA, S5CNA, S6CNA, S7CNA, S8CNA, and S9CNA received the in-service training.
Interview on 05/13/2024 at 1:25 p.m. with S4CNA revealed she was at the nurse's station on 04/28/2024 when Resident #1 walked in the facility from outdoors after smoking. S4CNA stated Resident #1 asked S12Ward Clerk for a cigarette and S12 [NAME] Clerk refused. S4CNA stated Resident #1 told her she didn't know anything and called S12Ward Clerk a b .ch. S4CNA stated S12Ward Clerk then told Resident #1 if he called her that again she would slap him. S4CNA stated she then got between Resident #1 and S12Ward Clerk to prevent further escalation. S4CNA confirmed she did not receive re-training on abuse and neglect following this incident.
Interview on 05/14/2024 at 9:45 a.m., S1Administrator stated the facility did not have any documented evidence the above mentioned staff were provided abuse and neglect training after the staff to resident incident of verbal abuse that occurred on 04/28/2024.
Mar 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (Resident #18) of 2 (Resident #18 and Resident #20) sampled residents in...
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Based on record review and interview the facility failed to ensure a reportable incident was reported to the State Agency for 1 (Resident #18) of 2 (Resident #18 and Resident #20) sampled residents investigated for abuse. The facility failed to report an allegation of staff to resident abuse.
Findings:
Review of a policy and procedure titled, Abuse Prevention and Investigation, revealed in part:
The appropriate State Agency will be notified per regulations for any abuse, suspected abuse, and injury of unknown origin using the State-Mandated Protocol for Reporting.
Review of the EHR revealed Resident #18 was admitted to the facility on of 09/23/2022 with diagnoses that included: Unspecified Psychosis, Hypertensive Heart Disease, and Type 2 Diabetes Mellitus with Diabetic Nephropathy, Depression, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease.
Review of Resident #18's Quarterly MDS with an ARD of 01/15/2024 revealed Resident #10 had moderate cognitive impairment with adequate vision and hearing.
Interview on 03/18/2024 at 1:00 p.m. with Resident #18, during a resident council meeting, Resident #18 informed the surveyor he had been slapped by a CNA who was no longer employed at the facility. Resident #18 stated he reported being slapped to the ladies in the front office the day after it happened.
Review of the facility's SIMS reports since last annual survey revealed there were no incidents logged related to abuse for Resident #18.
Review of the facility's grievance log revealed a grievance dated 12/05/2023 revealed during resident rounds, Resident #18 reported to the Social Service Director that he was slapped by a CNA last evening (12/04/2023). SSD reported the allegation to S1 Adm. and S2 DON.
In a telephone interview on 03/20/2024 at 8:47 a.m., Resident #18's RP stated the resident called (unable to recall date) one evening crying and stated that a staff had slapped him. Resident #18's RP stated on the next day, someone (not certain who) from the facility's office called her and informed her that Resident #18 stated that he had been slapped by a staff and the facility would be conducting an investigation. She stated they visited the facility later that day or the next day and Resident #18 stated to them that an aide had slapped him.
In an interview on 03/19/2024 at 12:10 p.m., S2 DON confirmed Resident #18 did make a complaint to her on 12/05/2023 alleging S7 CNA had slapped him. S2 DON stated she and S1 Administrator interviewed Resident #18 after he reported the incident and explained that an investigation would be conducted and the incident would be reported to the state. S1 DON stated Resident #18 began waving his arms in the air and stated nothing happened to me and no one hit me, just leave it alone.
In an interview on 03/20/2024 at 3:30 p.m., S1Administrator confirmed she did not report the alleged incident of S7 CNA slapping Resident # 18 to the state agency. S1 Administrator stated the incident was not reported because Resident #18 denied repeatedly that S7 CNA had slapped him. S1 Administrator stated that since Resident #18 had retracted his statement, a SIMS was not opened.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the MDS Assessment accurately reflected a reside...
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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 the MDS Assessment accurately reflected a residents' status during the observation period for 1 (Resident #49) of 1 residents sampled for dental. The total sample size was 23 residents. Findings:
Review of Resident #49's clinical record revealed Resident #49 was admitted to the facility on [DATE]. Resident #49 had diagnoses that included Peripheral Vascular Disease, Obstructive Sleep Apnea, Asthma, and Essential Hypertension
Review of Resident #49's Significant Change MDS Assessment with ARD 11/23/2023 indicated Resident #49 had, none of the above, checked on his dental assessment.
Interview on 03/18/2024 at 10:1a.m. with Resident #49 revealed he had been having dental pain on and off to his right upper molar. Observation of Resident #49's oral cavity and dentition at the time of interview revealed 1 decayed right upper molar, 1 decayed left upper molar and 4-5 broken, decayed, front bottom teeth, all other teeth missing.
Interview on 03/19/2024 at 5:45 p.m. with S2 DON revealed Resident #49's Oral/Dental section of the 11/23/2023 MDS Assessment had been completed and signed by a nurse working remotely.
Observation on 03/19/2024 at 5:55 p.m. of Resident #49's oral cavity and dentition accompanied by S2 DON revealed the presence of decayed, missing, and broken teeth as observed on 03/18/2024. S2 DON confirmed the Significant Change MDS Assessment completed on 11/23/2023 did not accurately reflect Resident #49's dental status and should have.
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 interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable phys...
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Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #18) sampled resident in a total sample of 23 residents. The facility failed to ensure a comprehensive care plan was developed for a resident newly diagnosed with Dementia.
Findings:
Review of the EHR revealed Resident #18 was admitted to the facility on of 09/23/2022 with diagnoses that included: Unspecified Psychosis, Hypertensive Heart Disease, and Type 2 Diabetes Mellitus with Diabetic Nephropathy, Depression, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease. Additional Diagnoses on 01/10/2024 included Unspecified Dementia, Unspecified severity with Agitation, and Dementia with other Behavioral disturbances.
Review of 03/2024 physician orders for Resident #18 revealed:
Memantine 5 mg po bid - Dx: Unspecified Dementia- 01/10/2024
Review of Resident #18's Quarterly MDS with an ARD of 01/15/2024 revealed a BIMS of 10 (moderately impaired cognition).
Review of Resident #18's Care Plan with a target date of 04/15/2024 revealed no care plan was developed which addressed Dementia.
In an interview on 03/20/2024 at 12:20 p.m. with S8 RN MDS Nurse revealed she and S3 RN MDS Nurse were responsible for residents care plans. S8 RN MDS Nurse confirmed Resident #18 was not care planned for Dementia and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure care and services were provided to meet professional standards of practice. The facility failed to accurately document ...
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Based on observation, interview and record review, the facility failed to ensure care and services were provided to meet professional standards of practice. The facility failed to accurately document administration of respiratory services provided for 1 resident (Resident #37) of 23 sampled residents. Findings:
Review of Resident #37's Medical Record revealed an admission date of 10/28/2022 with diagnoses that included Acute Cough, Chronic Obstructive Pulmonary Disease, Disease of Upper Respiratory Tract, Allergic Rhinitis and Acute Upper Respiratory Infection.
Review of Resident #37's Physician's Orders for March 2024 revealed an order dated on 11/08/2023 for Ipratropium-Albuterol 0.5-3(2.5) mg/3ml inhale one nebulizer BID Diagnosis Cough/ Wheeze Bilateral.
Review of Resident #37's MARs for March 2024 revealed S5 LPN documented Ipratropium-Albuterol nebulizer treatment as administered on 3/19/2024 at 8:00 a.m. and on 3/20/2024 at 8:00 a.m.
Review of Resident #37's Quarterly MDS with an ARD of 2/14/2024 revealed a BIMS score of 15, indicative of intact cognition.
Review of Resident #37's Care Plan with a Target date of 5/14/2024 revealed Diagnosis of COPD with interventions that included in part . 11/8/2023 - Duo-Neb breathing treatment BID due to cough/ wheeze.
Interview on 3/19/2024 at 9:05 a.m. with Resident #37 stated he did not have a breathing treatment this morning because he told the nurse that he didn't want it.
Interview on 3/20/2024 at 9:30 a.m. with Resident #37 in his room stated he did not get a breathing treatment this morning. Resident #37 stated he had a breathing treatment last night. Observation of Resident #37 lying in bed and pulled his blanket back over his head.
Interview on 3/20/2024 at 9:54 a.m. with S5 LPN revealed that Resident #37 had refused his nebulizer breathing treatment this morning and wanted to go smoke outside instead. S5 LPN revealed she needed to notify his MD to get his orders for nebulizer treatments changed to as needed because he frequently refused his breathing treatments. Review of Resident #37's MARS accompanied with S5 LPN verified she initialed and documented his 8:00 a.m. nebulizer inhaler treatments as administered on 3/19/2024 and 3/20/2024 at 8:00 a.m. and had not been administered. S5 LPN confirmed that she just clicked on the electronic MAR for Resident #37's nebulizer treatments as given on 3/19/2024 at 8:00 a.m. and 3/20/2024 at 8:00 a.m. and should not have. S5 LPN revealed she should have clicked not administered for his 8:00 a.m. nebulizer treatments and marked it as refused on the dates 3/19/2024 and 3/20/2024, but did not.
Interview on 3/20/2024 at 4:30 p.m. with S2 DON confirmed S5 LPN should have documented on Resident #37's MARS that his 8:00 a.m. nebulizer treatments on 3/19/2024 and 3/20/2024 were not administered and 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents who were unable to carry out ADLs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents 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 to dependent residents for 1 (Resident #40) of 7 residents (Resident #10, Resident #18,Resident #28, Resident #40, Resident #44, Resident #53, and Resident #58) sampled for ADL's.
Findings:
Review of the facility policy titled: Nail Care, revealed in part .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated.
Review of the clinical record revealed Resident #40 admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following non-traumatic intracranial hemorrhage affecting left dominant side, Epilepsy, Encephalopathy, and Gastrostomy.
Review of Resident #40's Quarterly MDS Assessment with ARD of 02/15/2023 revealed Resident #40 had severe cognitive impairment, did not reject care, and was dependent on staff for hygiene, bathing, upper and lower body dressing and transfers.
Review of Resident #40's CPOC with target date 04/30/2024 revealed in part .
Requires assist with ADL's
Observation on 03/18/24 at 09:41 a.m. revealed Resident #40 awake in bed. Resident #40's nails were noted to be jagged, dirty and of varying lengths from 1/4 to 1/2 inch.
Observation on 03/19/2024 at 3:07 p.m. revealed Resident #40 awake in bed watching television. Resident #40's nails were noted to be long, jagged and dirty, with black/brown substance underneath nails on both hands.
Interview on 03/19/2024 at 3:18 p.m. with S6 Treatment Nurse while observing Resident #40's nails revealed S6 Treatment Nurse was not sure the last time Resident #40's nail care was done. S6 Treatment Nurse confirmed Resident #40's nails were dirty, long, and needed to be trimmed and cleaned and had not been. S6 Treatment Nurse stated Resident #40's nail care was probably done last month.
Review of Resident #40's Completed Care Task Flow Sheet revealed on 03/11/2024 at 11:44 a.m. and 03/18/2024 at 1:50 p.m. S6 Treatment Nurse had documented the task of Fingernails trimmed by licensed nurse as no, assessed but not needed at this time.
Interview on 03/19/2024 at 5:40 p.m. with S2 DON revealed nail care, including cleaning, should be performed daily with ADL care. S2 DON stated Resident #40 was scheduled to have body audits that included nail inspection and trimming weekly on Mondays.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 2 of 2 medication carts....
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Based on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 2 of 2 medication carts.
Findings:
Observation on 03/20/2024 at 2:10 p.m. of the X hall medication cart accompanied by S4 LPN revealed there were 8 loose pills in the second drawer of the medicine cart. S4 LPN confirmed the above findings and revealed it is the responsibility of each nurse to ensure their medication cart are clean and free of loose pills daily.
Observation on 03/20/2024 at 2:22 p.m. of the Y hall medication cart accompanied by S5 LPN revealed there were 1 loose pill observed in the middle drawer of the medications cart. S5 LPN confirmed the above findings at the time of observation.
Interview on 03/20/2024 at 2:40 p.m. with S2 DON revealed it was the responsibility of all nurses to ensure medication carts were clean and free of loose pills daily.
Mar 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #47
Review of Resident #47's medical record revealed an admit date of 07/20/2022 with diagnoses that included: Anxiety Disorder,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #47
Review of Resident #47's medical record revealed an admit date of 07/20/2022 with diagnoses that included: Anxiety Disorder, Delirium due to known physiological condition, Insomnia, and Depression.
Review of Resident #47's Quarterly MDS with an ARD of 03/01/2023 revealed a BIMS score of 15 (indicating intact cognition) and Resident #47 received 7 days of an antidepressant in the assessment period.
Review of Resident #47's 03/2023 Physician Orders revealed in part .an order for Trazodone 50 mg administer 1 tablet by mouth at bedtime related to depression, insomnia, sad mood, anxiety, and anorexia with a start date of 11/03/2022.
Review of Resident #47's electronic MAR revealed Trazodone was administered as ordered to Resident #47.
Review Resident #47's Psychoactive drug consents revealed there was no Psychoactive drug consent for the administration of Trazodone.
Interview on 03/22/23 at 11:00 a.m. with S2 DON revealed the hall nurses were responsible for obtaining consents for psychoactive drugs when they received an order for one. S2 DON reported MDS nurses were to check behind the hall nurses to ensure the consents were obtained.
Interview on 03/22/2023 at 11:05 a.m. with S3 RN MDS confirmed there was no consent for Trazodone in Resident #47's medical record, but there should have been.
Based on record review and interview, the Facility failed to ensure 2 (#31 and #47) of 5 (#1, #18, #31, #42 and #47) Residents reviewed for unnecessary medications gave consent to and were informed of the risks, benefits and side effects of an antidepressant medication (#47) and an antianxiety medication (#31) prior to the start of the medication. The total Facility census was 30 Residents.
Findings:
#31
Review of Resident #31's medical record revealed diagnoses to include in part .Type 2 Diabetes, Bipolar Disorder, Generalized Anxiety and Psychosis. Resident #31 was admitted to the Facility initially on 01/18/2022 and readmitted on [DATE].
Review of Resident #31's MDS assessment dated [DATE] revealed a BIMS of 13 (indicating intact cognition).
Review of Resident #31's Physician's Orders dated 08/2022 revealed in part .an order for Valium 5 mg by mouth every night for Anxiety.
Review of Resident #31's Physician's Orders dated 03/2023 and electronic MAR dated 03/2023 revealed Resident #31 was ordered Valium 2.5 mg one by mouth every night for anxiety and received the medication as ordered. The start date for the Valium, documented on the Physician's Order was 08/11/2022.
Review of Psychoactive drug consents for Resident #31 revealed there was no signed consent for the administration of Valium.
Interview with S3 RN MDS on 03/22/2023 at 10:50 a.m. confirmed the Facility did not have Resident #31 sign a written, informed consent prior to the administration of Valium. S3 RN MDS stated the Facility should have obtained a written informed consent from Resident #31 prior to the administration of the Valium. S3 RN MDS stated she was responsible for getting written, informed consent from Residents regarding medications, and she must have overlooked the Valium for Resident #31 and failed to obtain Resident #31's consent.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure their grievance policy and procedure was followed for 1 (Resident #25) of 30 sampled residents. The facility failed to ensure a writ...
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Based on interview and record review, the facility failed to ensure their grievance policy and procedure was followed for 1 (Resident #25) of 30 sampled residents. The facility failed to ensure a written summary of a grievance was provided to Resident #25.
Findings:
Review of the facility's policy titled Grievance/Complaints read in part .
7. A written summary of the report will also be provided to the resident which includes date grievance was received, summary of the grievance, a statement of whether or not the grievance was confirmed, any corrective action to be taken by the facility and the date the decision was issued. The summaries will be maintained in the facility for a period of no less than 3 years from issuance of the decision.
Review of Resident #25's medical record revealed he was admitted to facility on 09/22/2022 and had diagnoses including Impulsive Disorder, Schizoaffective Disorder, Major Depressive Disorder, and Anti-social Personality Disorder.
Review of Resident #25's Quarterly MDS with an ARD date of 01/04/2023 revealed a BIMS score of 10 (indicating moderate cognitive impairment).
Review of a facility grievance form dated 01/03/2023 filled out by S1 Administrator on behalf of Resident #25 revealed in part, a staff member had embarrassed him. Review of the grievance form revealed there was no documented date Resident #25 was notified of a resolution to his grievance, and Resident #25 was not notified in writing of the resolution to his grievance.
Interview on 03/21/2023 at 9:00 a.m. with Resident #25 revealed he did not receive a follow up to his grievance filed with S1 Administrator. Resident #25 stated No, she doesn't tell me anything, just that she'll take care of it.
Interview on 03/21/2023 at 1:14 p.m. with S1 Administrator revealed she received a grievance from Resident #25 on 01/03/2023. S1 Administrator stated she completed an investigation regarding the concern Resident #25 brought to her attention. S1 Administrator reported she provided a verbal follow up of the grievance to Resident #25. S1 Administrator was unable to state when the follow up was provided to Resident #25 because there was no documentation. S1 Administrator confirmed a written summary of the grievance was not provided to Resident #25, but it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 a Resident fed by enteral means received the ap...
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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 a Resident fed by enteral means received the appropriate treatment and services to prevent complications by failing to properly position the Resident during feeding for 1 (#263) of 2 (#9, #263) Residents who were investigated for enteral feeding. The total sample size was 30.
Findings:
Review of the facility policy titled Enteral Nutrition read in part .
Risk of aspiration will be assessed by the nurse and the physician and addressed in the individual care plan. Risk of aspiration may be affected by: c. improper positioning of the Resident during feeding.
Review of Resident #263's medical record revealed he was admitted to the facility on [DATE] and had diagnoses including Dysphagia, Unspecified Protein Calorie Malnutrition, Dietary Folate Deficiency Anemia, Pneumonia, and Respiratory Failure.
Review of Resident #263's Quarterly MDS with an ARD date of 03/01/2023 revealed Resident #263 had a BIMS of 6 (indicating severe cognitive impairment). Resident #263 was dependent on assistance with bed mobility, transfers, dressing, eating, personal hygiene, and toileting. Resident #263 had a feeding tube.
Review of Resident #263's 03/2023 Physician Orders revealed an order dated 01/04/2023 for Nutren 2.0 per peg tube at 45 cc/hr. every day per volumetric feeding pump, and an order dated 01/04/2023 to flush peg tube with 150 cc water every 4 hrs. per volumetric feeding pump.
Review of Resident #263's Care Plan with start date of 12/23/2022 revealed in part .
Peg tube feeding. Intervention: head of bed elevated 30 degrees at all times to prevent aspiration.
Observation on 03/20/2023 at 9:30 a.m. revealed Resident #263 was sleeping in bed. Resident #263's bed was observed in low lying position with head of bed flat, and not elevated. Resident #263 was observed lying flat on back, and was receiving tube feeding at a rate of 45 cc/hr. via pump.
Observation on 03/20/2023 at 1:00 p.m. revealed Resident #263 was awake in bed. Resident #263's bed was observed in low lying position with head of bed flat, and not elevated. Resident #263 was observed lying flat on back, and was receiving tube feeding at a rate of 45 cc/hr. via pump.
Observation on 03/21/2023 at 8:25 a.m. revealed Resident #263 was awake in bed. Resident #263's bed was observed in low lying position with head of bed flat, and not elevated. Resident #263 was observed lying flat on right side, and was receiving tube feeding at a rate of 45 cc/hr. via pump.
Interview and observation on 03/21/2023 at 8:30 a.m. with S4 LPN in Resident #263's room revealed Resident #263's head of bed was not elevated at least 30 degrees while Resident #263 was receiving the tube feeding. S4 LPN confirmed Resident #263's head of bed was not elevated at least 30 degrees, but it should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review, the Facility failed to ensure that a response and rationale for grievances reported during the Resident Council Meetings were addressed for 3 (11/2022, 12/2022, 0...
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Based on interview and record review, the Facility failed to ensure that a response and rationale for grievances reported during the Resident Council Meetings were addressed for 3 (11/2022, 12/2022, 01/11/2023) of 5 (11/2022, 12/2022, 01/2023, 01/11/2023 & 02/2023) Resident Council Meetings reviewed.
Findings:
Review of the meeting agenda for the Resident Council monthly 11/2022 meeting revealed the Residents voiced concerns of Residents not keeping the coffee area cleaned & different activities on the weekends.
Review of the meeting agenda for the Resident Council monthly 12/2022 meeting revealed the Residents reported concerns of having the coffee pot placed back on the coffee bar (accessible for self-service), and call light not being answered in a timely manner.
Review of the meeting agenda for the Resident Council monthly 01/2023 meetings revealed a special meeting on 01/11/2023 was called for issues with smoking policy, safe/unsafe smokers, designated smoking times, and use of community cigarettes.
Review of the Facility's Resident Council Binder revealed there were no minutes for Resident Council meetings since 10/2022. There were no documented evidences that the Facility had demonstrated and/or provided any response and/or rationales to the Resident Councils grievances voiced at the 11/2022, 12/2022, and 01/11/2023 meetings.
Interview on 03/22/2023 at 10:30 a.m. with S5 Activity Director revealed she was present for the last 5 months of Resident Council Meetings, and has been in charge of the Resident Council Meetings since 11/2022. S5 Activity Director stated she was not aware that she had to document minutes of the meeting. S5 Activity Director confirmed the Residents have expressed concern about issues such as: Coffee not being left out for self-service, smoking policy (smokers not being able to smoke at designated times, community cigarettes, safe/unsafe smokers), CNAs not answering call lights in timely manner, and lights out on the front porch and the dining area. S5 Activity Director stated she does not write the Residents' concerns down as newly identified issues or have them addressed. S5 Activity Director stated she was not aware that she was supposed to write down complaints.
Interview on 03/22/2023 at 3:00 p.m. with S2 DON confirmed there were no documented Resident Council Meeting Minutes since 10/2022 and there were no rationale and/or resolution follow-up for Residents Council grievances. S2 DON stated she and S1 Administrator were invited to the December 2022 Resident Council Meeting. S2 DON stated the issue with the coffee pot was addressed with no written resolution provided. S2 DON stated the coffee is monitored by the Dietary staff from 5:00 a.m. - 7:00 p.m. for safety of all Residents. S2 DON stated a Resident accidentally sustained a burn while trying to pour coffee from the coffee pot.
Interview on 03/22/2023 at 3:10 p.m. with S1 Administrator revealed the coffee pot, and smoking issues were addressed in person by S2 DON. S1 Administrator stated the Facility had no documented evidence which addressed resolutions to the Resident Councils grievances discussed at the 11/2022, 12/2022 and 01/11/2023. S1 Administrator stated since there were no minutes to the meetings, she failed to provide written rationales and resolutions to the Resident Council on grievances and/or concerns and to maintain files of the Resident Council Meetings.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 18 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $19,145 in fines. Above average for Louisiana. Some compliance problems on record.
- • Grade D (41/100). Below average facility with significant concerns.
Bottom line: Trust Score of 41/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Colonial Nursing And Rehabilitation Center's CMS Rating?
CMS assigns Colonial Nursing 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 Colonial Nursing And Rehabilitation Center Staffed?
CMS rates Colonial Nursing and Rehabilitation Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 53%, compared to the Louisiana average of 46%. RN turnover specifically is 83%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Colonial Nursing And Rehabilitation Center?
State health inspectors documented 18 deficiencies at Colonial Nursing and Rehabilitation Center during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 17 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 Colonial Nursing And Rehabilitation Center?
Colonial Nursing 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 RIGHTCARE HEALTH SERVICES, a chain that manages multiple nursing homes. With 64 certified beds and approximately 54 residents (about 84% occupancy), it is a smaller facility located in Marksville, Louisiana.
How Does Colonial Nursing And Rehabilitation Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Colonial Nursing and Rehabilitation Center's overall rating (2 stars) is below the state average of 2.4, staff turnover (53%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Colonial Nursing 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 you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Colonial Nursing And Rehabilitation Center Safe?
Based on CMS inspection data, Colonial Nursing 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 Colonial Nursing And Rehabilitation Center Stick Around?
Colonial Nursing and Rehabilitation Center has a staff turnover rate of 53%, which is 7 percentage points above the Louisiana average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Colonial Nursing And Rehabilitation Center Ever Fined?
Colonial Nursing and Rehabilitation Center has been fined $19,145 across 1 penalty action. This is below the Louisiana average of $33,270. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Colonial Nursing And Rehabilitation Center on Any Federal Watch List?
Colonial Nursing 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.