MARY GOSS NURSING HOME
For profit - Corporation
91 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
14/100
#141 of 264 in LA
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Mary Goss Nursing Home has received a Trust Grade of F, indicating significant concerns about the facility's quality and care. Ranked #141 out of 264 nursing homes in Louisiana, this position places them in the bottom half of facilities statewide, and #5 out of 10 in Ouachita County, suggesting limited better options nearby. The facility is currently worsening, with issues increasing from 9 in 2023 to 19 in 2024. Staffing shows some strength with a turnover rate of 28%, which is lower than the state average of 47%, but the facility has incurred concerning fines totaling $139,954, higher than 90% of Louisiana facilities, indicating ongoing compliance problems. While RN coverage is average, the inspector found critical incidents, including a resident at high risk for elopement who left through an unsecured exit and suffered injuries before being found. Overall, families should weigh the facility's strengths against its serious safety issues and compliance challenges.
- Trust Score
- F
- In Louisiana
- #141/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 28% annual turnover. Excellent stability, 20 points below Louisiana's 48% average. Staff who stay learn residents' needs.
- Penalties ⚠ Watch
- $139,954 in fines. Higher than 85% of Louisiana facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
14/100
Bottom 47%
Review needed
9 → 19 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 9 issues
2024: 19 issues
The Good
-
Low Staff Turnover (28%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (28%)
20 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: $139,954
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 33 deficiencies on record
2 life-threatening
Aug 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 (#1) of 2 (#1 and #2) sampled residents reviewed for elopement.
Findings:
Review of the Wandering and Elopement and Implementation dated 03/22/2024 revealed the following:
Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
Policy Interpretation and Implementation:
1. If identified as at risk for wandering, elopement or other safety issues utilizing the Elopement Risk Form, the resident's care plan will include strategies and interventions to maintain the resident's safety.
Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses that included myocardial infarction, alcoholic cardiomyopathy, acute respiratory failure with hypoxia, heart failure, acute kidney failure, Stage 3, and metabolic encephalopathy.
Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed resident #1 had a brief interview for mental status score of 04. A score of 00 - 07 indicated the resident had severely impaired cognitive skills for daily decision making.
Review of the August 2024 physician's orders revealed an order dated 05/07/2024 as follows: wanderguard bracelet to ankle. Should be 2 finger widths around ankle. Staff to answer door alarm immediately to ensure resident's safety. Further review revealed the following order dated 03/22/2024: Weekly check wanderguard is working properly on Fridays. Take resident to door and try to open door. Alarm should sound and door should not open.
Review of resident #1's Medication Administration Record for August 2024 revealed there was documentation of the weekly wanderguard checks every Friday.
Review of the Elopement Risk Record revealed on 05/20/2024 resident #1 was an elopement risk. Further review revealed resident #1 had eloped before, frequent monitoring was done every 30 minutes, and staff aware of resident's wander risk.
Review of the incidents and accidents report dated August 2024 revealed resident #1 was found walking in the parking lot on 08/12/2024 at 9:00 p.m. Further review of the report revealed that resident #1 apparently got out of his wheelchair, out of back door, and he had unsteady gait with confusion noted.
Review of the Elopement Risk Record revealed on 08/12/2024 resident #1 eloped through exit door at room (referring to resident #1's room). Discovered approximately 100 feet from door outside of building on feet. Brought back into building no injuries noted upon assessment. Dietary notified. Resumed every 30 minute census checks. The note was signed by S2Director of Nursing (DON).
Review of the nurse's note dated 08/12/2024 at 9:00 p.m. revealed the following documentation: door alarm sounds off nurse calls to nurse station (referring to the nurse's station that was located on the hall resident #1 was residing on at that time), asks what door alarm is sounding off, nurse at desk gives location. Simultaneously CNA (Certified Nursing Assistant) comes running up hall, was stating Resident #1 is not in his wheelchair! Nurse runs down hall out the door alarming. Resident observed outside, ambulating then stops at end of facility's parking lot. No injuries observed. Resident then escorted back towards door exited. CNA goes around to open door. Resident escorted to room CNA prepares resident for bed. Resident examined for injuries, none observed. Vital signs, blood pressure 109/75, heart rate 86, respirations 18, temperature 98.1. Nurse Practitioner notified, family member notified. Bed alarm activated. Monitoring documented. The note was signed by S3Licensed Practical Nurse (LPN).
On 08/21/2024 at approximately 8:35 a.m., an observation revealed resident #1 had a wanderguard intact to his right ankle due to a history of elopement. Further observation revealed S4LPN escorted resident #1 via his wheelchair into the hallway and to the exit door. An observation of the door revealed that it was fully closed and locked with the wanderguard key pad system showing a red light to indicate the door was locked. As S4LPN pushed the resident's wheelchair up to the exit door, the wanderguard system went off and an alarm then sounded to indicate that resident #1 was close to the exit door.
During an interview on 08/22/2024 at 9:00 a.m., S1Administrator confirmed the exit door was working correctly prior to resident #1's elopement on 08/12/2024. S1Administrator further revealed it was undetermined as to how resident #1 was able to open the door to exit the building, however the alarm activated upon the opening of the exit door.
On 08/22/2024 at 2:48 p.m., S2DON confirmed resident #1 required being monitored every thirty minutes due to his elopement on 08/12/2024 at 9:00 p.m. and to ensure that adequate supervisor was being provided for resident #1's safety.
Jul 2024
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 all medical records regarding the resident's code status con...
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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 all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#2) of 16 residents reviewed in the initial pool screening for advanced directives.
Findings:
Review of the facility Advance Directive Policy and Procedure revised [DATE] revealed in part:
4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive.
8. Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan.
Review of resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, and age-related cognitive decline.
Review of resident #2's Annual Minimum Data Set assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 00, which indicated she was severely cognitively impaired.
Review of resident #2's medical record revealed a red sticker on the front cover of her record that read No Code. Further review revealed a [DATE] physician's order for Full Code. Review of resident #2's current care plan revealed on [DATE] the resident's code status was a Full Code. Further review of her care plan revealed an intervention that her chart would be noted with proper code status.
Review of resident #2's Louisiana Physician Orders for Scope of Treatment (LaPOST) revealed resident #2's wishes were to receive Cardiopulmonary Resuscitation (CPR) in the event she was unresponsive, pulseless and was not breathing. Further review revealed resident #2's family member signed the form on [DATE] and her physician signed the form on [DATE].
An interview on [DATE] at 3:05 p.m. with S2Director of Nursing (DON) revealed she was not aware of the discrepancy in resident #2's code status in her medical record. The surveyor and S2DON reviewed resident #2's medical record and she confirmed there was a discrepancy with the resident's code status when comparing the red No Code sticker to resident 2's LaPOST, physician order, and current care plan, which indicated she was a Full Code.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to immediately notify the physician when a resident had a change in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to immediately notify the physician when a resident had a change in condition for 1 (#186) of 1 (#186) residents reviewed for notification of change by, failing to immediately notify the physician when resident #186's accucheck result was greater than 400 milligrams/deciliter.
Findings:
Review of resident #186's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Type II diabetes mellitus with diabetic polyneuropathy.
Review of the July 2024 physician's orders revealed an order dated 07/08/2024 for resident #186 to have Novolog 100 units/milliliter; give 8 units if accucheck greater than 240 and obtain accuchecks twice a day.
Review of the care plans revealed a problem onset: 04/05/2022, altered blood sugars due to diabetes. Further review revealed the documented approaches included accuchecks per physician orders, accuchecks twice a day and to notify the physician if glucose is less than 60 or greater than 400.
Review of the July 2024 Medication Administration Record (MAR) revealed that resident #186 was to have an accucheck obtained twice a day at 6:30 a.m. and 4:30 p.m. Further review revealed an accucheck result of 455 on 07/16/2024 at 4:30 p.m. Further review revealed there was no documented parameters on the MAR to indicate when the nurse was required to notify the physician and /or nurse practitioner with the results.
Review of the skilled nurse's notes dated 07/16/2024 revealed there was no documentation of the physician and /or nurse practitioner being notified of the accucheck result of 455.
During a telephone interview with the nurse practitioner on 07/17/2024 at 12:20 p.m., he confirmed that he had not been notified of resident #186's accucheck result of 455 on 07/16/2024 at 4:30 p.m.
During a telephone interview with the physician on 07/17/2024 at 12:25 p.m., he revealed that he was not notified of resident #186 having an accucheck result of 455 on 07/16/2024 at 4:30 p.m. The physician further revealed that he should have been notified of the accucheck result of 455.
During an interview with S4Assistant Director of Nursing (ADON) on 07/17/2024 at 10:15 a.m., she confirmed that resident #186 was to have accuchecks obtained twice a day at 6:30 a.m. and 4:30 p.m. S4ADON was notified of resident #186 having a documented accucheck result of 455 on 07/16/2024 at 4:30 p.m. S4ADON confirmed there was no documentation that the physician and/or nurse practitioner were notified of resident #186's accucheck result of 455. S4ADON further confirmed the physician should have been notified when the nurse became aware of resident #186's accucheck result of 455.
On 07/17/2024 at approximately 12:40 p.m., S1Administrator and S2Director or Nursing (DON) were notified of the above findings.
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 review of the Resident Council Meeting minutes and interviews, the facility failed to organize resident group meetings in the facility monthly.
Findings:
An interview on 07/15/2024 at 2:55 p....
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Based on review of the Resident Council Meeting minutes and interviews, the facility failed to organize resident group meetings in the facility monthly.
Findings:
An interview on 07/15/2024 at 2:55 p.m. with resident # 4 revealed the resident council has not had meetings in the last couple of months.
Review of the Resident Council Meeting minutes revealed no documentation of resident council meeting minutes since 04/17/2024.
An interview on 07/15/2024 at 3:05 p.m. with S15Activity Director confirmed the resident council has not had a meeting since 04/17/2024.
An interview on 07/15/2024 at 3:40 p.m. with S2Director of Nursing (DON) confirmed the resident council has not had a meeting since 04/17/2024, and should be done monthly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #136
Review of resident #136's medical record revealed she was admitted to the facility on [DATE] with diagnoses includ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #136
Review of resident #136's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, hemiplegia following cerebral infarction affecting the left non-dominant side, congestive heart failure, abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination.
Review of the admission MDS dated [DATE] revealed resident #136 had a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. Further review revealed resident #136 required extensive assistance to total dependence on staff for most activities of daily living.
Observations on 07/15/2024 at 1:30 p.m. and at 4:41p.m. revealed resident #136 was in wheelchair in her room with a pelvic restraint in place.
Observation on 07/16/2024 at 8:01 a.m. revealed resident #136 was in wheelchair in her room with a pelvic restraint in place. Further observation revealed the pelvic restraint was applied improperly with straps of restraint tied in a tight knot behind the back of the upper part of her wheelchair. An interview with resident #136 at this time revealed that she's comfortable today but sometimes the restraint feels too tight, especially when she goes out to Intensive Outpatient Program (IOP).
Observation on 07/16/2024 at 8:30 a.m. revealed resident #136 was in wheelchair in a van to transport her to IOP. Further observation revealed the resident's pelvic restraint was still tied improperly behind her wheelchair in a tight knot. The surveyor informed the transportation staff that a nurse needed to check her restraint before she left the facility. At 8:35 a.m. S2DON observed resident #136's pelvic restraint and confirmed the pelvic restraint was not secured/tied appropriately and should not be tied in a tight knot. S12Certified Nursing Assistant (CNA) got in the van and confirmed resident # 136's pelvic restraint was tied in a tight knot instead of a slip knot. S13CNA also observed the resident's pelvic restraint at this time and she confirmed that she did not tie it correctly, and that it should have been tied in a slip knot. At this time, S12CNA retied the restraint straps in a slip knot before the resident left for IOP.
Review of resident #136's July 2024 Physician's Orders revealed an order dated 07/08/2024 that resident may be up in wheelchair with pelvic restraint for doctor appointments and IOP program. There was no physician's order to monitor the restraint and release the restraint every 2 hours. Further review of the resident's medical record revealed there was no documented evidence that staff were monitoring and releasing resident # 136's pelvic restraint.
Review of resident #136's record revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #136.
Review of resident #136's Physical Restraint Informed Consent dated 07/08/2023 revealed the resident had a pelvic restraint while up in wheelchair for positioning and poor balance due to left hemiplegia to help prevent sliding out of her wheelchair.
Review of resident #136's current care plan revealed there was no documented evidence the resident's pelvic restraint was identified and no interventions regarding the safe and proper use of the restraint.
An interview on 07/16/2024 at 3:40 p.m. with S3LPN/MDS confirmed there was no pre-restraint assessment and resident #136's pelvic restraint was not identified on her care plan.
An interview on 07/17/2024 at 9:30 a.m. with S14Nurse Consultant confirmed there was no pre-restraint assessment and #136's pelvic restraint was not identified on her care plan.
During an interview on 07/17/2024 at 3:10 p.m. with S1Administrator and S2DON, they were informed of the following concerns regarding resident #136's pelvic restraint: there was no pre-restraint assessment, restraint was not identified on her care plan, and no documentation the restraint was monitored by staff.
Based on observations, record reviews, and interviews the facility failed to ensure residents have a right to be treated with respect and dignity, including the right to be free from any physical restraint not required to treat the resident's medical symptoms for 2 (31# and #136) of 3 (#27, #31, and #136) residents investigated for restraints. The facility failed to ensure 1) a pre-restraining assessments was completed and the residents' pelvic restraints were identified on their care plans (#31, #136), and 2) that staff properly applied, monitored, and released a pelvic restraint (#136).
Findings:
Review of the facility's current Restraint Policies and Procedures, Restraint Alternatives, (no date noted) revealed the policies and procedures failed to include guidelines regarding pre-restraint assessments, obtaining consents for restraints, initiating the use of restraints, proper use of restraints, and monitoring restraint use.
Resident #31
Review of the record for resident #31 revealed an admission of 05/11/2023 with following diagnoses: alcoholic cardiomyopathy, urinary tract infection, metabolic encephalopathy, syphilis, and heart failure.
Review of the annual MDS (Minimal Data Set) dated 06/03/2024 revealed resident #31 was assessed to be severely cognitively impaired and was totally dependent on staff for activities of daily living. Review of Section P- Restraints, revealed trunk restraints were used daily.
Observations of resident #31 on 07/15/2024 at 1:42 p.m. and 07/16/2024 at 9:00 a.m. revealed resident sitting up in wheelchair with pelvic restraint vest in place. Further observations revealed that the pelvic restraint was tied in the back of the wheelchair and that resident was unable to untie restraint.
On 07/17/2024 at 10:50 a.m., resident #31 was observed in his room in a wheelchair with a pelvic restraint in place and tied in the back of wheelchair.
Review of the active physician orders for July 2024 revealed an order for a pelvic restraint while up in a wheelchair. The order was written on 06/06/2024.
Further record review revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #31.
Review of the care plans revealed they were last updated on 05/20/2024. Further review of the care plans revealed the facility failed to identify his pelvic restraint and there were no approaches for the restraint.
On 07/16/2024 at 9:05 a.m, an interview with S6LPN (Licensed Practical Nurse) confirmed resident #31 was wearing a pelvic restraint and he was unable to remove it.
On 07/16/2024 at 2:00 p.m., an interview with S2DON (Director of Nursing) and S3LPN/MDS confirmed a pre-restraint assessment was not completed prior to the implementation of a pelvic restraint for resident #31. S3LPN/MDS confirmed there was no care plan for resident #31's pelvic restraint.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to conduct comprehensive assessments including 1) a smoking assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to conduct comprehensive assessments including 1) a smoking assessment for 1 (#15) of 1 (#15) resident reviewed for smoking, and 2) a pre-restraint assessment for 1 (#136) of 3 (# 27, #31, and #136) residents investigated for restraints.
Findings:
Resident #15
Review of the facility Smoking Policy revised 10/2023 revealed the following in part:
Policy Interpretation and Implementation:
9. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff.
Review of resident #15's medical record revealed he was admitted to the facility on [DATE] with diagnoses including quadriplegia, anxiety disorder, schizoaffective disorder, and dementia.
Review of resident #15's quarterly Minimum Data Set assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 00 which indicated he had severe cognitive impairment. Further review revealed he required limited/ 1 person assistance for most activities of daily living.
An observation on 07/17/2024 at 8:22 a.m. revealed resident # 15 was outside in his wheelchair in the designated smoking area with a white smoking apron on. S20Certified Nursing Assistant (CNA) was supervising resident as he smoked his cigarette. An interview with S20CNA at this time revealed resident #15 was an unsafe smoker and had to be monitored by staff.
Review of resident #15's Safe Smoking assessment dated [DATE] revealed he was assessed as an unsafe smoker. Further review revealed there was no documented evidence that the facility had conducted a quarterly smoking assessment for resident #15 per the facility policy.
An interview with S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) on 07/17/2024 at 2:30 p.m. revealed she had not completed resident #15's quarterly smoking assessments. S3LPN/MDS confirmed the most recent smoking assessment for resident #15 was on 10/31/2022.
During an interview with S1Administrator and S2Director of Nursing (DON) on 07/17/2024 at 2:30 p.m. they were informed there was no documentation of quarterly smoking assessments for resident #15 and his most recent assessment was 10/31/2022.
Resident #136
Review of the facility's current Restraint Policies and Procedures, Restraint Alternatives, (no date noted) revealed the policies and procedures failed to include guidelines regarding comprehensive assessments, including pre-restraint assessments.
Review of resident #136's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, hemiplegia following cerebral infarction affecting the left non-dominant side, congestive heart failure, abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination.
Review of the admission MDS dated [DATE] revealed resident #136 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Further review revealed resident #136 required extensive assistance to total dependence on staff for most activities of daily living.
Observations on 07/15/2024 at 1:30 p.m. and at 4:41 p.m. revealed resident #136 was in a wheelchair in her room with a pelvic restraint in place.
Review of resident #136's July 2024 Physician's Orders revealed an order dated 07/08/2024 that resident may be up in wheelchair with pelvic restraint for doctor appointments and Intensive Outpatient Program (IOP).
Review of resident #136's record revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #136.
Review of resident #136's Physical Restraint Informed Consent dated 07/08/2023 revealed the resident had a pelvic restraint while up in wheelchair for positioning and poor balance due to left hemiplegia to help prevent sliding out of her wheelchair.
An interview on 07/16/2024 at 3:40 p.m. with S3LPN/MDS confirmed there was no pre-restraint assessment for resident #136's pelvic restraint.
An interview on 07/17/2024 at 9:30 a.m. with S14Nurse Consultant confirmed there was no pre-restraint assessment for resident #136's pelvic restraint.
During an interview on 07/17/2024 at 3:10 p.m. with S1Administrator and S2DON, they were informed there was no pre-restraint assessment for resident #136's pelvic restraint.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24
Review of the medical record revealed resident #24 was readmitted to the facility on [DATE] with diagnoses that inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24
Review of the medical record revealed resident #24 was readmitted to the facility on [DATE] with diagnoses that included neuralgia, obesity, dementia with behavioral problems, late effects of cerebrovascular disease with dementia, chronic lymphedema of legs, left hemiparesis, heart disease, and arthritis.
Review of the July 2024 physician's orders revealed an order for resident #24 to have Aspirin 81 milligrams, enteric coated, administer one by mouth every day.
Review of the medical record revealed resident #24's care plans included that he was at risk for bleeding and falls, and at risk for limited movement related to neuralgia. Further review of the care plan revealed resident #24 had a risk for bleeding related to Aspirin use, and was identified on 02/03/2022. The documented approaches included to monitor for obvious bleeding: tea colored urine, black tarry stools, or petechiae.
Review of the July 2024 Medication Administration Record (MAR) revealed no documenation of resident #24 being monitored for bleeding while taking Aspirin daily.
On 07/16/2024 at 4:00 p.m., an interview with S3LPN/MDS confirmed that the approach of monitoring for bleeding had not been implemented, in accordance with resident #24's written plan of care.
Resident #136
Review of resident #136's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, hemiplegia following cerebral infarction affecting the left non-dominant side, congestive heart failure, abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination.
Review of the admission MDS assessment dated [DATE] revealed resident #136 had a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Further review revealed resident #136 required extensive assistance to total dependence on staff for most activities of daily living.
Observations on 07/15/2024 at 1:30 p.m. and at 4:41p.m. revealed resident #136 was in wheelchair in her room with a pelvic restraint in place.
Review of resident #136's July 2024 Physician's Orders revealed an order dated 07/08/2024 that resident may be up in wheelchair with pelvic restraint for doctor appointments and Intensive Outpatient Program (IOP).
Review of resident #136's record revealed there was no documentation that a pre-restraint assessment had been performed to determine the least restrictive restraint to be used for resident #136.
Review of resident #136's current care plan revealed there was no documented evidence the resident's pelvic restraint was identified and no interventions regarding the safe and proper use of the restraint.
An interview on 07/16/2024 at 3:40 p.m. with S3LPN/MDS confirmed there was no pre-restraint assessment and resident #136's pelvic restraint was not identified on her care plan.
An interview on 07/17/2024 at 9:30 a.m. with S14Nurse Consultant confirmed there was no pre-restraint assessment and #136's pelvic restraint was not identified on her care plan.
During an interview on 07/17/2024 at 3:10 p.m. with S1Administrator and S2Director of Nursing (DON), they were informed there was no pre-restraint assessment for resident #136's pelvic restraint and the restraint was not identified on her care plan.
Based on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental, and psychosocial needs. The facilitly failed to ensure 1) residents' care plan were developed for restraints and interventions for pelvic restraints (#31, #136); and 2) residents' care plan was not implemented regarding monitoring for bleeding (#24).
Resident #31
Review of the record for resident #31 revealed date of admission on [DATE] with following diagnoses: alcoholic cardiomyopathy, urinary tract infection, metabolic encephalopathy, syphilis,and heart failure.
Review of the Annual MDS (Minimal Data Set) assessment dated [DATE] revealed resident #31 was assessed to be severely cognitively impaired and was totally dependent on staff for activities of daily living. Further review of the MDS for resident #31 dated 05/20/2024 revealed the following: Section P- Restraints: (2) side rails and trunk restraints used daily. Further review of the MDS section P revealed bed alarms and wander/elopement alarm scored 2 and also used daily.
Review of the physician orders dated 06/06/2024 for resident #31 revealed an order for a pelvic restraint while up in wheelchair.
Review of the Care plan for resident #31 with last update on 05/20/2024 revealed no care plan and/or approaches for a restraint.
Observations of resident #31 on 07/15/2024 and 07/16/2024 revealed resident was sitting up in a wheelchair with pelvic restraint vest in place. Further observations revealed that the pelvic restraint was tied in the back of the wheelchair and that resident was unable to untie restraint.
Interview on 07/16/2024 at 2:00 p.m. with S3LPN/MDS (Licensed Practical Nurse/Minimal Data Set) at this time confirmed no care plan was developed for pelvic restraint for resident #31. S3LPN/MDS also confirmed that no pre-restraint assessment was completed for resident #31.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24
Review of the medical record revealed resident #24 was readmitted to the facility on [DATE] with diagnoses that inc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #24
Review of the medical record revealed resident #24 was readmitted to the facility on [DATE] with diagnoses that included neuralgia, obesity, dementia with behavioral problems, late effects of cerebrovascular disease with dementia, chronic lymphedema of legs, left hemiparesis, heart disease, and arthritis.
Review of the incident and accident reports revealed resident #24 was found on his knees while trying to get in the bathroom on 05/09/2024.
Review of resident #24's current care plan revealed the care plan was not revised with the resident's fall on 05/09/2024.
During an interview with S3LPN/MDS (Licensed Practical Nurse/Minimum Data Set) on 04/16/2024 at 4:00 p.m., she was notified of the findings regarding the plan of care not addressing resident #24's documented fall on the date of 05/09/2024. After reviewing the resident's care plan, S3LPN/MDS staff confirmed the plan of care had not been revised after the resident's fall on 05/09/2024.
On 07/17/2024 at approximately 12:40 p.m., S1Administrator and S2Director of Nursing were notified of the findings regarding the care plan not being revised to address resident #24's fall on 05/09/2024.
Based on record reviews and interviews, the facility failed to ensure the residents' care plans were revised to meet the residents' needs, by failing to ensure the resident's care plan was revised to include all new fall interventions in a timely manner for 2 (#2, and #24) of 4 (#2, #7, #24, and #31) residents reviewed for falls.
Findings:
Resident #2
Review of the record for resident #2 revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, paranoid schizophrenia, spinal stenosis, muscle wasting and atrophy, age-related cognitive decline, hallucinations, generalized anxiety disorder, and osteoporosis.
Review of resident #2's 07/05/2024 Annual Minimum Data Set (MDS) assessment revealed she had a Brief Interview for Mental Status (BIMS) score of 00, which indicated resident #2 was severely cognitively impaired. Further review revealed she required limited to extensive assistance for most activities of daily living.
Review of the facility incident report dated 6/20/24 at 8:40 a.m. revealed resident #2 had a fall in the chapel and her walker was observed at her feet. She did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions were noted in the medical record.
Review of the facility incident report dated 6/24/24 at 4:35 p.m. revealed resident #2 had a fall in her room. She was found sitting on the floor with rollator walker flipped over. Resident #2 did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions noted.
Review of resident #2's current care plan, revealed she was at high risk for falls. Further review revealed her care plan was revised with the 6/20/2024 fall, but the new intervention, to remind resident to wait for assistance, was not added until 06/26/2024. Further review of resident #2's care plan revealed the resident's bilateral fall mats were not identified on her care plan.
An interview on 07/17/2024 at 2:05 p.m. with S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) confirmed the following: Resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, and the resident's bilateral fall mats were not identified on her care plan.
During an interview on 07/17/2024 at 2:05 p.m. with S1Administrator and S2Director of Nursing (DON), they both were informed of the following: resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, the resident's bilateral fall mats were not identified on her care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents remained as free of accident hazar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents remained as free of accident hazards as possible for 2 (#2, #31) of 4 (#2, #7, #24, and #31) residents reviewed for accidents. The facility failed to ensure: 1) a thorough investigation was conducted for a resident's falls, staff placed a resident's fall mat in proper place, the resident's care plan was revised to include all new fall interventions in a timely manner, and the fall interventions were appropriate for the type of incident that occurred (#2); and 2) an investigation was conducted for an injury of unknown origin (#31). Findings:
Resident #2
Review of the facility policy Accidents and Incidents - Investigating and Reporting revised July 2017 revealed the following in part:
Policy Statement: All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator.
Review of the record for resident #2 revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, paranoid schizophrenia, spinal stenosis, muscle wasting and atrophy, age-related cognitive decline, hallucinations, generalized anxiety disorder, and osteoporosis.
Review of resident #2's 07/05/2024 Annual Minimum Data Set (MDS) assessment revealed she had a Brief Interview for Mental Status (BIMS) score of 00, which indicated resident #2 was severely cognitively impaired. Further review revealed she required limited to extensive assistance for most activities of daily living.
Review of the fall risk assessment dated [DATE] for resident #2 revealed she had a score of 8, which indicated she was at a low risk for falls. An interview on 07/17/2024 at 2:05 p.m. with S3Licensed Practical Nurse (LPN/MDS) confirmed resident #2 was at a high risk for falls with recent falls in June 2024. She confirmed the above fall risk assessment should have indicated she was at a high risk for falls.
On 07/16/2024 at 4:15 p.m., resident #2 was observed in her room in bed with her eyes closed. The fall mat on the left side of the bed was positioned improperly underneath her bed.
On 07/16/2024 at 10:50 a.m. resident #2 was observed in her room in bed. The fall mat on the left side of the bed was positioned improperly underneath her bed.
On 07/16/2024 at 5:00 p.m. the surveyor and S11Certified Nursing Assistant (CNA) observed resident #2's fall mat on the left side of the bed was positioned improperly underneath her bed. An interview with S11CNA at this time confirmed the fall mat should have been placed on the floor to the left of the resident's bed.
Review of the facility incident report dated 6/20/24 at 8:40 a.m. revealed resident #2 had a fall in the chapel and her walker was observed at her feet. She did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions were noted in the medical record.
Review of the facility incident report dated 6/24/24 at 4:35 p.m. revealed resident #2 had a fall in her room. She was found sitting on floor with rollator walker flipped over. Resident #2 did not have an injury; however there was no documentation of a thorough investigation of the above incident and no new interventions noted.
Review of resident #2's current care plan, revealed she was at a high risk for falls. Further review revealed her care plan was revised with the 6/20/2024 fall, but the new intervention was not added until 06/26/2024. Also the intervention was to remind resident to wait for assistance before trying to get up out of chair. This was an inappropriate intervention due to the resident's severe cognitive impairment and the fall occurred while she was using her walker. Further review of resident #2's care plan revealed the resident's bilateral fall mats were not identified on her care plan.
An interview on 07/17/2024 at 2:05 p.m. with S3LPN/MDS confirmed the following:
Resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, and the resident's bilateral fall mats were not identified on her care plan.
During an interview on 07/17/2024 at 2:05 p.m. with S1Administrator and S2Director of Nursing (DON), they both were informed of the following: there was no thorough investigation of resident #2's 6/20/2024 and 6/24/2024 falls, staff placed the resident's fall mat underneath her bed while she was in the bed, resident #2's new intervention for the 6/20/2024 fall was not revised on her care plan timely, the intervention was not appropriate, the resident's bilateral fall mats were not identified on her care plan.
Resident #31
Review of the record for resident #31 revealed date of admission on [DATE] with following diagnoses: alcoholic cardiomyopathy, urinary tract infection, metabolic encephalopathy, syphilis, and heart failure.
Review of annual MDS (Minimal Data Set) assessment dated [DATE] revealed resident #31 was assessed to be severely cognitively impaired.
Review of the fall risk assessment dated [DATE] for resident #31 revealed he had a score of 10, which indicated he was at a high risk for falls.
Review of resident #31's care plan with last update on 05/20/2024 revealed he was at risk for falls related to an unsteady gait.
Review of nurses' notes for resident #31 dated 05/25/2024 at 8:20 a.m. revealed that a housekeeper walked into resident #31's room and saw him lying on the floor. S5LPN entered his room and noted that he was lying on his right side with blood coming from the side of his right eye. Resident#31 was sent to a local hospital for evaluation.
Review of nurses' note dated 05/25/2024 at 3:00 p.m. revealed resident #31 returned to facility via ambulance; stable condition; sitting in wheelchair; continues on 30 minute monitoring; 4 sutures noted above right eye.
Observations of resident #31 on 07/15/2024 at 1:42 p,m, and 07/16/2024 at 9:00 a.m. revealed he was sitting up in wheelchair with a pelvic restraint vest in place. Resident #31 had a Wanderguard in place and he self-propelled his wheel chair in the hallway.
On 07/16/2024 at 10:15 a.m. surveyor requested 05/25/2024 incident and accident report and investigation regarding resident #31's injury of unknown origin.
Interview with S9LPN/treatment (Licensed Practical Nurse) on 07/17/2024 at 2:30 p.m. confirmed documentation on 05/25/2024 of a laceration above resident #31's right eye.
Interview with S2DON (Director of Nursing) on 07/17/2024 at 3:00 p.m. revealed that she was unable to locate 05/25/2024 incident and accident report and investigation regarding resident #31's injury of unknown origin. Further interview with S2DON confirmed there was no 05/25/2024 investigation completed regarding resident #31's incident of unknown origin.
Review of incident/accident report dated 04/14/2024 at 5:50 p.m. for resident #31 revealed S10CNA (Certified Nursing Assistant) pointed out to S8LPN that resident #31 has small laceration to left eye; origin unknown. Neuro-checks implemented; first aide given to injury and will continue to observe. S8LPN notified and began head injury scale on 04/14/2024 for 24 hours with no issues noted. Further review revealed no investigation was done to determine injury of unknown origin to laceration of left eye to resident #31.
Interview with S9LPN/treatment on 07/17/2024 at 2:30 p.m. confirmed she had no 04/14/2024 documentation of a laceration above resident #31's left eye.
Interview with S2DON on 07/17/2024 at 3:00 p.m. revealed that an investigation was not done for injury of unknown origin on above incident dated 04/14/2024. Further interview with S2DON revealed that she did not document the wound on the weekly status report.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to ensure that nursing staff are able to demonstrate competency in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to ensure that nursing staff are able to demonstrate competency in skills necessary to care for resident needs for 3 (#236, #27, and #186) of 3 (#236, #27, and #186) residents records reviewed. The facility failed by 1) not having documentation of sites for administration of insulin and by having omitted medications for resident #236, 2) not having a fall mat and bed alarm in place for resident #27 as ordered by the physician, and 3) not having documentation of accucheck results for resident #186 as ordered by the physician.
Findings:
Review of the Administering Medication Policy and Procedure revised April 2019, revealed in part
4. Medications are administered in accordance with prescriber orders, including any required time frames
22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
23. As required or indicated for a medication, the individual administered the medication records in the resident's medical record:
b. the dosage;
d. the injection site (if applicable);
e. any results achieved and when those results were observed.
Resident #236
Review of the medical record for resident #236 revealed an admission date of 03/14/2014, and readmission date of 07/08/2024 with diagnoses including diabetes mellitus, human immunodeficiency virus disease, pressure ulcer of sacral region stage 4, functional quadriplegia, paraplegia, dysphagia, cerebrovascular accident, anemia, urinary tract infection, other peripheral vascular disease, and type 2 diabetes mellitus.
Review of the most recent discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact.
Review of the July 2024 Physician's Orders revealed the following orders dated 07/08/2024:
-Diflucan 100 milligrams (mg) 1 per tube (PT) every (q) morning (am)
-Sulfamethoxazole-Trimethoprim 200-40/5 milliliters (ml) suspension- 4 teaspoons (tsp) (20 ml
Per peg twice a day (bid)
-Azithromycin 200 mg/5 ml- 6 tsp (30 cubic centimeters (cc)) by peg tube weekly
-Sliding scale with Humulin R insulin <70 hypoglycemia protocol- give coke or apple juice, 151-200=2 Units (U), 201-250= 4 U, 251-300= 6 U, 301-350= 8 U, 351-400= 10 U and notify the physician
-Lantus 8 U subcutaneously (SQ) q evening (pm)
-Accu-checks before meals (ac) and at hour of sleep (hs)
Review of the July 2024 Medication Administration Record (MAR) revealed the following:
-No documentation of location of site for the administration of Lantus 8 U SQ q pm
-No documentation of administration of Azithromycin 200 mg/5 ml- 6 tsp (30 cc) by peg tube weekly, indefinitely on 07/09/2024 and 07/16/2024 at 7:00 a.m.
-No documentation of Sulfamethoxazole-Trimethroprim 200-40/5 ml suspension- 4 tablespoons (20 ml) per peg bid administered on 07/09/2024 for a.m. and p.m. doses;
-No documentation of administration of Zidovudine 10 mg/ml give 30 ml PT bid on 07/09/2024 for 7:00 a.m. and 7:00 p.m. doses
-No documentation of site administered for sliding scale Humulin R insulin administered to resident #236 on the following dates and times: 07/09/2024 through 07/17/2024 for 6:30 a.m., 07/10/2024, 07/12/2024, 07/14/2024, and 07/16/2024 at 11:30 a.m., 07/09/2024 through 07/11/2024, 07/15/2024 and 07/16/2024 at 4:30 p.m., and 07/08/2024, 07/11/2024, 07/15/2024, and 07/16/2024 at 9:00 p.m.
An interview on 07/17/2024 at 12:52 p.m. with S2Director of Nursing (DON) confirmed no documentation of administration site for Lantus from 07/08/2024 through 07/16/2024; no documentation of administration of Diflucan on 07/09/2024, no documentation of administration of Azithromycin on 07/09/2024 and 07/16/2024, no documentation of administration of Sulfamethoxazole-trimethoprim and Zidovudine on 07/09/2024 for 7:00 a.m. or 7:00 p.m. doses. S2DON also confirmed no documentation of site administered for sliding scale Humulin R insulin administered to resident #236 on the following dates and times: 07/09/2024 through 07/17/2024 for 6:30 a.m., 07/10/2024, 07/12/2024, 07/14/2024, and 07/16/2024 at 11:30 a.m., 07/09/2024 through 07/11/2024, 07/15/2024 and 07/16/2024 at 4:30 p.m., and 07/08/2024, 07/11/2024, 07/15/2024, and 07/16/2024 at 9:00 p.m.
Resident #27
Review of the medical record revealed resident #27 was admitted to the facility on [DATE] with diagnoses including unspecified glaucoma, and primary open-angle glaucoma, stage unspecified.
Review of the annual minimum data set assessment dated [DATE] revealed resident #27 had a documented brief interview for mental status score of 00 according to section c: cognitive status. A score of 00-07 indicated the resident had severe cognitive impairment with daily decision making.
Review of the fall risk assessment dated [DATE] revealed a score of 14. According to the scoring scale documented on the fall risk assessment form, a total score of 10 or above indicated resident #27 was at a high risk for falls.
Review of the 2024 physician's orders revealed an order dated 05/16/2024 for resident #27 to have a bed alarm, the staff were to answer promptly when it was activated, and for fall mats times 2 as fall precautions.
During the survey dates of 05/15/2024 through 05/16/2024, observations of resident #27's room revealed there were no visible fall mats on the floor and no bed alarm on the resident's bed.
Review of the July 2024 medication administration record revealed that the bed alarm and fall mats times 2 was documented daily on the day, evening, and night shifts from 07/01/2024 through the 07/16/2024.
On 07/16/2024 at 4:13 p.m., S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) was notified of the physician's order for resident #24 to have a bed alarm and the staff were to answer promptly when activated. An observation of resident's room with S3LPN/MDS was conducted after the interview. During the observation, S3LPN/MDS confirmed there was no bed alarm/pad in the resident's room including on his bed.
During a telephone interview with S3LPN/MDS on 07/16/2024 at 4:40 p.m., she confirmed there were no falls and bed alarm observed in resident #27's room. She further onfirmed the documented approaches of the fall mats and bed alarm had not been implemented, in accordance with the physician's orders.
During an interview with S1Administrator and S2Director of Nursing on 07/17/2024 at approximately 12:40 p.m., they were notified of the above findings.
Resident #186
Review of resident #186's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses that included Type II diabetes mellitus with diabetic polyneuropathy.
Review of the July 2024 physician's orders revealed an order dated 07/08/2024 for resident #186 to have Novolog 100 units/milliliter; give 8 units if accucheck greater than 240 (milligrams/deciliter), and to obtain the accuchecks twice a day.
Review of the care plan revealed a problem onset of 04/05/2022; altered blood sugars due to diabetes. Further review revealed the documented approaches included accuchecks per physician orders, accuchecks twice a day, and notify the physician if the glucose was less than 60 or greater than 400.
Review of the July 2024 MAR revealed that resident #186 was to have an accucheck obtained twice a day at 6:30 a.m. and 4:30 p.m. Further review of the MAR revealed there was no documentation of an accucheck result being obtained on the date of 07/15/2024 at 6:30 a.m.
Review of the skilled nurse's notes dated 07/15/2024 revealed there was no documentation to indicate why the accucheck had not been obtained at 6:30 a.m.
During a telephone interview on 07/17/2024 at 12:20 p.m. with the nurse practitioner, he confirmed that he was not aware of an accucheck not being obtained on 07/15/2024 for resident #186.
During a telephone interview on 07/17/2024 at 12:25 p.m. with the physician, confirmed that he was not aware of an accucheck not being obtained on 07/15/2024 for resident #186.
During an interview with S4Assistant Director of Nursing (ADON) on 07/17/2024 at 10:15 a.m., she confirmed that resident #186 was to have accuchecks obtained twice a day at 6:30 a.m. and 4:30 p.m. After a record review was completed, S4ADON confirmed that there was no documentation to indicate why resident #186 did not have an accucheck result on 07/15/2024 at 6:30 a.m., as ordered by the physician.
On 07/17/2024 at approximately 12:40 p.m., S1Administrator and S2Director of Nursing were notified of the findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected multiple residents
Based on review of the personnel records, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 6 (S10CNA, S11CNA, S1...
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Based on review of the personnel records, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) of 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) personnel files reviewed.
Findings:
Review of S10CNA's personnel file revealed a hire date of 09/08/2022. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024.
Review of S11CNA's personnel file revealed a hire date of 12/06/1994. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024.
Review of S12CNA's personnel file revealed a hire date of 06/14/2010. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024.
Review of S17CNA's personnel file revealed a hire date of 03/25/2024. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024.
Review of S18CNA's personnel file revealed a hire date of 02/08/2024. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024.
Review of S19CNA's personnel file revealed a hire date of 10/10/2023. Review revealed there was documentation of a State Adverse Actions check on 04/23/2024. Further review revealed there was no documentation of a State Adverse Actions check after the date of 04/23/2024 through the present date of 07/17/2024.
On 07/17/2024 at 5:35 p.m., an interview with S1Administrator confirmed that monthly State Adverse Action checks were not being done monthly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations, review of the policy, and interview, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an open medication cart, unlocked a...
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Based on observations, review of the policy, and interview, the facility failed to ensure that all drugs and biologicals are stored in locked compartments by having an open medication cart, unlocked and drawers open with medications in direct view and staff not present. The medication cart was in a place where residents and unauthorized staff could access the medication cart.
Findings:
Review of facility's policy and procedure for Administering Medications (revised April 2019) revealed the following: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
Observation on 07/17/2024 at 7:08 a.m. revealed the medication cart for hall A was located in the hallway. Further observation revealed the cart was unlocked, and drawers were opened with medications in direct view. No nurse or staff members were present on the hallway at that time. Resident #306 was observed self-ambulating in a wheelchair, and passed by the open medication cart.
Observation on 07/17/2024 at 7:10 a.m. revealed that S2Director of Nursing (DON) entered the hall A and also observed the medication cart unlocked with open drawers and left unattended. S2DON then notified S7Licensed Practical Nurse (LPN), responsible for the unlocked cart, to return to the cart and lock the cart. S7LPN was located behind a closed door assisting resident #236 when the medication cart was observed unlocked on hall A.
Observation on 07/17/2024 at 7:54 a.m. revealed the medication cart for hall A was observed once again unlocked with no staff in view of the cart.
Interview on 07/17/2024 at 7:15 a.m. with S2DON confirmed that the medication cart was to be locked when medications were not being prepared and the nurse was not in view of the cart.
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 observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidence by, 1) having dirty serving tr...
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Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidence by, 1) having dirty serving trays on a rolling cart, 2) having a grime build up on the kitchen cabinets, shelves, and window ledge, 3) storing an expired nutritional supplement in the refrigerator, and 4) storing food items that belonged to an employee in the storage room and available for resident use.
Findings:
During an initial tour of the kitchen on 07/15/2024 at 8:10 a.m., an observation revealed a rolling cart located near the steam table. Further observation revealed there were six serving (meal) trays that had old dried food particles on the trays. Further observations revealed there were large amounts of thick, black grime build up on shelves that were located in the bottom and top cabinets throughout the kitchen. The dirty shelves had various cooking pots, pans, and /or eating utensils stored on them.
After the initial tour of the kitchen was completed, a tour of the outside storage room revealed one, eight ounce carton of Boost stored inside of the refrigerator. Observation of the carton revealed a use by date of 06/2023. Further observation of the storage room revealed a small box that contained 2 boxes of macaroni and cheese, one box of wheat noodles, two cans of pork and beans, and one can of black beans. The can of black beans had approximately one half of the label stained with a dark colored unknown substance.
S16Dietary [NAME] was present during the observations of the kitchen and outside storage room. She reported that a visitor had left the box of food items for an employee and she (S16Dietary Cook) had placed the box in the storage room for an employee. S16Dietary [NAME] confirmed that the kitchen cabinets and window ledge were dirty and needed to be cleaned and the serving trays contained old dried food particles. S16Dietary [NAME] further confirmed the carton of Boost was expired, and the box of food items left for the employee should not have been stored in outside storage room and available for resident use.
On 07/15/2024 at approximately 8:45 a.m., S1Administrator was notified of the above findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interviews and review of the facility's Infection Control Records, the facility failed to ensure the Infection Preventionist, who is responsible for the facility's infection prevention and co...
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Based on interviews and review of the facility's Infection Control Records, the facility failed to ensure the Infection Preventionist, who is responsible for the facility's infection prevention and control program, had completed specialized training in infection prevention and control.
Findings:
Review of the facility's Infection Control Records revealed there was no documented evidence the Infection Preventionist, S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS), had completed specialized training in infection prevention and control.
An interview with S3Licensed Practical Nurse/Minimum Data Set (LPN/MDS) on 7/16/2024 at 1:30 p.m. revealed she had not completed the Infection Preventionist Training.
An interview with S2Director of Nursing on 7/17/2024 at 3:10 p.m. confirmed S3LPN/MDS had not completed the Infection Preventionist Training.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to maintain all mechanical equipment in safe operating condition by having shavings on the manual can opener.
Findings:
During an initial tour o...
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Based on observation and interview, the facility failed to maintain all mechanical equipment in safe operating condition by having shavings on the manual can opener.
Findings:
During an initial tour of the kitchen on 07/15/2024 at 8:10 a.m., an observation revealed a large can opener with a buildup of metal shavings on the blade. Further observation revealed S16Dietary [NAME] began opening a large can of canned sweet green peas, for the lunch service. She was notified of the buildup of the metal shavings and confirmed that the can opener blade needed to be cleaned.
On 07/15/2024 at approximately 8:45 a.m., S1Administrator was notified of the above findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on review of the personnel records and interviews, the facility failed to ensure all required in-service training for Certified Nurse Aides (CNA) included dementia management training for 6 (S10...
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Based on review of the personnel records and interviews, the facility failed to ensure all required in-service training for Certified Nurse Aides (CNA) included dementia management training for 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA and S19CNA) of 6 (S10CNA, S11CNA, S12CNA, S17CNA, S18CNA, and S19CNA) personnel files reviewed.
Findings:
Review of S10CNA's personnel file revealed a hire date of 09/08/2022. Further review revealed there was no documentation of dementia care management training.
Review of S11CNA's personnel file revealed a hire date of 12/06/1994. Further review revealed there was no documentation of dementia care management training.
Review of S12CNA's personnel file revealed a hire date of 06/14/2010. Further review revealed there was no documentation of dementia care management training.
Review of S17CNA's personnel file revealed a hire date of 03/25/2024. Further review revealed there was no documentation of dementia care management training.
Review of S18CNA's personnel file revealed a hire date of 02/08/2024. Further review revealed there was no documentation of dementia care management training.
Review of S19CNA's personnel file revealed a hire date of 10/10/2023. Further review revealed there was no documentation of dementia care management training.
On 07/17/2024 at 5:40 p.m., an interview with S1Director of Nursing confirmed that dementia care training had not been provided to the CNAs listed above.
Mar 2024
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to provide an environment free of accident hazards for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to provide an environment free of accident hazards for 1 (#1) of 1 (#1) residents identified at high risk for elopement. The facility failed to ensure all exit doors were secured to prevent residents at risk for elopement from exiting the facility unsupervised and failed to provide continued monitoring after resident #1 was returned to the facility.
This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2024 at 3:30 p.m. when resident #1 (a cognitively impaired resident identified as an elopement risk) was found a 1/2 block away from the facility. Resident #1 was located 10 minutes after he eloped on 03/15/2024 through an unsecured door and was returned to the facility at 3:45 p.m. Resident #1 was located at 3:40 p.m., by a staff member and found in a ditch, sitting in water, and had a laceration to his left eye and bruise to his left shoulder. Resident #1 was returned to the facility by S7 CNA (Certified Nursing Assistant) and S1Administrator in the nursing home van and then the resident was sent for evaluation to the local hospital by ambulance at 4:00 p.m.
S1Administrator was notified of the Immediate Jeopardy on 03/22/2024 at 11:40 a.m.
The Immediate Jeopardy was removed on 03/22/2024 at 5:40 p.m., as confirmed by onsite verification through observations, interviews and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Review of the current facility's Wandering and Elopement policy dated 12/2009 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring.
Review of the medical record for resident #1 revealed an admission date of 05/11/2023 with a readmission date of 03/06/2024. Further review revealed diagnosis of myocardial Infarction, alcoholic cardiomyopathy, acute respiratory failure with hypoxia, syphilis, heart failure, alcohol abuse, trichomonas, acute kidney failure, and metabolic encephalopathy.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed resident #1 had severe cognition for daily decisions making and required assistance with one person assist for bed mobility and supervision with one person assist with transfers.
Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls.
Review of resident #1's Elopement Risk Record dated 02/29/2024 revealed no complaints of elopement, but was high risk and the only intervention noted was a bed alarm. Further review revealed the risk record was updated 03/15/2024 to include the incident of the resident leaving the building without staff and interventions were noted as bed alarm, staff aware of residents wander risk and frequent monitoring.
Review of resident #1's current care plan revealed he was care planned for elopement with an intervention of monitoring for needs and needs will be met as necessary. Further review revealed on 03/15/2024 care plan updated - resident eloped from the nursing home, with new approaches that included census checks q (every) 30 minutes for whereabouts and elopement attempts.
Review of resident #1's record failed to reveal documentation of monitoring the resident's needs and needs being met prior to the elopement prior to 03/15/2024.
Review of resident #1's Incident & Accident report dated 03/15/2024 at 3:40p.m. revealed an unwitnessed fall outside the facility, resulting in a gash over the left eye and bruise to the left shoulder. No other injuries noted at this time. Able to move upper and lower extremities. Resident #1 sent by ambulance to the local hospital for evaluation.
Resident #1s discharge hospital report dated 03/15/2024 revealed CT (computed tomography) scan done with no injuries found, incision to left upper eye with fibrin sealant. Discharge back to nursing facility and follow up with resident's physician.
An interview on 03/21/2024 at 9:55 a.m. with S4LPN (Licensed Practical Nurse) that was taking care of resident #1, confirmed there was no documentation of the monitoring for needs and needs will be met as necessary prior to the 03/15/2024 elopement and for the census checks for the resident's whereabouts every 30 minutes after the elopement on 03/15/2024.
An interview on 03/21/2024 at 10:20 a.m. with S9CNA stated resident #1 was checked on by staff every 30 minutes, but they don't document it anywhere.
An interview on 03/22/2024 at 9:00 a.m. with S8CNA and S10CNA that was taking care of resident #1, confirmed there was no documentation of monitoring the resident before or after the elopement attempt on 03/15/2024.
An interview on 03/21/2024 at 9:50 a.m. with S1Administrator revealed when he was notified resident #1 was not in the facility, he drove the nursing home van down the block and saw the resident sitting on the ground in the water. The Administrator stated he and the other staff member assisted the resident to a standing position and assisted him to the van to be brought back to the nursing home. S1Administrator stated the resident was assessed and found to have a gash above his left eye and bruise to the left shoulder and nursing had received an order from the resident's physician to send the resident to the hospital for evaluation. S1Administrator stated he began investigating how the resident eloped from the facility. It was found that the door the resident went out of was normally locked and a code would have to be used to open it, but he stated it must not have closed completely due to when the resident pushed the door opened the alarm did sound. S1Administrator stated he contacted the agency that works on the facilities locked doors and they came to inspect the doors. The agency determined that the door was functioning properly and if it happened again, contact them and they would respond immediately. S1Administrator stated they would have placed a wander guard bracelet on the resident, but the facility did not have any bracelets on hand and he had to order some. S1Administrator stated resident #1 will be monitored by staff every 30 minutes until the wander guard arrives.
An interview on 03/21/2024 at 9:55 a.m. with S4LPN that was taking care of resident #1, stated he had never tried to go outside by himself before the incident on 03/15/2024. When asked how he was being monitored after the elopement she stated staff make observations of the resident every 30 minutes, he is taken to the Chapel to eat all meals, and if the resident seems restless they will bring him to the nurse's station to be monitored. When asked where the observations every 30 minutes were documented S4LPN stated they were not documented.
An interview on 03/22/2024 at 9:10 a.m. with S2DON (Director of Nurses) stated the facility had not received the wander guard bracelets, but they were ordered. She further stated the resident was being monitored by staff every 30 minutes, but the every 30 minute monitoring had not been documented.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected 1 resident
Based on observations, record review and interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently by failing to have an adequate s...
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Based on observations, record review and interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure 1(#1) of 1 ((#1) residents who was at high risk for elopement was adequately supervised to prevent Resident #1 from eloping from the facility.
This deficient practice resulted in an Immediate Jeopardy situation on 03/15/2024 at 3:30 p.m. when resident #1 (a cognitively impaired resident identified as an elopement risk) was found a 1/2 block away from the facility. Resident #1 was located 10 minutes after he eloped on 03/15/2024 through an unsecured door and was returned to the facility at 3:45 p.m. Resident #1 was located at 3:40 p.m., by a staff member and was found in a ditch, sitting in water, and had a laceration to his left eye and bruise to his left shoulder. Resident #1 was returned to the facility by S7 CNA (Certified Nursing Assistant) and S1Administrator in the nursing home van and then the resident was sent for evaluation to the local hospital by ambulance at 4:00 p.m.
S1Administrator was notified of the Immediate Jeopardy on 03/22/2024 at 11:40 a.m.
The Immediate Jeopardy was removed on 03/22/2024 at 5:40 p.m., as confirmed by onsite verification through observations, interviews and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Cross Reference F689
Review of the facilities Wandering and Elopement policy dated 12/2009 revealed there was no guidance in the policy on placing a resident that had eloped on any type of supervision or monitoring.
Review of the Incident and Accident report dated 03/15/2024 at 3:40 p.m. stated the resident had an unwitnessed fall outside resulting in a gash over his left eye and bruise on his left shoulder. No other injuries noted at this time, the resident was able to move his upper and lower extremities. Further review revealed the resident was sent to the local emergency room for evaluation at 4:00 p.m. on 03/15/2024.
An interview on 03/21/2024 at 09:50 a.m. with S1Administrator confirmed he began investigating how the resident eloped from the facility on 03/15/2024. The investigation found that the door the resident went out of was normally locked and a code would have to be used to open it. S1 Administrator stated the door must have not closed completely due to when the resident pushed the door opened the alarm did sound. S1Administrator stated he contacted the agency that maintains the facilities locked doors and they came immediately to inspect the doors. The agency determined that the door was functioning properly and if it happened again, to contact them and they would respond immediately. S1Administrator stated they would have placed a wander guard bracelet on the resident, but the facility did not have any bracelets on hand and he had to order them. S1Administrator stated the facility does not have a system in place to monitor the locked doors to ensure they are in working order.
Interview on 03/22/2024 at 9:10 a.m. with S2DON (Director of Nurses) stated the facility had not received the wander guard bracelets, but they were ordered. She further stated the resident was being monitored by staff every 30 minutes but the monitoring had not been documented.
During the survey, there was no documented evidence of monitoring the resident for elopement and monitoring proper working order of the locking of exit doors before or after the elopement incident on 03/15/2024.
Jan 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to protect the resident's right to be free from verbal abuse by staff when staff used profanity and threatening language towards the resident. ...
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Based on record review and interview the facility failed to protect the resident's right to be free from verbal abuse by staff when staff used profanity and threatening language towards the resident. The incident involved 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse. Findings:
Review of the facility's current abuse policy and procedures revealed in part, the following: it is the policy of the facility to assure that its residents are free from verbal, sexual, physical and mental abuse and the misappropriation of property. Verbal aggressive behavior; such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidation. Following are examples of abuse or neglect by nurse aides: Threatening a resident with harm; yelling at or making fun of a resident. Purpose: to identify any act of abuse in our facility and to assure that it is dealt with in a timely and proper manner. Procedure: any type of abusive act is to be report to the Administrator or the DON (Director of Nursing). If the Administrator or DON is not available, it is to be reported to the nurse in charge. The nurse will notify the Administrator or DON as soon as possible. If the complaint cannot be substantiated the accused employee will not be allowed to work with that resident. This employee will be monitored for 30 days. If the complaint is substantiated, the accused employee may be terminated at that time and the complaint will be filed with the proper authorities.
Review of the facility incident report dated 12/25/2023 revealed on 12/24/2023 at approximately 7:00 p.m. Resident #1 and S6CNA (Certified Nursing Assistant) got into a verbal altercation in front of the nurse's station, down stairs hall. According to the report, Resident #1 was asking for a soda and evidently was on some type of fluid restrictions. She also supposedly asked for a cigarette. When resident #1 received her dinner tray, it had juice instead of a soda and she became upset as a result and began to shout at S6CNA. Both staff and resident began to shout at each other. Further review of the report revealed that S6CNA began to curse back at resident #1. I'm going to whoop her a-- if she comes close to me was witnessed by S4LPN (Licensed Practical Nurse).
Review of the record for Resident #1 revealed an admission date of 06/17/2019 with diagnoses of following: Schizophrenia, End Stage Renal Disease with Dialysis, and Diabetes. Review of the BIMS (Brief Interview of Mental Status) score of 12 which indicates the resident is mostly cognitively aware and able to make daily decisions.
Review of the care plan for resident #1 revealed the following problems: psychoactive medication; Episodes of verbal abuse towards staff since 03/09/2020. Verbal altercation with staff on 12/24/2023. Repetitive requests every day for money, going home, cigarettes and calling sisters; fluid restrictions due to End Stage Renal Disease.
Interview with resident #1 on 01/18/2024 at 8:30 a.m. was conducted in resident's room. Resident #1 was alert to person, place, and time. She reported no conflicts with any staff; not aware of S6CNA; not aware of any incident on or around Christmas Eve. She is pleasant, no apparent distress. Again, the surveyor asked about staff S6CNA and she was unable to recall any issues with her or any other staff member. She again denied any conflict with staff and reported that she loved her staff.
Interview with S4LPN on 01/18/2024 at 2:40 p.m. revealed that on 12/24/2023 between 6 and 7 p.m. she was passing medications on the down stairs hall and witnessed in the hall way in front of nursing station S6CNA speaking aggressive and cursing at Resident #1 in a loud tone of voice. S4LPN stated she attempted to calm staff and resident down and separate the two of them. S4LPN further stated S6CNA proceeded to threaten Resident #1 stating she will whoop her a-- if she comes close to her and promised I'm going to jail today for whooping your a--. S4LPN stated S6CNA told her (S4LPN) do not give cigarettes to Resident #1 to smoke and if she did that she (S6CNA) will break them up. S4LPN stated S6CNA told Resident #1 that she promised, you are not smoking today. S4LPN reported she separated the two to deescalate the situation and that was when S6CNA went upstairs away from Resident #1. S4LPN reported she notified S2DON after the incident.
Interview with S2DON on 01/18/2024 at 8:50 a.m. revealed that she was notified by S4LPN on 12/24/2023 at 9:00 p.m. that S6CNA was verbally abusive and made threatening remarks to Resident #1. Further interview with S2DON confirmed that verbal abuse was substantiated and S6CNA was immediately suspended and remains suspended.
Review of the facility plan of action revealed following: S6CNA was immediately suspended. Facility began monitoring Resident #1 hourly for any psychological trauma regarding incident. Staff were in-serviced on Elderly abuse on 12/26/2023 and 12/27/2023.
Interview with S1 Administrator on 01/18/2024 at 4:00 p.m. revealed that S6CNA was immediately suspended and remains suspended and has been going through anger management classes.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that a resident received adequate supervision to prevent a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that a resident received adequate supervision to prevent accidents and incidents for 2 (#1 and #2) of 3 (#1, #2, and #3) sampled residents reviewed for incidents and accidents. The facility failed to ensure resident #1 and #2 received increased supervision after an altercation with each other.
Findings:
Resident #1
Review of the record for resident #1 revealed an admission date of 02/03/2022 with diagnoses including
neuralgia and neuritis, morbid obesity, edema, cerebral infarction due to thrombus of left middle vertebral artery, hemiplegia affecting left non-dominant side, and major depressive disorder
Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Further review of the MDS revealed resident #1 has a history of behavioral symptoms.
Review of resident #1's care plan dated 10/22/2023 revealed resident had episodes of verbal and physical abuse towards staff and resident. Interventions included the following: try to keep residents separated to minimize chances of altercation, previous interventions included the following: confront abusive behaviors as such, encourage resident to verbalize feelings instead of acting out, social services to have 1 on 1 conversation with resident regarding behavior, be firm, calm and forceful in all communications or interaction with resident, if resident continue behaviors be looking for alternate placement such as behavioral unit. Further review of the care plan revealed resident uses profanity, altered sexuality pattern related to safe sex practices and lack of privacy, and inappropriate sexual behavior.
Review of the incident report for resident #1 dated 11/16/2023 revealed it was reported by staff that resident was kicked and put in a headlock by another resident. The incident continued outside where resident #1 spit on another resident and kicked him. Follow Up Assessment of Accidents/Incidents revealed no new orders received.
An interview on 12/11/2023 at 9:45 a.m. with resident #1 revealed that he did have an altercation with resident #2 sometime last month. Resident #1 reported he went to the movies at the facility, and he was sitting in his wheelchair at the door and resident #2 kicked his wheelchair. Resident #1 reported he tried to hit resident #2 but he swung his fist and missed him. Reported resident #2 put both his hands around his neck and Activity Director broke them up and separated them. Resident #1 reported both residents went out to smoke within minutes of this incident and him and resident #2 continued to have words in smoking area, but denied there was any spitting/hitting/kicking between the 2 residents while in smoking area. Resident #1 reported he had no injuries from the altercation. Resident #1 reported he was counselled by the Administrator. Resident #1 reported no issues with resident #2 since the altercation occurred.
Resident #2:
Review of the record for resident #2 revealed an admission date of 05/27/2016 with diagnoses including Human Immunodeficiency Virus (HIV) disease, hypertension, cerebrovascular accident, hemiplegia and hemiparesis, tobacco use, and transient cerebral ischemic attack.
Review of the MDS dated [DATE] revealed a BIMS score of 15 indicating cognitively intact.
Review of the resident #2's care plan dated 11/16/2023 revealed an altercation with another resident on 11/16/2023 and interventions included to separate residents at 1st sign of any distress and try to talk to residents and settle their differences peacefully.
Review of Incident Report for resident #2 dated 11/16/2023 revealed that resident #2 and another resident exchanged words and started a fight between them. Resident #2 reported he was not hit, and had no injuries.
An interview on 12/11/2023 at 9:55 a.m. with resident #2 revealed that he did have an altercation with resident #1 last month. Resident #2 reported he went to movie, and resident #2 was asleep in the doorway and he tried to wake up resident #1 so he could move through doorway. Resident #2 reported resident #1 swung a fist at him and missed, then he wrapped his hands around resident #1's neck and the Activity Director broke them up and separated them. Resident #2 reported within a few minutes of this incident, both residents went to the smoking area and resident #1 tried to spit on him and was cursing at him, but denied any kicking, spitting, or hitting in smoking area.
An interview on 12/11/2023 at 2:00 p.m. with S3Activity Director revealed the altercation between resident #1 and resident #2 occurred in chapel after the movie on 11/16/2023. Resident #1 was blocking the door, resident #2 told him to move, then resident #2 kicked resident #1's wheelchair, then resident #1 swung at resident #2 and hit him in the chest with his forearm. S3Activity Director separated both residents by taking resident #1 outside to the smoking area, and she reported that resident #2 followed them outside. S3Activity Director reported that S4Housekeeper was in the smoking area and she told her to keep these 2 residents separated because they just had an altercation during activity. S3Activity Director reported she saw the nurse on her way back in to get the rest of the residents from the chapel and she notified the nurse at that time. S3Activity Director reported she did leave both residents in the smoking area with a housekeeper immediately following an altercation.
An interview on 12/11/2023 at 2:10 p.m. with S4Housekeeper revealed on 11/16/2023 she was in the smoking area awaiting her ride to pick her up. S4Housekeeper reported S3Activity Director brought out resident #1 to the smoking area, and resident #2 followed behind them. S3Activity Director told her to keep these 2 residents separated due to having an altercation in activity a few minutes ago. S4Housekeeper reported that resident #1 spit on resident #2 but missed him, and resident #1 kicked resident #2's foot, and tried to spit on him again but missed again. Resident #1 was cussing at resident #2 while they were in the smoking area. S4Housekeeper reported the nurse came out and she spoke to the residents and resident #2 went inside.
An interview on 12/11/2023 at 2:20 p.m. with S1Administrator confirmed that resident #1 and resident #2 were not immediately separated following the 1st altercation but were allowed to be in the smoking area together within minutes of incident.
An interview on 12/12/2023 at 11:20 a.m. with S2DON confirmed that the S3Activity Director should not have left resident #1 and resident #2 in the smoking area together with off duty housekeeper immediately after the altercation occurred.
An interview on 12/12/2023 at 12:00 p.m. with S1Administrator confirmed that S3Activity Director should not have left resident #1 and resident #2 in smoking area together with off duty housekeeper immediately following the altercation.
Sept 2023
8 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to implement the plan of care and follow policy and procedures related to resident refusal of medication. The facility failed to ensure nursin...
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Based on record review and interview, the facility failed to implement the plan of care and follow policy and procedures related to resident refusal of medication. The facility failed to ensure nursing staff reported resident refusal of treatment to their supervisor, director of nurses, physician, or responsible party for 1 (#14) of 23 sampled residents.
Findings:
Review of the Refusal of Treatment Policy and Procedure revealed in part the following:
-when resident refuses a medication, the refusal is to be immediately reported to the witnessing employee's supervisor and the exact refusal documented in the resident's clinical record; and
-the physician will be notified as per pharmacy policies and procedures upon refusal of medication, and nurse will inform the DON, Medical Doctor, and responsible party as necessary.
Review of the record for resident #14 revealed a readmit date of 10/21/2022 with diagnoses including human immunodeficiency virus, pressure ulcer of sacral region stage 4, and type 2 diabetes mellitus.
Review of the Annual Minimum Data Set for resident #14 revealed a Brief Interview of Mental Status score of 15 indicating she was cognitively intact.
Review of the current care plan dated 06/12/2018 revealed altered blood sugars related to diabetes mellitus, interventions included administer medications as ordered.
Review of the September 2023 (current) Physician's Orders revealed an order dated 10/21/2022 for Lantus Solostar Pen 100 units/3milliliters give 22 units into skin nightly.
Review of the August 2023 Medication Administration Record (MAR) revealed the following:
-No documented evidence that resident #14 was administered Lantus Solostar Pen 100 unit/milliliters 22 units into skin nightly for the month of August.
Review of the September 2023 MAR revealed the following:
-No documented evidence that resident #14 was administered Lantus Solostar Pen 100 unit/milliliters 22 units into skin nightly from 09/01/2023-09/18/2023.
Review of the August 2023 Nurses Notes revealed no documentation of the following:
-resident #14's refusal of Lantus in clinical record; and
-notifying supervisor regarding resident #14's refusal of medications (Lantus); and
-notifying physician regarding resident #14's refusal of medications (Lantus).
An interview on 09/20/2023 at 9:20 a.m. with S1 Director of Nursing (DON) confirmed the following:
-No documented evidence that resident #14 was administered Lantus 22 units nightly from 08/01/2023 through 09/18/2023; and
-No documented evidence in the clinical record that nurses documented resident #14 refusing medication (Lantus) from 08/01/2023 through 09/18/2023; and
-No documented evidence that the nurses notified supervisor, Director of Nursing, physician, or responsible party of resident #14's refusal of medication (Lantus).
An interview on 09/20/2023 at 11:05 a.m. with S2 DON confirmed the nurses failed to follow the facility's policy and procedure for Refusal of Treatment for resident #14 by failing to:
-Document in resident #14's clinical record refusal of medication (Lantus); and
-Notify supervisor, DON, physician, or responsible party of resident #14's refusal of medication (Lantus).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
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 pharmacist failed to identify irregularities to the attending physician and the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the pharmacist failed to identify irregularities to the attending physician and the facility's medical director and director of nursing for 2 (#14, #40) of 7 (#6,#9,#11,#14,#18,#34,#40) sampled residents reviewed for unnecessary medications and insulin administration.
Findings:
Resident #14
Review of the record for resident #14 revealed a readmit date of 10/21/2022 with diagnoses including human immunodeficiency virus, pressure ulcer of sacral region stage 4, and type 2 diabetes mellitus.
Review of the September 2023 (current) Physician's Orders revealed an order dated 10/21/2022 for Lantus Solostar Pen 100 units/3milliliters- give 22 units into skin nightly (9PM).
Review of the August 2023 Medication Administration Record (MAR) revealed no documentation of Lantus (insulin) Solostar Pen 100 units/milliliters 22 units into skin nightly from 08/01/2023 through 08/29/2023.
Review of the Pharmacy Consultant Review dated 08/29/2023 revealed pharmacist reviewed resident #14's chart and documented no irregularities. Further review revealed no documentation that pharmacist notified the facility, DON, or medical director regarding resident #14 not receiving Lantus 22 units during the month of August 2023.
An interview on 09/20/2023 at 9:20 a.m. with S1Director of Nursing (DON) confirmed that there was no documentation of administration of Lantus (insulin) administered during August 2023. S1DON further confirmed no documentation by pharmacy consultant on monthly drug regimen review to notify the facility, DON, or medical director that resident #14 did not receive Lantus (insulin) during August 2023.
Resident#40
On 09/19/23 at 08:09 a.m., Resident # 40 was observed sleeping in his bed with the television turned on. His feet were underneath the covers so I was unable to observe feet for edema.
On 09/19/23 at 02:01 p.m., resident # 40 was observed in his room. Socks were on both of resident #40's feet but his feet did not to appear to be grossly swollen.
Record review revealed Resident # 40 was re-admitted to the facility on [DATE] with diagnoses that included alcoholic cardiomyopathy, respiratory failure, congestive heart failure (CHF), chronic kidney disease, anemia, alcohol abuse, and syphilis.
Review of the most recent minimum data set minimum data set (MDS) dated [DATE] revealed in section C -Cognitive Status- a brief interview of mental status (BIMS) score could not be obtained due to memory problems and his cognitive skills related to daily decision making was moderately impaired.
Review of active orders for September and August 2023 included an order for Lasix 40 milligrams (mg) by mouth daily.
Review of medication administration record (MAR) for August and September 2023 revealed Lasix 40 mg had been given daily as ordered with no record of edema monitoring in the medical record.
Review of the monthly medication regimen review for August 2023 revealed no record of the licensed pharmacist reporting edema was not being monitored to the medical director or director of nurses while Lasix was being administered to Resident #40.Review of care plans revealed an active care plan initiated on 05/11/2023 for decreased cardiac output related to CHF. The goal was listed for Resident # 40 to experience little or no edema. An approach to the CHF care plan was for staff to check edema every day for signs of edema.
On 09/20/23 at 09:50 a.m., an interview with S2 Director of Nurses (DON) confirmed Resident # 40 was not monitored but should have been monitored for edema while receiving a diuretic. S2 DON also confirmed the pharmacy consultant did not report the failure to monitor the edema in the monthly medication regimen review for the month of August 2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate monitoring was recorded for 1(#40) of ...
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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 monitoring was recorded for 1(#40) of 5(#9,#11,#18,#34,#40) residents reviewed for unnecessary medications.
On 09/19/23 at 02:01 p.m., Resident # 40 was observed in his room. Socks and shoes were on both of Resident # 40`s feet. Resident #40 was not sure if his feet had swelling.
Record review revealed Resident # 40 was re-admitted to the facility on [DATE] with diagnoses that included alcoholic cardiomyopathy, respiratory failure, congestive heart failure (CHF), chronic kidney disease, anemia, alcohol abuse, and syphilis.
Review of the most recent minimum data set minimum data set (MDS) dated [DATE] revealed in section C -Cognitive Status- a brief interview of mental status (BIMS) score could not be obtained due to memory problems and his cognitive skills related to daily decision making was moderately impaired.
Review of active orders for September and August 2023 included an order for Lasix 40 milligrams (mg) by mouth daily.
Review of medication administration record (MAR) for August and September 2023 revealed Lasix 40 mg had been given daily as ordered with no record of edema checks in the medical record.
Review of the monthly medication regimen review revealed no record of the licensed pharmacist reporting edema was not being monitored while Lasix was being administered.
Review of care plans revealed an active care plan initiated on 05/11/2023 for decreased cardiac output related to CHF. The goal was listed for Resident # 40 to experience little or no edema. An approach to the CHF care plan was for staff to check edema every day for signs of edema.
On 09/20/23 at 09:50 a.m., an interview with S2 Director of Nurses (DON) confirmed Resident # 40 should have been monitored for edema while receiving a diuretic as directed by the plan of care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of five percent or greater by ...
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Based on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of five percent or greater by committing 5 errors out 29 opportunities for an error rate of 17.24%. Findings:
Observation of the medication pass on 09/19/2023 at 9:40 a.m. for resident #11 revealed the following medication errors.
1. Arthrotec, (non-steroidal, anti-inflammatory medication) 50mg (milligrams), 1 tablet per Peg Tube (Percutaneous Endoscopic Gastrostomy) twice daily. This medication was not administered.
Review of the September 2023 physician orders for resident #11 revealed an order for Arthrotec 50mg, 1 tablet per PT (Peg Tube) twice daily.
Interview on 09/19/2023 at 2:55 p.m. with S6LPN (Licensed Practical Nurse) confirmed that she did not administer the medication Arthrotec to resident #11.
2. Liquid Protein, 30 cc (cubic centimeter) per Peg Tube twice daily. This supplement was not administered.
Review of the September 2023 physician orders for resident #11 revealed an order for Liquid Protein, 30 cc's, per Peg Tube twice daily.
Interview on 09/19/2023 at 2:55 p.m. with S6LPN confirmed this supplement was not administered.
3. Observation of medication pass for resident #11 on 09/19/2023 at 9:40 a.m. revealed S6LPN administered Docusate Sodium, (stool softener), 50mg (milligram)/5ml(milliliter), 5ml only for total of 50mg.
Review of the September 2023 physician orders revealed an order to administer Docusate Sodium 100mg, 1 tablet per PT three times daily.
Interview on 09/19/2023 at 2:55 p.m. with S6LPN confirmed that she administered Docusate Sodium Liquid, 50mg/5ml, 5 ml only for total of 50mg.
4. Observation of the medication pass for resident #11 on 09/19/2023 at 9:40 a.m. revealed S6LPN administered Lactulose (laxative) 10grams/15ml, 10 ml per Peg Tube.
Review of the September 2023 physician orders revealed an order to administer for Lactulose, 10 grams/15ml, give 15 ml every day.
Interview on 09/19/2023 at 2:55 p.m. with S6LPN confirmed that she administered Lactulose 10 grams/15ml, 10 ml instead of ordered 15ml.
5. Observation of the medication pass for resident #11 on 09/19/2023 at 9:40 a.m. revealed S6LPN administered the antipsychotic medication Haldol, 1mg, 1 tablet via Peg Tube.
Review of the September 2023 physician orders for resident #11 revealed an order for Haldol 0.5mg, 1 tablet per Peg Tube every morning.
Interview on 09/19/2023 at 2:55 p.m. with S6LPN confirmed that she administered Haldol 1mg tablet instead of Haldol 0.5mg tablet.
Interview on 09/19/2023 at 3:30 p.m. with S2DON, (Director of Nursing) confirmed that medications are to be administered as ordered. S2 DON was informed of all medication errors at this time.
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 observations, review of the dietary menu, and interviews, the facility to ensure the menu was followed for 6 (#4, #8, #9, #19, #27, and #38) of 6 (#4, #8, #9, #19, #27, and #38) residents who...
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Based on observations, review of the dietary menu, and interviews, the facility to ensure the menu was followed for 6 (#4, #8, #9, #19, #27, and #38) of 6 (#4, #8, #9, #19, #27, and #38) residents who were ordered a pureed diet and received their meals from the kitchen.
The facility failed to ensure that mustard greens and cornbread were pureed, available, and offered to the residents with orders for a pureed diet and who received their meals from the kitchen during the lunch service.
Findings:
Review of the physician orders list revealed residents #4, #8, #9, #19, #27, and #28 were ordered pureed diets. Further review revealed there was no evidence of a reason why the residents should not have pureed mustard greens and pureed cornbread.
Review of the dietary menu dated 09/18/2023 revealed the lunch service was to consist of chili beans, creamed potatoes, oven roasted chicken, mixed vegetables, mustard greens, cornbread, and cake.
On 09/18/2023 at 11:45 a.m., observation during the lunch service revealed there was no pureed mustard greens and pureed cornbread on the steam table and /or stove. Further observations during the preparing and serving of the meal (lunch) trays revealed residents #4, #8, #9, #19, #27, and #38's revealed the residents were not served pureed mustard greens and pureed cornbread. S5Dietary [NAME] confirmed she had not prepared and pureed the mustard greens and cornbread as part of the lunch meal and further confirmed the foods were not available and offered to the residents who were ordered a pureed diet.
On 09/20/2023 at 2:50 p.m., S1Administrator and S2Director of Nursing were notified of the findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to store, prepare, and distribute in a sanitary manner. The facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to store, prepare, and distribute in a sanitary manner. The facility failed to:
1) ensure that foods including ice for resident consumption was stored a refrigerator, deep freezer, and /or ice machine;
2) ensure foods stored in the refrigerator and deep freezer were properly sealed and not exposed to air;
3) ensure the kitchen cabinet doors were cleaned; and,
4) ensure that foods brought into the facility by visitors were not stored inside of the kichen deep freezer.
According to review of the Physician Orders List provided by S3Dietary Manager, there was a total of 36 residents that received a meal from the kitchen and could be affected by the above mentioned failed practice.
Findings:
On 09/18/2023 at 8:20 a.m., observations during the initial tour with S3Dietary Manager, revealed there was old spillage, splatters, and a build-up of grime on the cabinet doors that were located next to the dishwashing machine. One large manual can opener was observed with a thick layer of grime on the top of the blade. One large key ring containing multiple keys was observed laying on and in direct contact with a food preparation table. An [NAME] book, hand fan, word search book was stored inside of a bin that contained the Safety Data Sheets. One large container of pudding that was opened without a label with an datethe container was opened. Further observations revealed a refrigerator, located in an outside storage room with old spillage of liquids and food particles.
Observation further revealed a deep freezer located next to the refrigerator with a layer of a dark black unknown substance that looked to be black mold. The substance was observed on the deep freezer where the top door sealed with the bottom part to the freezer. Further observations revealed one large bag of biscuits, one large bag of rolls, and one bag of sliced pepperoni. The biscuits, rolls, and pepperoni bags were open and the foods were exposed to air with the pepperoni spilling out of the bag and into the deep freezer. Observation further revealed one box of ice cream bars that was open and some of the contents had spread to a large and thick build-up of ice to the side of the freezer. The ice build-up was observed throughout the deep freezer.
After the observations were completed, S3Dietary Manager confirmed the kitchen, including the equipment, needed to be cleaned. S3Dietary Manager also confirmed personal items and foods brought in from visitors should not be stored in the kitchen and /or deep freezer, the opened foods were not properly sealed and the foods should not have been exposed to air.
On 09/18/2023 at 2:51p.m., an observation revealed S4Dietary retrieving ice from the ice machine that was located in the dining room. She removed the ice, placed it inside of a pan and then took it into the kitchen. S4Dietary then placed cans of Ensure, and [NAME] on top of the ice. She confirmed the drinks were available for resident consumption. Observation of the ice machine revealed a black, unknown substance that looked to be mold located inside of the ice machine in various places. Further interview with S4Dietary revealed she did had not noticed the black substance in the machine. She confirmed the machine was dirty and needed to be cleaned.
On 09/20/2023 at 2:50 p.m., S1Administrator and S2Director of Nursing were notified of the findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to electronically submit complete and accurate direct care staffing information, based on payroll, to Centers for Medicare and Medicaid Service...
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Based on record review and interview the facility failed to electronically submit complete and accurate direct care staffing information, based on payroll, to Centers for Medicare and Medicaid Services (CMS) as required.
Findings:
Review of the PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 3 2023 (April 1-June 30) revealed triggers for the following: Failed to have licensed nursing coverage 24 hours/day.
Review of the time and work schedules revealed there were temporary (Temp) workers noted as Licensed Practical Nurses, worked on the dates of 04/01/2023, 04/02/2023, 04/08/2023, 04/09/2023, and 05/06/2023. The dates worked were confirmed by review of the worker's time sheets.
On 09/19/2023 at 4:00 p.m., interview with S1Administrator revealed that he (S1Administrator) was responsible for submitting the facility's PBJ information for the nursing staff which included the temporary (Temp) workers for the FY Quarter 3 2023 in April 2023 and May 2023. S1Administrator confirmed he had not included the temporary nursing staff when he submitted the PBJ information for FY Quarter 3 2023 and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Review of the personnel record for S7CNA revealed a hire date of 10/26/2022. Further review revealed no documentation of dementia training.
An interview on 09/20/2023 at 1:00 p.m. with S1Administrato...
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Review of the personnel record for S7CNA revealed a hire date of 10/26/2022. Further review revealed no documentation of dementia training.
An interview on 09/20/2023 at 1:00 p.m. with S1Administrator revealed S7CNA has not completed dementia training since she was hired. S1Administrator confirmed S7CNA should have been provided required in-service training that included dementia training.
Based on review of the personnel records, training records, and interviews, the facility failed to provide the required in-service training for nurse aides that included dementia management training for 6 (S7CNA, S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA) of 6 Certified Nursing Assistants (CNA) (S7CNA, S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA) reviewed for dementia care training.
Findings:
Review of the personnel records revealed the following:
S8CNA's date of hire: 07/27/2023;
S9CNA's date of hire: 05/30/2023;
S10CNA's date of hire: 08/22/2016;
S11CNA's date of hire: 09/08/2023; and,
S12 CNAs date of hire: 06/10/2022.
Review of the personnel and training records revealed there was no documented evidence of S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA being provided with dementia management training.
On 09/20/2023 at 2:10 p.m. S1Administrator reported that he was responsible for providing dementia care management training to the CNA staff. He confirmed the last time he had provided S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA with dementia management training was December 2021.
Aug 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhanc...
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Based on observation and interview, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#6 and #145) of 2 (#6 and #145) residents reviewed for dignity. Resident #6 and #145 were pulled backwards in their gerichairs down the hall.
Findings:
Observation on 08/16/2022 at 8:20AM revealed S9Speech Therapist (ST) was pulling resident #145 backwards in her gerichair down the hall to the therapy room.
Observation on 08/16/2022 at 8:35AM revealed S9ST was pulling resident #6 backwards in her gerichair down the hall to the therapy room. Interview at this time with S10 Licensed Practical Nurse(LPN) revealed S9ST should not pull residents backwards in their gerichairs down the hall.
An interview with S9ST on 08/17/2022 at 10:45AM confirmed she pulled resident #145 and resident #6 backwards down the hall to the therapy room. She reported that since then she has been instructed to not pull the residents' backwards in their gerichairs.
During an interview with S2DON (Director of Nursing) on 08/17/2022 at 11:00AM, was notified that S9ST pulled resident #6 and #145 backwards in their gerichairs down the hall.
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** Resident #14
Review of the medical record for resident #14 revealed the resident was admitted on [DATE] with diagnoses of diabet...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #14
Review of the medical record for resident #14 revealed the resident was admitted on [DATE] with diagnoses of diabetes, gastronomy, cerebrovascular disease, chronic pain, hypertension, cerebral infarction affecting right dominant side, legal blindness, vascular dementia, and aphasia.
Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required total assistance for all activities of daily living.
Review of the physician orders dated August 2022 revealed an order for morning/evening/bedtime care for grooming, oral care, shampoo, hygiene, nail care, skin care, and appropriate dressing.
Review of the record revealed the following care plan: requires total assistance with activities of daily living - staff to perform for resident bathing, dressing, feeding, clothes changes, oral care, hair, nail care, transfers and locomotion.
Observations on 08/15/2022 at 10:00AM and 08/16/2022 at 9:30AM revealed the resident was up in his gerichair in his room and his fingernails were long.
An interview on 08/17/2022 at 9:00AM with S7Certified Nursing Assistant reported that the wound care nurse trims all of the residents' fingernails.
Observation on 08/17/2022 at 9:30AM with S3Wound Care Nurse of resident #14's fingernails revealed the resident had long fingernails. An interview at this time revealed the resident's fingernails need to be trimmed.
During an interview on 08/17/2022 at 11:00AM, S2Director of Nursing was notified of resident #14's long fingernails.
Resident #42
Review of the medical record for resident #42 revealed the resident was admitted on [DATE] with diagnoses of epilepsy, hypertensive chronic kidney disease stage III, hemiplegia affecting right dominant side, diabetes, obstructive sleep apnea, and viral encephalitis.
Review of the Minimum Data Set, dated [DATE] revealed the resident was independent with cognitive skills for daily decision making. The resident required one person extensive assistance with personal hygiene.
Review of the physician orders dated August 2022 revealed an order for morning/evening/bedtime care for grooming, oral care, shampoo, hygiene, nail care, skin care, and appropriate dressing.
Observations on 08/15/2022 at 9:30AM and 08/16/2022 at 8:00AM revealed the resident was up in his wheelchair and his fingernails were long.
An interview on 08/17/2022 at 9:00AM with S7 Certified Nursing Assistant reported that the wound care nurse trims all of the residents fingernails.
Observation on 08/17/2022 at 9:45AM with S3 Wound Care Nurse of resident #42's fingernails revealed the resident had long fingernails. An interview at this time revealed the resident's fingernails need to be trimmed.
During an interview on 08/17/2022 at 11:00AM, S2Director of Nursing was notified of resident #42's long fingernails.
Based on observation, record review, and interview, the facility failed to ensure residents who were unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to ensure resident's fingernails were cleaned and trimmed in a timely manner for 3 (#14, #37, #42) of 3 (#14, #37, #42) residents reviewed for activities of daily living.
Findings:
Resident #37
Review of the medical record for sampled resident #37 revealed diagnoses of muscle wasting, hypocalcemia, schizophrenia, Alzheimer's disease, hyperlipidemia, malaise, abnormality of gait, and mobility, neuralgia, intracranial injury, and epilepsy.
Review of the physician orders dated August 2022 revealed an order for morning/evening/bedtime care for grooming, oral care, shampoo, hygiene, nail care, skin care, and appropriate dressing.
Review of the careplan dated 11/18/2014 revealed the resident required extensive assistance with activities of daily living. Staff are to assist resident with bathing, dressing, oral, hair, and nail care.
Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident had moderate cognitive impairment for daily decision making and required one person extensive assistance for hygiene and required one person total assistance for bathing.
On 08/15/2022 at 11:42AM, 08/16/2022 at 10:30AM, and 08/17/2022 at 9:10AM observations of resident #37 revealed he had long fingernails.
On 8/17/2022 at 9:45AM an interview with S3Wound Care Nurse confirmed resident #37's nails needed to be trimmed.
On 8/17/2022 at 11:00AM S2Director of Nursing (DON) was informed of resident #37's nails needed to be trimmed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 staff had the appropriate competencies and skill sets to prov...
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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 staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nursing staff were competent to transfer residents with the Hoyer lift after resident #3 fell out of the lift by not inservicing staff regarding the use of the Hoyer lift. This deficient practice had the potential to affect 14 residents that currently require transfers using the Hoyer lift. Findings:
Review of the medical record revealed diagnoses of pathological fracture, constipation, idiopathic gout, hypertension, hypothermia, altered mental status, elevated lactic acid levels, and depression.
Review of the careplan revealed the resident required assistance with bathing, dressing, feeding, transfers and locomotion.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had independent cognitive skills for daily decision making and was totally dependent with one person assistance for bed mobility, dressing, eating, toileting, hygiene and bathing. Further review of the MDS revealed the resident was totally dependent for transfers with two person assistance.
Review of the Incident/Accident Report dated 05/22/2022 at 10:20PM revealed the resident was being transferred from the wheelchair to the bed with 3 person assistance with the Hoyer lift. The resident flipped out of the Hoyer lift sling and fell onto the floor.
On 8/16/22 at 3:40PM an interview with S8Licensed Practical Nurse (LPN) revealed she worked with the resident the night of the incident on 05/22/2022. S8LPN revealed she and 2 Certified Nursing Assistants (CNA) were assisting the resident in the Hoyer lift and once they had the resident in the lift, the resident leaned forward and fell on the floor.
On 8/17/22 at 10:15AM an interview with S1Administrator and S2Director of Nursing (DON) revealed they verbally inserviced the employees involved in the incident on 05/22/2022 but the facility did not conduct an inservice with all of the employees after the resident fell from the Hoyer lift.
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 review of the resident council minute meetings and interviews, the facility failed to organize resident group meetings in the facility. This deficient practice had the potential to affect 40 ...
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Based on review of the resident council minute meetings and interviews, the facility failed to organize resident group meetings in the facility. This deficient practice had the potential to affect 40 residents residing in the facility.
Findings:
On 08/15/2022 at 10:02AM interview with S5Certified Nursing Assistant (CNA) revealed she was the Activity Director until January 2022. S5CNA revealed they have not had a resident council meeting since the beginning of COVID-19 pandemic but they still have a resident council president. Further interview with S5CNA revealed she was unable to locate the minutes from the last resident council meeting.
On 08/15/20222 at 10:15AM interview with S6Licensed Practical Nurse (LPN) revealed she helped with activities until they recently placed a staff member over the activity department. S6LPN revealed she was unaware of the last resident council meeting that was conducted with the residents.
On 8/16/2022 at 3:00PM interview with S2Director of Nursing (DON) revealed they have not had resident council meetings due to the COVID-19 pandemic.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to prevent and contain COVID-19 by:
1.)
Not ensuring the facility staff vaccination rate was 100% (current rate was 98%),
2.)
Not developing...
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Based on interview and record review the facility failed to prevent and contain COVID-19 by:
1.)
Not ensuring the facility staff vaccination rate was 100% (current rate was 98%),
2.)
Not developing and/or implementing policy and procedure to address staff refusals for COVID-19 testing and tracking proper screening of staff upon entry to facility, and
3.)
Having a COVID-19 outbreak in the facility from 06/23/2022 - 08/10/2022 with 24 residents testing positive for COVID-19.
Findings:
1. On 08-15-2022 at 8:00AM, an interview was conducted with S2 DON (Director of Nursing). She reported current census is 40 residents with 11 residents (#2, 22, 33, 31, 41, 9, 15, 38, 26, 39, 42) positive for COVID-19. She stated no deaths or hospitalizations of residents related to COVID-19 had occurred during this recent outbreak from 06-23-2022 to 08-10-2022. S2 DON further reported that all residents have been vaccinated and that all but one staff, S4 CNA (Certified Nursing Assistant), have been vaccinated.
Review of the COVID-19 Staff Vaccination Status Matrix form for the facility revealed 64 employees, with 63 employees completely vaccinated and one staff, S4 CNA (Certified Nursing Assistant) with no documentation of vaccination status and/or exemption.
Review of the personnel file for S4 CNA revealed date of hire of 06-12-2022. No was no information in the personnel file regarding vaccination status and/or exemption. S4 CNA's personnel file also had no information regarding COVID policies and/or testing for COVID.
On 08-15-2022 at 1:00PM, an interview was conducted with S2 DON (Director of Nursing). She confirmed that staff S4 CNA (Certified Nursing Assistant) date of hire was 06-12-2022. She further stated that S4 CNA had not been vaccinated and/or completed an exemption. S2 DON stated that S4 CNA has declined all COVID testing since she has been employed with the facility.
2. Review of the Facility's COVID-19 staff testing records revealed that the facility has been testing residents and staff twice weekly since 06-17-2022. Further review of COVID-19 testing records confirmed that S4 CNA has not tested since employed with the facility on 06-12-2022.
On 08-15-2022 at 4:00PM, an interview was conducted with S2 DON. S2 DON stated that S4 CNA has declined all COVID testing since she has been employed with the facility. S2 DON further stated that S4 CNA had continued to provide direct care although she is not vaccinated and has refused to be tested. S2 DON confirmed that the community transmission rate is currently at a high level for COVID-19.
On 08-15-2022 at 4:40PM, an interview was conducted with S4 CNA. She confirmed that her date of hire was 06-12-2022. She further stated she had not been vaccinated and/or completed the exemption form until today, 08-15-2022, when she arrived to work for the evening shift. She also confirmed that she has not been tested since she has been employed at the facility. She stated she has been asked by S2 DON to be tested, but had declined.
On 08-16-2022 at 10:00AM, an interview was conducted with S2 DON. She revealed that all staff are to complete COVID screening prior to beginning their work shift. She stated that when reporting to work you must sign in, take your temperature, and answer the COVID questions in the blue binder located on the side table by the couch in the lobby area. She further stated if staff does not complete the COVID screening, they are not to clock in.
Review of the COVID-19 employee screening form revealed from 06-12-2022 to 08-15-2022 no evidence that S4 CNA had documented any self-screening information as per facility policy.
On 08-16-2022 at 2:40PM, an interview was conducted with S4 CNA. She stated that she had not been self-screening for COVID-19 prior to beginning her shift.
Review of the policy and procedures for COVID vaccination for staff and residents: Policy - It is the policy of the facility for all employees (except those pending or granted requests for exemptions/temporarily delayed) receive at a minimum, one dose of COVID-vaccine prior to providing care/treatment/services for the facility and/or residents.
A process will be in place to ensure that all staff (except those who have been granted an exemption or have a temporary delay) are fully vaccinated for COVID-19.
The Facility's policy and procedure also continued with: Requiring at least weekly testing for staff who have not completed their primary vaccination series (including those who have pending requests or been granted an exemption, or a temporary delay) for or until the regulatory requirement is met. Weekly testing should be conducted in the facility or services site regardless of the level of community transmission.
Track and securely document staff who have requested or have been granted an exemption by the facility for COVID-19 vaccination.
Track/secure documentation of delayed staff vaccination for clinical precautions/considerations and:
Contingency plans for staff that are not fully vaccinated for COVID-19
Document the actions the facility will take when staff indicate they will not get vaccinated and do not qualify for an exemption.
3. Review of the Facility's COVID-19 resident testing data revealed the following residents were positive for COVID-19 from 06-23-2022 through current date of 08-17-2022. The list below includes the date each resident tested positive for COVID-19:
1. Resident #44: 06-23-2022
2. Resident #37: 07-01-2022
3. Resident #21: 07-01-2022
4. Resident #6: 07-04-2022
5. Resident #16: 07-06-2022
6. Resident #35: 07-22-2022
7. Resident #5: 07-22-2022
8. Resident #145: 07-29-2022
9. Resident #30: 08-03-2022
10. Resident #25: 08-03-2022
11. Resident #13: 08-03-2022
12. Resident #29: 08-03-2022
13. Resident #42: 08-04-2022
14. Resident #39: 08-04-2022
15. Resident #26: 08-05-2022
16. Resident #19: 08-05-2022
17. Resident #22: 08-08-2022
18. Resident #38: 08-09-2022
19. Resident #2: 08-09-2022
20. Resident #15: 08-09-2022
21. Resident #9: 08-09-2022
22. Resident #33: 08-09-2022
23. Resident 41: 08-09-2022
24. Resident #31: 08-10-2022
On 08-17-2022 at 3:00PM, an interview was conducted with S1 Administrator and S2 DON. Both staff confirmed that the COVID-19 vaccination policy does not address staff who are not vaccinated and refuse testing. Further interview confirmed that S4 CNA has not been vaccinated and that an exemption was not obtained until 08-15-2022. In addition, S4 CNA had not been self-screening for COVID prior to beginning work and had not tested for COVID-19 until 08-15-2022 at approximately 5:00PM.
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
- • 28% annual turnover. Excellent stability, 20 points below Louisiana's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $139,954 in fines. Review inspection reports carefully.
- • 33 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $139,954 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (14/100). Below average facility with significant concerns.
Bottom line: Trust Score of 14/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Mary Goss's CMS Rating?
CMS assigns MARY GOSS NURSING HOME 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 Mary Goss Staffed?
CMS rates MARY GOSS NURSING HOME's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 28%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Mary Goss?
State health inspectors documented 33 deficiencies at MARY GOSS NURSING HOME during 2022 to 2024. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) 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 Mary Goss?
MARY GOSS NURSING HOME is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 91 certified beds and approximately 37 residents (about 41% occupancy), it is a smaller facility located in MONROE, Louisiana.
How Does Mary Goss Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, MARY GOSS NURSING HOME's overall rating (2 stars) is below the state average of 2.4, staff turnover (28%) 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 Mary Goss?
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 Mary Goss Safe?
Based on CMS inspection data, MARY GOSS NURSING HOME has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Mary Goss Stick Around?
Staff at MARY GOSS NURSING HOME tend to stick around. With a turnover rate of 28%, the facility is 18 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.
Was Mary Goss Ever Fined?
MARY GOSS NURSING HOME has been fined $139,954 across 18 penalty actions. This is 4.1x the Louisiana average of $34,478. 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 Mary Goss on Any Federal Watch List?
MARY GOSS NURSING HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.