Legacy Nursing and Rehabilitation of Morgan City
For profit - Corporation
88 Beds
LEGACY NURSING & REHABILITATION
Data: November 2025
Trust Grade
0/100
#221 of 264 in LA
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Legacy Nursing and Rehabilitation of Morgan City has received a Trust Grade of F, indicating significant concerns about the facility's performance. Ranking #221 out of 264 nursing homes in Louisiana places it in the bottom half, and #2 out of 3 in St. Mary County means there is only one local option that is better. The facility's trend is worsening, with issues increasing from 6 in 2024 to 11 in 2025, highlighting ongoing problems. Staffing is a significant weakness, rated at just 1 out of 5 stars, with a high turnover rate of 66%, which is concerning compared to the state average of 47%. In terms of incidents, there have been serious issues such as a resident being verbally abused by another resident, which caused emotional distress, and two residents sustaining first-degree burns from unsupervised hot coffee spills. Additionally, there were concerns about expired medications being available and improper documentation of medication administration, raising questions about the quality of care. Overall, while there may be some staff who care for residents, the numerous deficiencies and high turnover rate make this facility a risky choice for families.
- Trust Score
- F
- In Louisiana
- #221/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 66% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $97,995 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 9 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.
0/100
Bottom 17%
Review needed
6 → 11 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 11 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 66%
19pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $97,995
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: LEGACY NURSING & REHABILITATION
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (66%)
18 points above Louisiana average of 48%
The Ugly 33 deficiencies on record
2 actual harm
Aug 2025
9 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to protect a resident's right to be free from verbal ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to protect a resident's right to be free from verbal and mental abuse by another resident for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse. This deficient practice resulted in an actual harm on 07/06/2025 at approximately 9:30PM, when Resident #15, a resident with known aggressive behaviors towards staff and other residents, was overheard by her roommate, Resident #30, during a telephone conversation where Resident #15 used racial slurs so loudly that Resident #30 overheard the conversation. On 07/07/2025 at approximately 2:30PM, Resident #30 was observed by staff crying. Resident #30 informed S9Certified Nursing Assistant (CNA) of the conversation that was overheard on 07/06/2025 when Resident #15 used racial slurs. Resident #15 who was in the room during the conversation reacted to S9CNA and Resident #30 by using racial slurs, cursing, and kicking the trash can. Resident #30 indicated this aggressive behavior caused her to be anxious, nervous, and unable to avoid Resident #15 because she was bed bound. Resident #30 further indicated she kept her grabber within reach and planned to use it to defend herself against any physical attacks from Resident #15. Resident #30 indicated she notified S3Social Services, S4Infection Preventionist, S5CNA, S6CNA, S7CNA, S8CNA, S9CNA, and S11Licensed Practical Nurse (LPN) that she was upset, felt anxious and depressed having to room with Resident #15. The facility failed to intervene on behalf of Resident #30. Findings:Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents; abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Further review revealed the safety of other residents and employees of the facility was the primary concern. Resident #30Review of Resident #30's MDS with an ARD of 05/07/2025 revealed, in part, Resident #30 was admitted to the facility on [DATE] and was African American. Further review revealed Resident #30 had a BIMS score of 13, which indicated Resident #30 was cognitively intact. Review revealed Resident #30 was dependent on staff for all activities of daily living. Resident #15Review of Resident #15's electronic medical record (EMR) revealed, in part, Resident #15 was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder and depression. Review of Resident #15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/2025 revealed, in part, Resident #15 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated Resident #15 had moderate cognitive impairment. Further review revealed Resident #15 was capable of propelling herself in her manual wheelchair.Review of Resident #15's admission packet from Resident #15's previous facility revealed, in part, a nurse's note dated 09/27/2024 which indicated Resident #15 became upset at another resident and stated that black mother f*cker. Review of Resident #15's Follow-Up Question Report documentation by Certified Nursing Assistants (CNA) dated 05/15/2025 through 07/07/2025 revealed, in part, Resident #15 had documented behaviors including screaming at others, agitation, cursing at others, expressing frustration and anger at others, spitting, and physical aggression towards others. Review of Resident #15's Social Service Progress Note dated 07/07/2025 at 5:41PM revealed, in part, S3Social Services documented the CNA reported that on 07/06/2025, Resident #15 was talking on the phone and stated her roommate was the devil. Further review revealed Resident #15 made derogatory comments about African Americans due to the way she was raised. Further review revealed Resident #15 would have a psychiatric evaluation. Review of Resident #15's Psychiatric Evaluation dated 07/08/2025 revealed, in part, Resident #15 was seen due to displaying verbal aggression. Further review revealed Resident #15 was started on buspirone hydrochloride (a medication used to treat anxiety) 5 milligrams by mouth every 12 hours. Further review revealed the Psychiatric Evaluation did not address the incidents from 07/06/2025 and 07/07/2025. Review of Resident #15's Follow-Up Question Report documentation by CNAs dated 07/08/2025 through 08/06/2025 revealed, in part, Resident #15 continued to have behaviors following Resident #15's psychiatric evaluation and medication initiation. Further review revealed Resident #15's documented behaviors included cursing at others, expressing frustration and anger at others, disruptive sounds, agitation, screaming at others, threatening others, pushing others, and entering other residents' personal space. Review of Resident #15's record revealed, in part, Resident #15 did not have any additional documented incidents of verbally or mentally abusing Resident #30 following the 07/06/2025 and 07/07/2025 incidents. There was no documented evidence, and the facility failed to present any documented evidence, additional interventions were implemented to protect Resident #30 from additional mental and verbal abuse and ensure Resident #30 was assessed and provided services following the verbal and mental abuse by Resident #15. In an tearful interview on 08/05/2025 at 8:57AM, Resident #30 indicated on 07/06/2025 at approximately 9:30PM, she overheard her roommate, Resident #15, informing someone on the phone that Resident #15's niece brought home a n*gger. Resident #30 further indicated Resident #15 then stated if Resident #15's mother was aware, Resident #15's mother would beat the sh*t out of her because we do not like n*ggers. Resident #30 further indicated that on the same phone conversation, Resident #15 called Resident #30 evil and the devil. Resident #30 reported that on 07/07/2025 at approximately 2:30PM, S9CNA found Resident #30 crying and asked Resident #30 what was wrong. Resident #30 indicated she reported to S9CNA that Resident #30 overheard Resident #15's telephone conversation the night before. Resident #30 further indicated Resident #15 overheard Resident #30 and S9CNA speaking about the incident, and Resident #15 became violent and screamed racial slurs towards both Resident #30 and S9CNA. Resident #30 indicated this aggressive behavior caused her to be anxious, nervous, and unable to avoid Resident #15 because she was bed bound. Resident #30 further indicated she kept her grabber within reach and planned to use it to defend herself against any physical attacks from Resident #15. Resident #30 indicated she reported the incident to S3Social Services and several staff, but Resident #30 felt like the facility did not care because nothing was done. Resident #30 was not asked by the surveyor if S1Administrator offered her a room change. In an interview at 08/05/2025 at 10:35AM, S11LPN indicated Resident #15 stated she did not like black people because that was the way she was raised. S11LPN further indicated Resident #15 would often say racial slurs to Resident #30. S11LPN further indicated this would be considered bulling or verbal abuse due to Resident #30's reaction to the behavior by being tearful and visibly upset. In an interview on 08/05/2025 at 12:06PM, S11LPN indicated S3Social Services and S1Administrator were aware of the behavior from Resident #15 towards Resident #30. In an interview on 08/05/2025 at 1:21PM, S9CNA indicated on 07/07/2025 at about 2:30PM she was going into Resident #15 and Resident #30's room for rounds and upon entering she observed Resident #30 crying. Resident #30 explained to S9CNA that she overheard a phone conversation by Resident #15 in which Resident #15 used racial slurs of the n word and called Resident #30 the devil. S9CNA indicated during the conversation, Resident #15 overheard Resident #30 speaking to S9CNA and propelled her wheelchair over to Resident #30's side of the room and exclaimed, I was raised that way, I don't give a f*ck. S9CNA indicated Resident #15 continued to curse and yell at her and Resident #30. S9CNA further indicated she reported the above mentioned incident to S10CNA Supervisor. In an interview on 08/05/2025 at 1:46PM, S10CNA Supervisor indicated S9CNA reported that Resident #30 was upset because Resident #15 was used racial slurs and profanity towards S9CNA and Resident #30. S10CNA Supervisor further indicated she informed the S2DON, S3Social Worker, and S1Administer, and they came up with a plan to document all of Resident #15's aggressive behaviors. S10CNA Supervisor further indicated she was not made aware of any interventions implemented for Resident #30. In an interview on 08/05/2025 at 2:01PM, S3Social Services indicated she was aware Resident #15 was vulgar, aggressive and used racial slurs. S3Social Services further indicated she was aware of the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025 and was aware Resident #30 was upset as a result. S3Social Services further indicated the facility did not have another room available to separate the residents. In an interview on 08/05/2025 at 3:59PM, S8CNA confirmed worked with Resident #15 and 30 on 07/06/2025 from 6:00PM to 6:00AM. S8CNA indicated she was told by Resident #30 that Resident #15 was on a phone call with a friend when Resident #15 called Resident #30 derogatory names and stated that Resident #15 hated black people. S8CNA further indicated that Resident #15 often had behaviors and was very aggressive towards anyone around her. S8CNA confirmed that Resident #15 often cursed and said derogatory comments to Resident #30. S8CNA further indicated she did feel like Resident #15 was verbally abusive to Resident #30. In an interview on 08/05/2025 at 4:22PM, S5CNA, indicated she had witnessed Resident #15 use racial slurs to staff and Resident #30. S5CNA further indicated Resident #30 was negatively affected by Resident #15's derogatory racial slurs because she became upset and had nonverbal indicators of being upset. S5CNA further indicated Resident #15's racial slurs were considered verbal abuse to staff and Resident #30. S5CNA confirmed she was never made aware of any changes to Resident #30's care due to Resident #15's behaviors. In an interview on 08/05/2025 at 4:30PM, S7CNA indicated Resident #30 had informed her about the incident between Resident #15 and Resident #30 after the incident happened. S7CNA indicated Resident #30 was very upset about it. S7CNA further indicated that Resident #15 acted out and cursed everyone around her when Resident #15 was upset. S7CNA further indicated she could see how Resident #30 would take this behavior from Resident #15 as verbal abuse. In an interview on 08/05/2025 at 4:32PM, S6CNA confirmed she worked with Resident #15 and Resident #30. S6CNA confirmed Resident #15 cursed out staff and was very hostile and impatient. S6CNA confirmed on 07/07/2025, Resident #30 was crying and informed her that Resident #15 made racially inappropriate remarks on the telephone. S6CNA indicated Resident #30 was very upset and offended by what Resident #15 said on 07/06/2025. S6CNA further indicated the administration was aware of Resident #15's behaviors and never implemented anything new to divert Resident #15's behaviors. S6CNA confirmed Resident #15 verbally abused Resident #30 and staff. In an interview on 08/06/2025 at 10:33AM, S15CNO indicated she was not aware of Resident #15's aggressive behaviors or the incidents between Resident #15 and Resident #30 prior to the surveyor bringing the information to her attention. S15CNO further indicated that Resident #15 should have been removed from Resident #30's room immediately and interventions should have been in place for both residents following the discovery of the incidents on 07/06/2025 and 07/07/2025. S15CNO further indicated, per the Abuse and Neglect policy, Resident #30 was verbally and mentally abused by Resident #15. In an interview on 08/06/2025 at 10:48AM, S1Administrator indicated he was aware of the incidents between Resident #15 and Resident #30 prior to the survey because Resident #30 informed him of the telephone conversation where Resident #15 directed racial slurs towards Resident #30. S1Administrator further indicated he was aware that Resident #30 was upset, but was not aware that Resident #30 was crying or tearful. S1Administrator further indicated that Resident #15 was verbally aggressive, cursed, used racial slurs and based on the interviews and documentation the staff presented, S1Administrator would consider that Resident #15 verbally and emotionally abused Resident #30. S1Administrator indicated he offered Resident #30 a room change, but Resident #30 declined.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to report an allegation of verbal and mental abuse to the state agency for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) ...
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Based on interviews and record reviews, the facility failed to report an allegation of verbal and mental abuse to the state agency for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents reviewed for abuse.Findings:Cross Reference F600Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents. Further review revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Further review revealed staff should immediately report their knowledge related to abuse allegations to the Administrator or DON without fear of reprisal. Further review revealed an alleged violation of abuse will be reported immediately, but not later than 2 hours if the alleged violation involved abuse or had resulted in serious bodily injury. Review revealed the facility administrator, or designee shall report or ensure a report was submitted to the mandated state agency per reporting criteria within guidelines of notification of an alleged abuse. Review revealed the administrator would have 5 working days from the initial report of abuse to complete the Statewide Incident Management System (SIMS) report according to the Department of Health and Hospitals (DHH) guidelines.Review of Resident #15's social services progress note dated 07/07/2025 revealed, in part, staff reported Resident #15 was talking on the phone on 07/06/2025 and stated Resident #30 was the devil. Further review revealed Resident #15 and Resident #30 began to argue, and then Resident #15 made derogatory comments about African Americans. Review further revealed Resident #15 was asked to refrain from derogatory remarks.In an interview on 08/05/2025 at 8:57AM, Resident #30 indicated Resident #15 called one of her friends on speaker phone on 07/06/2025 at approximately 9:30PM and Resident #15 told her friend very loudly that Resident #15 did not like n****rs. Resident #30 further stated in Resident #15's same phone conversation, Resident #15 called Resident #30 evil and the devil. Resident #30 further indicated on 07/07/2025 at approximately 2:30PM she informed S9Certified Nursing Assistant (CNA) of the Resident #15's phone conversation from 07/06/2025. Resident #30 indicated during her conversation with S9CNA Resident #15 became violent and screamed profanities and racial slurs toward Resident #30 and S9CNA. Resident #30 further indicated Resident #30 spoke to the social worker and several staff about the incidents which occurred on 07/06/2025 and 07/07/2025.In an interview on 08/05/2025 at 9:04AM, S1Administrator reported the facility did not report any Statewide Incident Management Systems (SIMS) to the state agency for Resident #15 and Resident #30.In an interview on 08/05/2025 at 12:06PM, S11Licensed Practical Nurse indicated she was aware of the continued conflict between Resident #15 and Resident #30. S11LPN further indicated S3Social Services and S1Administrator were aware of the behavior from Resident #15 towards Resident #30.In an interview on 08/05/2025 at 1:21PM, S9CNA indicated on 07/07/2025 at approximately 2:30PM, Resident #30 was crying and informed her of the above mentioned incident from 07/06/2025. S9CNA further indicated while Resident #30 explained the incident to S9CNA, Resident #15 propelled herself over to Resident #30's side of the room and started to curse and yell at S9CNA and Resident #30. S9CNA further indicated she reported this incident to S10CNA Supervisor.In an interview on 08/05/2025 at 1:46PM, S10CNA Supervisor indicated S9CNA reported the above mentioned incidents to her immediately after it happened. S10CNA Supervisor further indicated she notified S1Administrator, S2Director of Nursing (DON), and S3Social Services of the above mentioned incidents on 07/07/2025.In an interview on 08/05/2025 at 2:01PM, S3Social Services indicated she was aware of the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025.In an interview on 08/06/2025 at 10:48AM, S1Administrator, indicated he was aware of the incidents on 07/06/2025 and 07/07/2025 between Resident #15 and Resident #30 prior to the survey. There was no documented evidence, and the facility did not present any documented evidence, the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025 had been reported to the state agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to have documented evidence a thorough investigation was completed following allegations of verbal and mental abuse for 1 (Resident #30) of ...
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Based on interviews and record reviews, the facility failed to have documented evidence a thorough investigation was completed following allegations of verbal and mental abuse for 1 (Resident #30) of 3 (Resident #15, Resident #30, Resident #33) sampled residents investigated for abuse. Findings:Cross Reference F600 Review of the facility's undated Abuse Prevention and Prohibition policy revealed, in part, each resident had the right to be free from abuse and should not be subjected to abuse by anyone, including other residents. Further review revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review revealed verbal abuse was defined as the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance or sight, regardless of their age, ability to comprehend, or disability. Review revealed an abuse investigation included interviewing employees who worked in the resident's room and signed statements should be obtained from the employees. Further review revealed the investigation included interviewing the resident if they were cognitive. Review revealed the facility employee or agent, who became, aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or director of nurses. Further review revealed the administrator or designee would notify the regional director and corporate nurse. Review of Resident #15's social services progress note dated 07/07/2025 revealed, in part, staff reported that on 07/06/2025, Resident #30 had overheard Resident #15's phone conversation in which Resident #15 stated Resident #30 was the devil, and the residents argued. Further review revealed Resident #15 then made derogatory remarks about African Americans. In an interview on 08/05/2025 at 12:06PM, S11Licensed Practical Nurse (LPN) indicated she was aware of the continued conflict between Resident #15 and Resident #30. S11LPN further indicated S3Social Services and the S1Administrator were aware of Resident #15's behaviors toward Resident #30. In an interview on 08/05/2025 at 1:21PM, S9Certified Nursing Assistant (CNA) indicated on 07/07/2025 at approximately 2:30PM, S9CNA observed Resident #30 crying. S9CNA further indicated Resident #30 informed her about Resident #15's phone conversation Resident #30 overheard on 07/06/2025 where Resident #15 called Resident #30 the devil and used racial slurs. S9CNA further indicated while Resident #30 explained the incident to S9CNA, Resident #15 propelled herself over to Resident #30's side of the room and started to curse and yell at S9CNA and Resident #30. S9CNA indicated she reported this incident to S10CNA Supervisor on 07/07/2025. In an interview on 08/05/2025 at 1:46PM, S10CNA Supervisor indicated S9CNA made her aware of the above mentioned incidents from 7/06/2025 and 07/07/2025. S10CNA Supervisor indicated she reported the incidents to S1Administrator, S2DON, and S3Social Services on 07/07/2025. In an interview on 08/05/2025 at 2:01PM, S3Social Services indicated she was aware of the incidents between Resident #15 and Resident #30 on 07/06/2025 and 07/07/2025 and she was aware Resident #30 was upset. In an interview on 08/06/2025 at 10:33AM, S15Chief Nursing Officer (CNO) indicated she was not aware of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025 prior to the survey; therefore, S15CNO did not have any documented evidence of an investigation was completed following the incidents. In an interview on 08/06/2025 at 10:48AM, S1Administrator indicated he was aware of the incident on 07/06/2025 and 07/07/2025 between Resident #15 and Resident #30 prior to the survey. S1Administrator further indicated based on the surveyor's presented findings, Resident #30 was verbally and mentally abused by Resident #15. In an interview on 08/06/2025 at 1:49PM, S2Director of Nursing (DON) was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S2DON indicated she would try to find the facility's investigation to provide to the surveyor.In an interview on 08/06/2025 at 11:25AM, S1Administrator was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S1Administrator indicated he would not present any further investigation regarding the incident between Resident #15 and Resident #30.In an interview on 08/06/2025 at 1:36PM, S3Social Services was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S3Social Services indicated the only investigation she completed regarding incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025 was the Social Services note she documented on 07/07/2025. In an interview on 08/06/2025 at 1:54PM, S1Administrator was asked for the facility's investigation of the incidents between Resident #15 and Resident #30 that occurred on 07/06/2025 and 07/07/2025. S1Administrator indicated the facility was refusing to present any documentation of an investigation following the 07/06/2025 and 07/07/2025 incidents between Resident #15 and Resident #30. There was no documented evidence, and the facility failed and/or refused to present any documented evidence, the facility had completed a thorough investigation following the 07/06/2025 and 07/07/2025 incidents between Resident #15 and Resident #30.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement interventions for residents who were ide...
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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 implement interventions for residents who were identified at risk for falls for 2 (Resident #3, Resident #7) of 8 (Resident #3, Resident #7, Resident #8, Resident #12, Resident #16, Resident #17, Resident #30, Resident #73) sampled residents investigated for accidents.Findings:Resident #3:
Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2025 revealed, in part, a Brief Interview for Mental Status score of 4. A score of 4 which indicated Resident #3 had severe cognitive impairment.
Review of Resident #3's electronic medical record (EMR) chart revealed, in part, a special instruction for Resident #3 to have an auto lock brakes feature. (An auto lock brake feature engages the wheelchair's brakes when the user's weight is removed from the seat, preventing the chair from rolling away unintentionally).
Review of Resident #3's Fall Risk assessment dated [DATE] revealed, in part, a score of 55 (A score of 45 or higher indicated high risk of falls).
Review of Resident #3's care plan revealed, in part, Resident #3 was identified at risk for falls related to an unsteady gait. Further review revealed Resident #3's Care Plan included a documented intervention, dated 12/13/2024, for the auto lock brake feature.
Review of Resident #3's social service progress note dated 07/24/2025 revealed, in part, Resident #3 was up daily in his wheelchair with confusion, impulsivity, and attempted to transfer without assistance. Further review revealed redirection was unsuccessful.
Observation on 08/06/2025 at 1:45PM revealed Resident #3 was in his wheelchair and the wheelchair did not have the auto lock brake feature.
In an interview on 08/06/2025 at 2:25PM, S2Director of Nursing (DON) confirmed Resident #3 was in a wheelchair which did not have the auto lock brake feature.
Resident #7
Review of Resident #7's EMR revealed Resident #7 was admitted to the facility on [DATE] with a diagnosis of, in part, dementia (a loss of brain function that occurs with certain diseases) and a history of falls.
Review of Resident #7's MDS with an ARD of 07/16/2025 revealed, in part, Resident #7 had a history of falls with two or more falls since admit.
Review of Resident #7's care plan with the latest revision revealed, in part, Resident #7 was at risk for falls and injury related to a history of falls prior to admission, psychoactive medication use, impaired safety awareness, unsteady gait (how a person walks), dementia, and left sided weakness with a revised date of 07/28/2025. Further review revealed an intervention to provide Resident #7 with a wheelchair pocket attachment to facilitate the storage of snacks to be easily accessible to avoid dropping items on the floor.
Observation on 08/05/2025 at 8:35AM revealed Resident # 7 was in her wheelchair at the nursing station. Further observation revealed no evidence Resident #7's wheelchair had a pocket attachment.
Observation on 08/06/2025 at 8:40AM revealed Resident #7 was in her wheelchair at the nursing station. Further observation revealed no evidence Resident #7's wheelchair had a pocket attachment.
In an interview on 08/05/2025 at 12:35PM, S13Licensed Practical Nurse (LPN) indicated the staff put Resident #7's snacks close to Resident #7 to prevent Resident #7 from falls. S13LPN further indicated Resident #7 often forget she could not walk and attempted to get snacks which resulted in falls.
In an interview on 08/06/2025 at 8:45AM, S16LPN indicated Resident #7 had a history of attempting to retrieve items that were out of her reach; therefore, staff placed everything within her reach to prevent falls.
In an interview on 08/06/2025 at 9:00AM, S2DON indicated Resident #7's care plan implementation for the wheelchair pocket attachment was to facilitate storage of snacks.
In an interview on 08/06/2025 at 9:10AM, S17MDS Coordinator indicated all interventions on the current care plan should have implemented.
In an interview on 08/06/2025 at 9:30AM, S2DON indicated Resident #7 did not have a wheelchair pocket attachment as per Resident #7's care plan and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to:1. Follow a physician's order for oxygen administration (Resident #33, Resident #63); and, 2. Ensure oxygen tubing was cha...
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Based on observations, interviews, and record reviews, the facility failed to:1. Follow a physician's order for oxygen administration (Resident #33, Resident #63); and, 2. Ensure oxygen tubing was changed and dated weekly (Resident #33, Resident #63). This deficient practice was identified for 2 (Resident #33, Resident #63) of 2 (Resident #33, Resident #63) sampled residents investigated for respiratory care. Findings:1.Review of the facility's undated Oxygen Administration policy and procedure revealed, in part, staff should check the physician's order for liter flow rate of oxygen and method of administration. Further review revealed staff should adjust the liter flow rate of oxygen to the rate ordered by the physician. Resident #33Review of Resident #33's August 2025 Physician Orders revealed, in part, an order dated 09/29/2023 for oxygen to be administered at 2 liters per minute (LPM) via nasal cannula continuously related to chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of Resident #33's care plan dated 09/14/2023 revealed, in part, staff were to administer Resident #33's oxygen as ordered by the physician. Observation on 08/04/2025 at 4:57PM with S2Director of Nursing (DON) present, revealed Resident #33 received oxygen at 3.5LPM per nasal cannula. In an interview on 08/04/2025 at 4:57PM, S2DON confirmed Resident #33 received oxygen at 3.5LPM per nasal cannula. In an interview on 08/04/2025 at 4:59PM, S13Licensed Practical Nurse (LPN) indicated Resident #33 had an order for oxygen to be administered continuously at 2LPM via nasal cannula, and should not have received oxygen at 3.5LPM. Resident #63Review of Resident #63's August 2025 Physician Orders revealed, in part, an order for oxygen to be administered at 2LPM via nasal cannula as needed. Observation on 08/04/2025 at 9:23AM revealed Resident #63 received oxygen via nasal cannula between 2.5LPM and 3LPM. Observation on 08/04/2025 at 4:50PM with S13LPN present, Resident #63 received oxygen between 2.5LPM and 3LPM via nasal cannula. In an interview on 08/04/2025 at 4:50PM, S13LPN indicated Resident #63 had an order for oxygen to be administered at 2LPM as needed, and should not have received oxygen between 2.5LPM and 3LPM. In an interview on 08/06/2025 at 2:37PM, S2DON indicated Resident #33 and Resident #63 should have received oxygen according to their physician orders, as mentioned above. 2.Review of the facility's undated Oxygen Concentration Cleaning policy and procedure revealed, in part, oxygen tubing/cannula should be changed weekly and as needed. Resident #33Review of Resident #33's August 2025 Physician Orders revealed, in part, an order dated 09/29/2023 for oxygen to be administered at 2 liters per minute (LPM) via nasal cannula. Observation on 08/04/2025 at 4:57PM with S2DON present, revealed Resident #33 received oxygen via nasal cannula and Resident #33's oxygen tubing was not dated. In an interview on 08/04/2025 at 4:57PM, S2DON indicated Resident #33's oxygen tubing should have been dated on the day it was changed, and was not. Observation on 08/05/2025 at 12:22PM with S4Infection Preventionist present, revealed Resident #33's oxygen tubing was not dated. In an interview on 08/05/2025 at 12:22PM, S4Infection Preventionist indicated Resident #33's oxygen tubing was not dated, and should have been. Resident #63Review of Resident #63's Quarterly Minimum Data Set with an Assessment Reference Date of 06/18/2025 revealed, in part, Resident #63 had a BIMS score of 13, which indicated Resident #63's cognition was intact. Review of Resident #63's August 2025 Physician Orders revealed, in part, an order dated 12/26/2023 for oxygen to be administered at 2LPM via nasal cannula as needed. Observation on 08/04/2025 at 9:23AM revealed Resident #63 received oxygen via nasal cannula and Resident #63's oxygen tubing was not dated. In an interview on 08/04/2025 at 9:23AM, Resident #63 indicated her oxygen tubing had not been changed for approximately 2 weeks. Observation on 08/04/2025 at 4:45PM revealed Resident #63 received oxygen via nasal cannula and Resident #63's oxygen tubing was not dated. In an interview on 08/04/2025 at 4:50PM, S13LPN confirmed Resident #63 received oxygen via nasal cannula, and Resident #63's oxygen tubing was not dated. S13LP confirmed Resident #63's oxygen tubing should have been dated to indicate when it was last changed and was not. There was no documented evidence, and the facility was unable to provide any documented evidence, Resident #33's and Resident #63's oxygen tubing was changed weekly, as required. In an interview on 08/06/2025 at 2:37PM, S2DON indicated Resident #33's and Resident #63's oxygen tubing should have been dated to indicate the date it had been changed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to: 1. ensure food stored in the facility's refrigerator was labeled with an opened date and/or discarded prior to the item's ...
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Based on observations, interviews, and record review, the facility failed to: 1. ensure food stored in the facility's refrigerator was labeled with an opened date and/or discarded prior to the item's expiration date; and,2. ensure scoops were not stored inside the dry goods storage bins. Findings:1.Review of the facility's undated Food Safety and Sanitation policy and procedure revealed, in part, leftovers were to be dated when stored, and foods with expiration dates were to be used prior to the use by date on the package. Observation on 08/04/2025 at 8:30AM of the facility's kitchen with S14Dietary Manager revealed an opened gallon size container of ranch dressing stored in the facility's refrigerator. Further review revealed the container of ranch dressing had not been labeled with an opened date and had an expiration date of 07/24/2025. In an interview on 08/04/2025 at 8:39AM, S14Dietary Manager confirmed the container of ranch dressing, as mentioned above, was not labeled with an opened date and had an expiration date of 07/24/2025. S14Dietary Manager indicated the opened container of ranch dressing should have been discarded and should not have been available for resident consumption. 2. Observation on 08/04/2025 at 8:30AM of the facility's kitchen with S14Dietary Manager revealed the sugar and flour dry storage bins had scoops stored inside of the bins, with the handle of the scoop in direct contact with the flour and sugar. In an interview on 08/04/2025 at 8:30AM, S14Dietary Manager confirmed scoops were stored inside of the sugar and flour dry storage bins, and should not have been. In an interview on 08/06/2025 at 2:37PM, S2Director of Nursing (DON) confirmed the opened gallon sized container of ranch dressing, with an expiration date of 07/24/2025, should have been discarded and should not have been available for resident consumption. S2DON confirmed scoops should not have been stored inside the flour and sugar storage bins.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interviews, and record reviews, the facility failed to:1. Ensure expired medications were not available for resident use (Medication Cart A);2. Ensure the facility's shift verifi...
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Based on observation, interviews, and record reviews, the facility failed to:1. Ensure expired medications were not available for resident use (Medication Cart A);2. Ensure the facility's shift verification of controlled substances count sheet was completed every shift (Medication Cart A); and,3. Ensure medications were documented as administered on the electronic Medication Administration Record (eMAR) when administered (Resident #83).This deficient practice was identified for 1 (Medication Cart A) of 2 (Medication Cart A, Medication Cart B) sampled medication carts observed during medication storage observations and 1 (Resident #83) of 1 (Resident #83) sampled residents investigated for hospice. Findings:1.
Review of the facility's undated Storage of Medications policy and procedure revealed, in part, no discontinued, outdated, or deteriorated medications were available for use in the facility. Further review revealed all discontinued, outdated, or deteriorated medications were to be destroyed.
Observation of Medication Cart A on 08/06/2025 at 3:30PM revealed, in part:
-Advair diskus (medication used to treat inflammatory lung issues) with an expiration date of 10/11/2024 prescribed to Resident #36;
- Famotidine (medication used to treat excessive stomach acid) 10 milligram tablets for general resident use with an expiration date of 07/2025; and,
- Four Hydrocortisone Acetate (medication used to treat inflammation) 25 mg suppositories (medication inserted into the rectum) for general resident use with an expiration date of 07/2025.
In an interview on 08/06/2025 at 3:35PM, S16Licensed Practical Nurse (LPN) confirmed the above mentioned medications' expiration dates and confirmed the above mentioned medications were expired and should not have been on the medication cart available for resident use.
In an interview on 08/07/2025 at 9:55AM, S2Director of Nursing (DON) confirmed the above mentioned expired medications should not have been available for resident use.
2.
Review of facility's undated Narcotics policy and procedure revealed one licensed nurse from the off-going shift and one licensed nurse from the oncoming shift must count and sign the narcotic count sheet in front of the narcotic box.
Review of Medication Cart A's Shift Verification of Controlled Substances Count document revealed, in part:
-no documented evidence of the nurse from the off-going 6:00PM-6:00AM shift having verified the narcotic count on: 06/04/2025 and 07/04/2025;
-no documented evidence of the off-going 10:00PM-6:00AM shift having verified the narcotic count on: 6/12/2025;
-no documented evidence of the nurse from the off-going 6:00AM-10:00PM shift having verified the narcotic count on: 6/28/2025;
-no documented evidence of the nurse from the off-going 6:00AM-6:00PM shift having verified the narcotic count on: 07/08/2025;
-no documented evidence of the nurse from the on-coming 6:00AM-6:00PM shift having verified the narcotic count on: 07/04/2025 and 7/21/2025; and,
-no documented evidence of the nurse from the on-coming unidentified shift having verified the narcotic count on: 06/27/2025
In an interview on 08/06/2025 at 3:35PM, S16LPN confirmed the above mentioned shifts did not have documentation of the off-going and on-coming shift verified the narcotic count, as required.
In an interview on 08/07/2025 at 1:38PM, S2DON indicated the facility had no further documentation to present and had no further explanation for the omission of signatures on the above mentioned dates.
3.
Review of the facility's undated Medication Administration policy and procedure revealed, in part, each dose of medication administered shall be properly recorded in the resident's medical record.
In an interview on 08/04/2025 at 4:05PM, S13LPN indicated Resident #83 was administered Ativan 0.5milligrams/mg (a medication used to treat anxiety) earlier during the shift. The surveyor asked S13LPN what time she administered Resident #83's Ativan. S13LPN indicated Resident #83's Ativan 0.5mg was administered at approximately 12:30PM; however, S13LPN failed to document the administration of Ativan 0.5mg on Resident #83's eMAR.
There was no documented evidence, and the facility was unable to present any documented evidence, Resident #83's Ativan 0.5mg was documented as administered on 08/04/2025.
In an interview on 08/06/2025 at 1:26PM, S2DON indicated when a medication was administered the nurse should document the administration on the eMAR. S2DON confirmed S13LPN did not document the administration of Resident #83's on 08/04/2025 on Resident #83's eMAR, and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to:1. Ensure the scoop used to serve ice did not have the handle submerged in the residents' ice (Ice Chest A); 2. Ensure sta...
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Based on observations, interviews, and record reviews, the facility failed to:1. Ensure the scoop used to serve ice did not have the handle submerged in the residents' ice (Ice Chest A); 2. Ensure staff properly handled soiled linen (S12Certified Nursing Assistant); and, 3. Ensure staff implemented Enhanced Barrier Precautions (EBP) for a resident (Resident #76). This deficient practice was identified for 1 (Ice Chest A) of 2 (Ice Chest A, Ice Chest B) ice chests used to provide ice to residents; 1 (S12CNA) of 1 (S12CNA) CNAs observed during random linen handling observations; and, 1 (Resident #76) of 12 (Resident #5, Resident #9, Resident #10, Resident #17, Resident #32, Resident #70, Resident #76, Resident #77, Resident #81, Resident #85, Resident #90, Resident #91) sampled residents observed on EBP. Findings: 1.Observation on 08/04/2025 at 8:46AM revealed a blue and white ice chest located in the dining room with the ice scoop handle submerged in water and ice. In an interview on 08/04/2025 at 8:55AM, S2Director of Nursing (DON) confirmed the ice scoop handle was inside the ice chest submerged in the residents' water and ice. S2DON indicated the ice scoop should be stored in the ice scoop holder on outside of ice chest and should have not been in the ice chest submerged in residents' water and ice. 2. Review of the facility's undated Linen Handling policy revealed, in part, soiled linen should be bagged, in or near the resident's room, and securely closed prior to transport. Observation on 08/04/2025 at 8:40AM revealed S12Certified Nursing Assistant (CNA) walked in the hallway with unbagged soiled linen.In an interview on 08/04/2025 at 8:42AM, S10Certified Nursing Assistant Supervisor indicated S12CNA should not have walked in the hall with unbagged soiled linen.In an interview on 08/04/2025 at 8:55AM, S2DON indicated S12CNA should not have walked in the hallway with unbagged soiled linen. In an interview on 08/04/2025 at 10:11AM, S12CNA indicated she should not have walked in the hallway with unbagged soiled linen. 3. Review of the facility's undated (EBP) policy and procedure revealed, in part, EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms, where employees wear gowns and gloves during high contact resident care activities. Further review of the policy revealed EBP was to be used for residents with indwelling medical devices which included central lines. Review of the policy also revealed EBP should be used when performing care of or accessing a central line. Review of Resident #76's record revealed, in part, Resident #76 had a peripherally inserted central catheter (PICC) for the administration of intravenous (administered directly into the vein) medication due to a diagnosis of osteomyelitis (infection of the bone). Observation on 08/05/2025 at 7:40AM revealed an EBP signage was present on Resident #76's door indicating personal protective equipment of gloves and gowns were required. Observation on 08/05/2025 at 8:00AM revealed S11Licensed Practical Nurse (LPN) prepared an IV medication for administration and entered Resident #76's room without wearing a surgical gown. In an interview on 08/05/2025 at 8:05AM, S11LPN indicated Resident #76 required EBP and she administered an IV antibiotic via Resident #76's PICC line. S11LPN further indicated she did not wear a gown when accessing Resident #76's PICC line for medication administration. In an interview on 08/05/2025 at 8:15AM, S4Infection Preventionist (IP) indicated EBP required staff to wear gloves and gowns when administering medications via a PICC line. S4IP further indicated S11LPN should have worn a gown when she accessed Resident #76's PICC line for medication administration. In an interview on 08/05/2025 at 9:59AM, S2DON confirmed S11LPN should have worn a gown when she accessed Resident #76's PICC line for medication administration.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to post the most recent survey results in a place readily accessible to residents.Findings: Review of the facility's survey hist...
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Based on observation, interview, and record review, the facility failed to post the most recent survey results in a place readily accessible to residents.Findings: Review of the facility's survey history revealed the last survey conducted was a complaint survey with an exit date of 04/03/2025. Observation on 08/05/2025 at 2:27PM of the facility's past survey results binder posted in the hallway next to the dining room revealed the last survey results available for review were dated 08/22/2024 for the recertification survey. There was no documented evidence, and the facility was unable to provide any documented evidence, the last survey results were posted in a place readily accessible to residents as required. In an interview on 08/05/2025 at 3:59PM, S1Administrator confirmed the complaint survey with an exit date of 04/03/2025 was not in the survey results binder.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure a resident received the required physical therapy services for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) reside...
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Based on interviews and record reviews, the facility failed to ensure a resident received the required physical therapy services for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents investigated for rehabilitation services.
Findings:
Review of Resident #1's February and March 2025 physician's orders revealed, in part, an order dated 02/27/2025 for physical therapy (PT) to evaluate and treat Resident #1, five times per week for 8 weeks as indicated. Further review revealed an order dated 03/06/2025 for PT to evaluate and treat Resident #1 five times per week for 8 weeks as indicated.
Review of Resident #1's Electronic Medical Record (EMR) revealed she did not receive physical therapy services between 02/27/2025 and 03/06/2025.
In an interview on 04/01/2025 at 9:20AM, S2Director of Rehabilitation (DOR) indicated when a resident required PT the physical therapist would write orders for the resident to be evaluated and treated for PT services, then the resident's physician would sign those orders. S2DOR further indicated Resident #1 did not receive PT services between 02/27/2025 and 03/06/2025, because a physical therapist was not available to evaluate Resident #1 after her insurance changed the week of 02/23/2025.
In an interview 04/03/2025 at 11:57AM, S8Medical Director indicated Resident #1 was admitted to the facility for the purpose of Resident #1 getting therapy services. S8Medical Director acknowledged a physical therapist should have been available to evaluate Resident #1 for physical therapy services after her insurance changed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to ensure the required number of nursing staff members were present and working in the facility for 22 (10/19/2024, 10/20/2024, 10/26/2024, ...
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Based on interviews and record reviews, the facility failed to ensure the required number of nursing staff members were present and working in the facility for 22 (10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/10/2024, 11/16/2024, 02/16/2025, 02/18/2025, 02/22/2025, 02/23/2025, 02/24/2025, 03/01/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/13/2025) of 53 (10/05/2024, 10/06/2024, 10/12/2024, 10/13/2024, 10/19/2024, 10/20/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/30/2024, 12/07/2024, 12/08/2024, 12/14/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/28/2024, 12/29/2024, 02/16/2025, 02/17/2025, 02/18/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 02/28/2025, 03/01/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/10/2025, 03/11/2025, 03/12/2025, 03/13/2025, 03/14/2025, 03/15/2025) days reviewed for sufficient staff.
Findings:
Review of the facility's Facility Assessment, last updated on 02/18/2025 revealed, in part, the average daily census from 01/01/2024 to 12/31/2024 was 83 residents. Further review revealed on a weekday, the facility required 72 hours of Licensed Practical Nurses (LPNs) providing direct care a day, 144 hours of Certified Nursing Assistants (CNAs) care a day, 40 hours of other nursing/administrative nursing personnel per day, and 8 hours of other staff to provide behavioral healthcare and services (for a total of 264 hours.) Further review revealed, on a weekend, the facility required 72 hours of LPNs providing direct care per day, 144 hours of CNAs care per day, 8 hours of a RN per day, and 8 hours of other staff to provide behavioral healthcare and services (for a total of 232 hours.)
Review of the facility's Resident Council Meeting minutes dated 01/08/2025 revealed, in part, residents had issues with not getting changed on time and issues with CNAs not checking on them at night. Further review revealed a resident indicated the facility needed more CNAs.
Review of the facility's Resident Council Meeting minutes dated 02/12/2025 revealed, in part, residents had issues with not getting changed in a timely manner.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 10/05/2024 through 10/27/2024 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following weekend days did not meet or exceed the number of required hours:
On 10/19/2024 the facility had a census of 83. Further review revealed the facility provided 202.10 nursing staff hours, which was 29.90 hours less than the required 232 hours.
On 10/20/2024 the facility had a census of 82. Further review revealed the facility provided 198.34 nursing staff hours, which was 33.66 hours less than the required 232 hours.
On 10/26/2024 the facility had a census of 85. Further review revealed the facility provided 201.97 nursing staff hours, which was 30.03 hours less than the required 232 hours.
On 10/27/2024 the facility had a census of 85. Further review revealed the facility provided 223.97 nursing staff hours, which was 8.03 hours less than the required 232 hours.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 11/02/2024 through 11/30/2024 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following weekend days did not meet or exceed the number of required hours:
On 11/02/2024 the facility had a census of 82. Further review revealed the facility provided 212.89 nursing staff hours, which was 19.11 hours less than the required 232 hours.
On 11/03/2024 the facility had a census of 82. Further review revealed the facility provided 220.22 nursing staff hours, which was 11.27 hours less than the required 232 hours.
On 11/10/2024 the facility had a census of 82. Further review revealed the facility provided 224.76 nursing staff hours, which was 7.24 hours less than the required 232 hours.
On 11/16/2024 the facility had a census of 84. Further review revealed the facility provided 201.40 nursing staff hours, which was 30.60 hours less than the required 232 hours.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 02/16/2025 through 03/01/2025 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following days did not meet or exceed the number of required hours:
On 02/16/2025 the facility had a census of 87. Further review revealed the facility provided 206.55 nursing staff hours, which was 25.45 hours less than the required 232 hours.
On 02/18/2025 the facility had a census of 86. Further review revealed the facility provided 255.06 nursing staff hours, which was 8.94 hours less than the required 264 hours.
On 02/22/2025 the facility had a census of 86. Further review revealed the facility provided 222.23 nursing staff hours, which was 9.77 hours less than the required 232 hours.
On 02/23/2025 the facility had a census of 85. Further review revealed the facility provided 201.72 nursing staff hours, which was 30.28 hours less than the required 232 hours.
On 02/24/2025 the facility had a census of 85. Further review revealed the facility provided 254.94 nursing staff hours, which was 9.06 hours less than the required 264 hours.
On 03/01/2025 the facility had a census of 87. Further review revealed the facility provided 204.80 nursing staff hours, which was 27.2 hours less than the required 232 hours.
Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Forms, dated 03/02/2025 through 03/15/2025 signed as complete and accurate by S1Administrator on 04/01/2025 revealed, in part, the following days did not meet or exceed the number of required hours:
On 03/02/2025 the facility had a census of 86. Further review revealed the facility provided 203.08 nursing staff hours, which was 28.92 hours less than the required 232 hours.
On 03/03/2025 the facility had a census of 86. Further review revealed the facility provided 242.52 nursing staff nursing staff hours, which was 21.48 hours less than the required 264 hours.
On 03/04/2025 the facility had a census of 87. Further review revealed the facility provided 254.15 nursing staff hours, which was 9.85 hours less than the required 264 hours.
On 03/05/2025 the facility had a census of 87. Further review revealed the facility provided 261.81 nursing staff hours, which was 2.19 hours less than the required 264 hours.
On 03/07/2025 the facility had a census of 86. Further review revealed the facility provided 253.38 nursing staff hours, which was 10.62 hours less than the required 264 hours.
On 03/08/2025 the facility had a census of 86. Further review revealed the facility provided 209.08 nursing staff hours, which was 22.92 hours less than the required 232 hours.
On 03/09/2025 the facility had a census of 86. Further review revealed the facility provided 202.97 nursing staff hours, which was 29.03 hours less than the required 232 hours.
On 03/13/2025 the facility had a census of 86. Further review revealed the facility provided 252.71 nursing staff hours, which was 11.29 hours less than the required 264 hours.
In an interview on 03/26/2025at 12:32PM, Resident #1's family member indicated she felt the facility was understaffed on the skilled nursing unit of the facility.
In an interview on 03/31/2025 at 10:00AM, Resident #2's spouse indicated she thought there was an issue with staffing in the facility that was causing a delay in care.
In an interview on 03/31/2025 at 10:45AM, S8CNA indicated there was a 50/50 chance there would not be enough staff working in the facility when she comes into work.
In an interview on 03/31/2025 at 10:56AM, S9CNA indicated she does not feel like there was enough staff on the skilled nursing unit of the facility because the residents that resided on the skilled unit required more care from CNAs due to their care needs.
In a telephone interview on 04/01/2025 at 12:27PM, S6LPN indicated the facility does not have enough CNA staff, especially on the skilled nursing unit of the facility, because the residents there need more care. S6LPN indicated residents are going without care due to the lack of CNA staff. S6LPN further indicated, with an adequate number of staff, residents could better meet their care goals.
In an interview on 04/02/2025 at 11:50AM, S4LPN indicated the facility definitely needed to staff more CNAs. S4LPN further indicated the facility's CNAs are getting burnt out and rarely get breaks because they work constantly. S4LPN further indicated she felt the facility does not schedule the needed number of CNAs.
In an interview on 04/02/2025 at 11:54AM, S10CNA indicated the facility does not have enough CNAs working in the facility. S10CNA further indicated the staff were getting burned out because they are having to overwork to take care of the resident's care needs.
In an interview on 04/02/2025 at 12:00PM, S5LPN indicated there was an issue with CNA staffing. S5LPN further indicated the facility's CNAs are getting burnt out by the amount of work they are having to do to meet the needs of the residents.
In an interview on 04/02/2025 at 12:05PM, S7LPN indicated the facility needed another nurse on the skilled nursing unit of the facility and more CNAs. S7LPN further indicated the facility definitely needed more CNAs to work on the skilled nursing unit of the facility because of the acuity of the residents.
In an interview on 04/02/2025 at 12:10PM, S11CNA indicated the facility's staffing was not good. S11CNA further indicated the facility's residents sometimes had to wait longer than usual to receive care because the CNAs were busy caring for other residents.
In an interview on 04/03/2025 at 9:39AM, Resident #R7 indicated there were very few CNAs on the weekends and other residents were having to wait 30 minutes to get care when they called for assistance.
In an interview on 04/03/2025 at 11:30AM, S1Administrator offered no evidence that disputed the above deficient practice.
Aug 2024
6 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation and interview, the facility failed to ensure residents were supervised and kept free from thermal burns for 2 (Resident #19 and Resident #49) of 2 (Resident #19 and Resident #49) ...
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Based on observation and interview, the facility failed to ensure residents were supervised and kept free from thermal burns for 2 (Resident #19 and Resident #49) of 2 (Resident #19 and Resident #49) sampled residents investigated for an accident/hazard related to burns.
This deficient practice resulted in actual harm when on 02/04/2024 for Resident #49 and on 02/21/2024 for Resident #19, when Resident #19 and Residnet #49 were left unsupervised and sustained first degree superficial burns from spilled coffee.
Findings:
Review of Appendix PP of the State Operations Manual, last revised on 08/08/2024, revealed, in part, third degree burns can occur within 1 to 2 seconds with hot water temperatures between 140 degrees Fahrenheit (F) and 155 degrees F.
Review of the National Library of Medicine's Burn Evaluation and Management article, last revised on 08/08/2023, revealed, in part, burns may be caused by hot liquids. Further review revealed superficial burns (first degree) are red on the skin.
Resident #19
Review of Resident #19's Electronic Medical Record (EMR) revealed, in part, Resident #19 had diagnoses which included epilepsy (a seizure disorder) and Hemiplegia (muscle weakness or partial paralysis on one side of the body)/Hemiparesis (a condition that causes partial or total paralysis of one side of the body) following a cerebral infarction (a type of stroke) that affected Resident #19's Left Non-Dominant side.
Review of Resident #19's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2024 revealed, in part, Resident #19 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated Resident #19 cognition was severely impaired. Further review revealed Resident #19 required supervision and/or touching assistance (occasionally assisting to steady food) with eating.
Review of Resident #19's progress note dated 02/21/2024 at 6:00 a.m., revealed, in part, Resident #19 received a thermal superficial burn from hot coffee with redness noted to the top of her fingers and the palm of her hand.
Review of Resident #19's Skin and Wound Evaluation dated 02/21/2024 revealed, in part, Resident #19 had a reddened area on her left 3rd finger that measured 1.5 centimeters (cms) by 1 cm.
In an interview on 08/22/2024 at 9:55 a.m., S7Licensed Practical Nurse (LPN) indicated the coffee pot in the main dining area was not supervised.
Resident #49
Review of Resident #49's EMR revealed, in part, Resident #49 had diagnoses which included anoxic brain damage, type 2 diabetes, and altered mental status.
Review of Resident #49's MDS with an ARD of 11/22/2023 revealed, in part, Resident #49 had a BIMS score of 12 which indicated Resident #49's cognition was moderately impaired. Further review revealed Resident #49 required supervision and/or touching assistance with eating.
Review of Resident #49's progress note dated 02/04/2024 at 10:46 p.m. revealed, in part, at 7:35 a.m., Resident #49 was yelling hospital hospital. Further review revealed, upon inspection, it was noted that Resident #49 spilled hot coffee on herself. Further review revealed Resident #49 had a red areas to lower left abdomen that measured 12 cm by 4 cm, right upper leg that measured 7cm by 2 cm, and right upper leg that measured 12 cm by 15 cm.
Observation on 08/21/2024 at 10:08 a.m., revealed Resident #49 went up to the coffee pot in Dining Room a, placed a coffee cup under coffee dispenser spigot, and pressed the dispenser button to make herself a cup of coffee. Further observation revealed Resident #49 continuously repositioned the coffee cup under the spigot while attempting to fill the cup with coffee. Further observation revealed a staff member was present in the dining area, but had her back turned to the coffee dispenser. Further observation revealed staff did not intervene when Resident #49 attempted to pour coffee in her coffee cup.
A check of the coffee temperature on 08/21/2024 at 10:09 a.m. with S15Dietary Supervisor revealed the coffee in the coffee dispenser in Dining Room a was 150.8 degrees Fahrenheit.
In an interview on 08/21/2024 at 10:45 a.m., S14Certified Nursing Assistant (CNA) indicated Resident #49 needed assistance and supervision with filling her coffee cup due to her cognition. S14CNA further indicate staff had to redirect and assist Resident #49 with the coffee pot.
In an interview on 08/22/2024 at 10:56 a.m., S15Dietary Supervisor indicated the coffee dispenser in Dining Room a was not always supervised. S15Dietary Supervisor further indicated attempts were initially made to address the hot coffee issue, but nothing was put in place and supervision was not increased.
In an interview on 08/22/2024 at 12:05 p.m., S1Administrator acknowledged a resident in the facility should not be burned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a pressure reducing wheelchair cushion was b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a pressure reducing wheelchair cushion was being utilized for a resident assessed as being at high risk for skin breakdown for 1 (Resident #5) of 3 (Resident #5, Resident #14, and Resident #17 sampled residents investigated for pressure injuries, pressure ulcers, or skin integrity.
Findings:
Review of Resident #5's Electronic Medical Record revealed, in part, Resident #5 had diagnoses which included, a Non-Pressure chronic ulcer of the left lower leg, chronic venous hypertension with ulcer and inflammation of the bilateral lower extremities, and diabetes. Further review revealed Special Instructions: wheelchair cushion listed in Resident #5's care tasks.
Review of Resident #5's Minimum Data Set with an Assessment Reference Date of 05/22/2024 revealed, in part, Resident #5 had a Brief Interview for Mental Status score of 9 which indicated Resident #5's cognition was moderately impaired.
Review of Resident #5's Braden Scale assessment dated [DATE] revealed, in part, Resident #5 had a score of 12 which indicated a high risk for skin concerns/breakdown (Score of 10-12=high risk for skin breakdown).
Review of Resident #5 Care Plan revealed, in part, Resident #5 remained in his wheelchair all day and often slept in his wheelchair.
In an interview on 08/20/2024 at 9:55 a.m., Resident #5 indicated he mentioned to the CNA when they provided incontinence care that his buttock was hurting.
Observation on 08/20/2024 at 9:56 a.m., revealed a pressure reducing cushion was not in place for Resident #5's wheelchair.
Observation on 08/20/2024 at 12:45 p.m., revealed a pressure reducing cushion was not in place for Resident #5's wheelchair.
In an interview on 08/20/2024 at 1:29 p.m., Resident #5 indicated he sometimes sleeps in his wheelchair and takes a nap.
Observation on 08/20/2024 at 1:30 p.m. revealed a pressure reducing cushion was not in place for Resident #5's wheelchair.
In an interview on 08/20/2024 at 2:45 p.m., S2Certified Nursing Assistant (CNA) indicated she did not recall the last time Resident #5 had a cushion for his wheelchair. S2CNA verified Resident #5 remained in his wheelchair the majority of the day.
Observation on 08/21/2024 at 8:38 a.m. revealed a pressure reducing cushion was not in place for Resident #5's wheelchair.
In interview on 08/21/2024 at 1:25 p.m., S2Director of Nursing (DON), indicated all residents should have a cushion on their wheelchair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, record reviews, and interviews the facility failed to ensure S6Licensed Practical Nurse (LPN) disposed of a resident's medication as required for 1 (S6LPN) of 3 (S6LPN, S7LPN, an...
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Based on observation, record reviews, and interviews the facility failed to ensure S6Licensed Practical Nurse (LPN) disposed of a resident's medication as required for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration.
Findings:
Review of the facility's Medication Administration Policy and Procedure with effective date of 03/03/2022 revealed, in part, medication shall be prepared immediately prior to administration. Further review revealed if a medication was held because of the nurse's discretion, a notation shall be made on the resident's medication record. Review also revealed wasted control drugs shall be witnessed and co-signed.
Review of Resident #86's August 2024 Physician's Orders revealed, in part, Resident #86 was to be administered Oxycodone/Acetaminophen (a controlled medication to treat pain) 10/325 milligrams (mg) one tablet by mouth every 6 hours as needed for pain.
Observation on 08/20/2024 at 1:09 p.m. revealed S6LPN assessed Resident #86 for pain. Resident #86 voiced he had a pain level of 8 out 10 (0 indicating no pain and 10 indicating the worst pain imaginable). S6LPN then obtained Resident #86's Oxycodone/Acetaminophen 10/325mg from the blister pack and placed the medication in a medication cup. Further observation revealed S6LPN attempted to document the administration of Resident #86's Oxycodone/Acetaminophen 10/325mg in Resident #86's electronic medication record, and noted it was 20 minutes too early to administer Resident #86's Oxycodone/Acetaminophen 10/325mg. S6LPN then placed Resident #86's Oxycodone/Acetaminophen 10/325mg tablet from the medication cup back into Resident #86's Oxycodone/Acetaminophen 10/325mg blister pack. S6LPN then placed a piece of tape over the opening of Resident #86's blister pack.
In an interview on 08/20/2024 at 1:15 p.m., S6LPN confirmed she should have disposed of Resident #86's Oxycodone/Acetaminophen 10/325mg when it was unable to be administered.
In an interview on 08/21/2024 at 4:25 p.m., S2Director of Nursing (DON) indicated Resident #86's Oxycodone/Acetaminophen 10/325mg medication should have been disposed of when S6LPN removed the medication from the blister pack and was unable to administer it. S2DON further indicated S6LPN should not have placed Resident #86's Oxycodone/Acetaminophen 10/325mg medication back into the blister pack for administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to:
1. Ensure a resident's most recent hospice plan of care and recertification of terminal illness was obtained from the contracted hospice...
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Based on record reviews and interviews, the facility failed to:
1. Ensure a resident's most recent hospice plan of care and recertification of terminal illness was obtained from the contracted hospice agency (Resident #13); and,
2. Ensure facility staff were aware of the contracted hospice agency's responsibilities in implementing the hospice plan of care (Resident #13).
This deficient practice was identified for 1 (Resident #13) of 1 (Resident #13) sampled resident reviewed for hospice services.
Findings:
Review of Resident #13's Significant Change Minimum Data Set with an Assessment Reference Date of 05/08/2024 revealed, in part, Resident #13 received hospice services while a resident in the facility.
Review of Resident #13's facility hospice care plan initiated on 04/26/2024 revealed, in part, the facility should coordinate Resident #13's care with the contracted hospice agency.
Review of Resident #13's August 2024 Physician's Orders revealed, in part, an order to admit Resident #13 to the contracted hospice agency on 04/26/2024.
1.
Review of the facility and contracted hospice agency's Residential Hospice Agreement dated 06/23/2022 revealed, in part, the Hospice Plan of Care was a written care plan established, maintained, reviewed, and modified, if necessary, at intervals established by the contracted Hospice Interdisciplinary Group (IDG), which included: an assessment of each hospice patient's needs; an identification of the Hospice Services; and, details of the scope and frequency of such Hospice services. Further review revealed the contracted hospice agency will develop a Plan of Care for each Residential Hospice Patient and promptly furnish it to the nursing facility. Review also revealed the facility's designee to implement the facility and contracted hospice agency's Residential Hospice Agreement was listed as the administrator.
Review of Resident #13's contracted hospice agency's binder revealed, in part, the following:
-Resident #13 was admitted to the contracted hospice agency on 04/26/2024;
-Resident #13's certification period was from 04/26/2024 through 07/24/2024;
-The only hospice plan of care documented was Resident #13's Hospice Interim Plan of Care dated 04/26/2024, which did not identify Resident #13's hospice services needs or detail the scope and frequency of such hospice services; and,
-No documented evidence of a current certification of Resident #13's terminal illness.
There was no documented evidence, and the facility was unable to present any documented evidence of current hospice information for Resident #13.
In an interview on 08/21/2024 at 3:45 p.m., S2Director of Nursing (DON) confirmed Resident #13 received hospice services from the contracted hospice agency.
In an interview on 08/22/2024 at 11:18 a.m., S6Licensed Practical Nurse (LPN) indicated she was unsure how often Resident #13's contracted hospice agency updated the information in Resident #13's hospice binder.
In an interview on 08/22/2024 at 11:46 a.m. S2DON indicated Resident #13's hospice binder contained the most current information the facility had regarding Resident #13's contracted hospice agency. S2DON further indicated it was not the facility's policy to ensure Resident #13's hospice binder was up to date.
In an interview on 08/22/2024 at 2:51 p.m., Resident #13's Contracted Hospice Agency Case Manager (CHACM) indicated Resident #13's last hospice IDG meeting to review Resident #13's hospice plan of care was on 08/20/2024. Resident #13's CHACM confirmed hospice care plans were updated at least every 60 days. Resident #13's CHACM confirmed Resident #13's 04/26/2024 Hospice Interim Plan of Care was not Resident #13's current plan of care. Resident #13's CHACM indicated the contracted hospice agency should bring updated hospice documents to the facility at least every 2 weeks.
In an interview on 08/22/2024 at 2:51 p.m., S1Administrator confirmed he was the facility staff designated to ensure the facility and contracted hospice agency's agreement was followed. S1Administrator indicated he was not aware Resident #13's hospice binder was not kept up to date. S1Administrator confirmed the only hospice plan of care for Resident #13 was dated 04/26/2024.
2.
Review of the facility's undated Hospice Benefit Care Requirements Policy and Procedure revealed, in part, the contracted hospice agency and the facility should be aware of the other's responsibilities in implementing the plan of care.
Review of Resident #13's hospice binder revealed no documented evidence, and the facility was unable to present any documented evidence the facility was aware of the frequency in which Resident #13's hospice personnel were to provide services.
In an interview on 08/22/2024 at 11:18 a.m., S6LPN indicated she was unsure how often Resident #13's contracted hospice nurse visited. S6LPN further stated she was unsure how often the hospice agency updated the resident's binder.
In an interview on 08/22/2024 at 11:46 a.m., S2DON indicated the contracted hospice agency nurse's visits change based on the individual hospice resident's needs and condition, so S2DON was unable to determine how often Resident #13's contracted hospice agency nurse visited Resident #13.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record review, observations, and interviews, the facility failed to ensure:
1. S8Certified Nursing Assistant (CNA) performed hand hygiene after providing incontinence care for 1 (Resident #19...
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Based on record review, observations, and interviews, the facility failed to ensure:
1. S8Certified Nursing Assistant (CNA) performed hand hygiene after providing incontinence care for 1 (Resident #19) of 1 (Resident #19) sampled residents observed during incontinence care;
2. S5Treatment Nurse (TN) performed hand hygiene during wound care for 2 (Resident #5 and Resident #17) of 3 (Resident #5, Resident #14, and Resident #17) sampled residents observed for wound care;
3. S6Licensed Practical Nurse (LPN) did not handle Resident #86's medication with ungloved hands for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration;
4. S6LPN performed hand hygiene after removing her gloves and prior to applying clean gloves for 1 (S6LPN) of 3 (S6LPN, S7LPN, and S11LPN) nurses observed during medication administration;
5. Clean items in the facility's laundry room were not kept in the contaminated laundry area; and,
6. Staff identified and took corrective action when a cluster of 3 bacterial urinary tract infections were identified for residents who resided in close proximity of each other in the facility.
Findings:
Review of the facility's Hand Washing/Hand Hygiene Policy and Procedure revealed staff were to perform hand hygiene prior to applying gloves and after removing gloves.
1.
Observation on 08/20/2024 at 12:52 p.m., revealed S8CNA put on a pair of gloves and completed incontinence care for Resident #19. Further observation revealed S8CNA did not remove her gloves nor perform hand hygiene and proceeded to pulled up Resident #19's blankets, adjusted Resident #19's pillow, adjusted Resident #19's bed using the bed remote, handed Resident #19 a television remote, and opened Resident #19's side table drawer with the same gloved hands used during incontinence care.
In an interview on 08/20/2024 at 1:09 p.m., S8CNA acknowledged she did not remove her gloves or perform hand hygiene after completing Resident #19's incontinence care before touching the above mentioned items, and should have.
In an interview on 08/22/2024 at 8:50 a.m., S2Director of Nursing (DON) acknowledged S8CNA should have removed her gloves and performed hand hygiene after completing Resident #19's incontinence care, and prior to touching before touching the above mentioned items in Resident #19's room.
2.
Resident #5
Observation on 08/20/2024 at 9:42 a.m. revealed S5Treatment Nurse (TN) applied two pairs of gloves on her hands before performing wound care to Resident #5's left buttock wound. Observation revealed after removing Resident #5's soiled dressings S5Treatment Nurse removed the top pair gloves, did not remove the second pair of gloves, and did not perform hand hygiene prior to providing treatment to Resident #5's right lower leg wound.
Resident #17
Observation on 08/21/2024 at 11:18 a.m. revealed S5TN hand sanitized and applied gloves and went into Resident #17's room and set up her wound care supplies. S5Treatment Nurse removed her gloves did not perform hand hygiene and then applied two sets of gloves on each hand. S5Treatment Nurse then removed the dirty dressing and cleaned Resident #17's right ischium wound. S5Treatment Nurse removed the first set of gloves and did not remove the second set of gloves or perform hand hygiene and then applied Resident #17's collagen and creams, and clean dressing.
In an interview on 08/21/2024 at 11:25 a.m., S5TN indicated she had always double gloved for wound care and had not realized she was to perform hand hygiene after removing gloves.
In an interview on 08/21/2024 at 4:28 p.m., S2DON indicated S5TN should have changed her gloves and performed hand hygiene between clean and dirty procedures.
3.
Observation on 08/20/2024 at 1:09 p.m. revealed S6Licensed Practical Nurse (LPN) pulled Resident #86's Oxycodone/Acetaminophen (narcotic pain medication used to treat pain) 10/325 milligrams (mg) from the blister pack and into a medication cup. Further observation revealed S6LPN identified she was unable to administer Resident #86's Oxycodone/Acetaminophen 10/325 mg. Further observation then revealed S6LPN did not perform hand hygiene,, and used her ungloved hand to remove Resident #86's Oxycodone/Acetaminophen 10/325 mg out of the medication cup and place the Oxycodone/Acetaminophen 10/325 mgh back into the blister pack.
In an interview on 08/20/2024 at 1:15 p.m., S6LPN confirmed she should not have grabbed Resident #86's medication with an ungloved hand and placed in the blister pack for administration.
4.
Observation on 08/20/2024 at 1:09 p.m. revealed S6LPN applied gloves and grabbed the handle of the water pitcher. S6LPN then administered Resident #86's medication. Further observation revealed S6LPN proceeded to remove her gloves and apply a new pair of gloves without performing hand hygiene, and then cleaned Resident #86's PICC (peripherally inserted central catheter) hub.
In an interview on 08/20/2024 at 1:15 p.m., S6LPN confirmed she should have performed hand hygiene after removing her gloves.
5.
Observation on 08/20/2024 at 8:35 a.m. of the contaminated area of the facility's laundry room revealed a yellow contamination bag of soiled laundry was on the floor, and the above mentioned laundry bag was leaned against a rack of clean clothing.
In an interview on 08/20/2024 at 8:35 a.m., S10Laundry confirmed the yellow contamination bag of soiled laundry was on the floor was leaning against a rack of clean clothing.
In an interview on 08/20/2024 at 8:57 a.m., S10Housekeeping Supervisor indicated the rack of clean clothing should not have been stored on the contaminated side of the laundry room.
In an interview on 08/22/2024 at 12:05 a.m., S2DON confirmed the rack of clean clothing should not have been stored on the contaminated side of the laundry room.
6.
Review of the facility's undated Infection Control Policy and Procedure revealed, in part, the facility's infections would be tracked and trended on a monthly basis by infection category, infection culture, and location. Further review revealed, in part, the Director of Nursing or designee would conduct in-service training for staff on the infection control program as needed.
Review of Resident #17's laboratory results revealed, in part, Resident #17's urine culture collected on 06/05/2024 was positive for Proteus Mirabilis (a gram-negative bacteria).
Review of Resident #48's laboratory results revealed, in part, Resident #48's urine culture collected on 06/05/2024 was positive for Proteus Mirabilis.
Review of Resident #64's laboratory results revealed, in part, Resident #64's urine culture collected on 06/07/2024 was positive for Proteus Mirabilis.
Review of the facility's June 2024 Antibiotic Use Tracking Sheet revealed, in part, the following:
-Resident #17 had a urinary tract infection caused by Proteus Mirabilis;
-Resident #48 had a urinary tract infection caused by Proteus Mirabilis; and,
-Resident #64 had a urinary tract infection caused by Proteus Mirabilis.
Review of the facility's June 2024 infection tracking floor map revealed, in part, Resident #17, Resident #48, and Resident #64 were documented to have the same type of infection and resided in close proximity to each other.
There was no documented evidence, and the facility did not present any documented evidence S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) was able to identify the above mentioned cluster of infections in June 2024 or that facility staff took corrective actions such as monitored, educated, or audited on infection control practices during pericare and/or catheter care following Resident #17's, Resident #48's, and Resident #64's urinary tract infections caused by Proteus Mirabilis.
In an interview on 08/22/2024 at 2:30 p.m., S3ADON/IP indicated she did not identify Resident #17, Resident #48 and Resident #64 having the same type of infection caused by the same organism while residing in close proximity to one another was considered a cluster. S3ADON/IP further indicated she had not identified Proteus Mirabilis as the predominate bacteria in Resident #17's, Resident #48's, and Resident #64's urinary tract infections. S3ADON/IP confirmed she did not monitor or complete audits of staff for proper hand hygiene during pericare and/or catheter care. S3ADON/IP further confirmed she did not implement any staff education and training on hand hygiene or methods to reduce the risk of cross contamination between residents.
In an interview on 08/22/2024 at 2:48 p.m., S2DON stated the facility's infections were monitored on the facility logs for tracking and training purposes, which included identifying clusters of infections on the facility's floor map. S2DON agreed in June 2024, S3ADON/IP used the facility floor map to document infections, but S3ADON/IP did not identify Proteus Mirabilis as the dominant bacteria in residents with urinary tract infections. S2DON further indicated the S3ADON/IP did not identify the potential cause of Proteus Mirabilis in the trending urinary tract infections for June 2024 and/or implement preventative measures to decrease the risk of further Proteus Mirabilis urinary tract infections, and should have. S2DON confirmed S3ADON/IP should have completed pericare audits, hand hygiene check-offs, and nurse audits for catheter changes and/or insertions.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days of completion for 3 (Resident #28, Resident #44, and Resident #241) of 5 (Resident #4, Resident #28, Resident #44, Resident #73, and Resident #241) residents reviewed for resident assessments.
Findings:
Resident #28
Review of Resident #28's Quarterly MDS with an Assessment Reference Date (ARD) of 07/17/2024 revealed, in part, the MDS was completed on 07/18/2024.
Review of the facility's MDS 3.0 Nursing Home (NH) Final Validation Report revealed, in part, Resident #28's Quarterly MDS with an ARD of 07/17/2024 was transmitted on 08/20/2024, which was greater than 14 days after the completion date.
Resident #44
Review of Resident #44's record revealed, in part, Resident #44 was admitted to the facility on [DATE] and discharged from the facility on 07/18/2024.
Review of Resident #44's Quarterly MDS with an ARD of 07/17/2024 revealed, in part, Resident #44's Quarterly MDS was completed on 07/31/2024.
Review of Resident #44's Discharge MDS with an ARD of 07/18/2024 revealed, in part, Resident #44's Discharge MDS was completed on 08/01/2024.
Review of the facility's MDS 3.0 NH Final Validation Report revealed, in part, Resident #44's Quarterly MDS was transmitted on 08/20/2024, which was greater than 14 days after the completion date of 07/31/2024. Further review revealed, Resident #44's Discharge MDS with an ARD of 07/18/2024 was transmitted on 08/20/2024, which was greater than 14 days after the completion date of 08/01/2024.
Resident #241
Review of Resident #241's record revealed, in part, Resident #241 discharged from the facility on 07/20/2024.
Review of Resident #241's Discharge MDS with an ARD of 07/20/2024 revealed, in part, the discharge MDS was completed on 08/03/2024.
Review of the facility's MDS 3.0 NH Final Validation Report revealed, in part, Resident #241's Discharge MDS with an ARD of 07/20/2024 was transmitted on 08/20/2024, which was greater than 14 days after the completion date.
In an interview on 08/22/2024 at 3:21 p.m., S4MDS Corporate Nurse indicated an MDS assessment should be transmitted within 14 days of the assessment's completion date. S4MDS Corporate Nurse confirmed she transmitted the above mentioned MDS assessments on 08/20/2024.
Oct 2023
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 3 ( Resident #12, Resident #19, and Resident #69) of 19 (Resident #1, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12, Resident #14, Resident #19, Resident #21, Resident #27, Resident #36, Resident #49, Resident #69, Resident #72, Resident #74, Resident #82, Resident #235, and Resident #237) sampled residents whose care plan was reviewed in the final investigation sample.
Findings:
Resident #12
Review of the Resident #12's Electronic Medical Record (EMR) revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Dementia and Generalized Anxiety.
Review of Resident #12's October 2023 Physician's orders revealed, in part, an order with a start date of 08/28/2023 for Ativan (a medication used to treat anxiety) 1 milligram (mg) by mouth every 8 hours as needed and an order dated 08/16/2023 for Sertraline (a medication used to treat depression) 50 mg by mouth at bedtime.
Review of Resident #12's Comprehensive Care Plan revealed, in part, no documented evidence of goals or interventions related to Resident #12 anti-anxiety or anti-depressant medication usage.
In an interview on 10/04/2023 at 3:05 p.m., S5Minimum Data Set(MDS)/Licensed Practical Nurse (LPN) stated residents with orders for antidepressants and antianxiety medications should have a care plan with goals and interventions that addresses the usage of antidepressant and antianxiety medication. S5MDS/LPN further confirmed that Resident #12's use of antianxiety and antidepressant medications was not address in Resident #12's care plan.
Resident #19
Review of Resident #19's Quarterly MDS (Minimum Data Set) was completed with an ARD (Assessment Reference Date) of 07/05/2023.
Review of Resident #19's Care Plan revealed, in part, the care plan had a target date of 05/18/2023.
In an interview on 10/05/2023 at 10:50 a.m., S5Minimum Data Set (MDS) Licensed Practical Nurse (LPN) stated Resident #19 should have had an updated care plan on 07/19/2023 and Resident #19's care plan was not updated.
Resident #69
Review of Resident #69's EMR revealed Resident #69 was admitted on [DATE] with a diagnosis of, in part, tobacco use.
Review of Resident #69's Smoking Safety Screen with a completion date of 6/27/2023 revealed Resident #69 was assessed as having altered mental status, not safe to smoke independently, and should wear a smoking apron when smoking.
Review of Resident #69's record revealed no documented evidence and the facility presented no documented evidence that a care plan had been developed for Resident #69's behavior of unsafe smoking.
In an interview on 10/05/2023 at 4:25 p.m., S22MDS/LPN confirmed no care plan was developed for Resident #69's unsafe smoking status, and Resident #69's unsafe smoking status should have been care planned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure the facility had eight consecutive hours per day of registered nurse (RN) services for 2 of the 40 days reviewed for RN staffing hour...
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Based on record review and interview the facility failed to ensure the facility had eight consecutive hours per day of registered nurse (RN) services for 2 of the 40 days reviewed for RN staffing hours.
Findings:
Review of the facility's time card report dated 09/23/2023 revealed S10Registered Nurse (RN) clocked in for 6.10 hours.
Review of the facility's time card report dated 09/30/2023 revealed S10RN clocked in for 7.70 hours.
There was no documented evidence and the facility did not present any documented evidence of having eight consecutive hours per day of registered nurse (RN) services for the above mentioned dates.
In an interview on 10/05/2023 at 3:23 p.m., S2Administrator confirmed the facility did not have RN coverage for eight consecutive hours on 09/23/2023 and 09/30/2023.
In an interview on 10/05/2023 at 4:38 p.m., S8Director of Nursing (DON) stated she was aware S10RN did not work 8 consecutive hours on 09/23/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to have the nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
Findings:
Observatio...
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Based on observation and interview, the facility failed to have the nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
Findings:
Observation on 10/02/2023 at 10:00 a.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
Observation on 10/02/2023 at 3:35 p.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
Observation on 10/03/2023 at 9:32 a.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
Observation on 10/03/2023 at 4:10 p.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
Observation on 10/04/2023 at 9:05 a.m., revealed nurse staffing data was not located in a prominent place that was readily accessible to residents and visitors.
In an interview on 10/04/2023 at 11:42 a.m., S19Ward Clerk indicated the daily nurse staffing data was posted flat on the desk behind a counter.
In an interview on 10/04/2023 at 2:12 p.m., S20Human Resource Director stated nurse staffing data was posted flat on the desk behind the counter of the nurse's station at the main entrance. S20Human Resource Director stated the nurse staffing data was not in a prominent place at the nurse's station that was accessible to visitors and residents.
In an interview on 10/05/2023 at 3:23 p.m., S2Administrator stated the nurse staffing data should be in a prominent place for all residents and visitors. S2Administrator confirmed the nurse staffing data was not in a prominent place for all residents and visitors when it was lying flat on the desk behind the counter of the nurse's station.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement program was developed, implemented, and/or maintained.
Findings:
Review ...
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Based on record review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement program was developed, implemented, and/or maintained.
Findings:
Review of the facility's Quality Assurance Policy and Procedure revealed, in part, the facility must identify quality assessment and assurance issues and develop, implement, and oversee the implementation of appropriate plans of correction for identified quality deficiencies.
There was no documented evidence and the facility was unable to present any documented evidence the facility had a Quality Assurance program in place.
In an interview on 10/05/2023 at 4:07 p.m., S1Regional Administrator stated the facility had no current or up to date Quality Assurance program.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to:
1. Ensure the Quality Assessment and Assurance committee met at least quarterly to identify facility issues and coordinate and evaluate pe...
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Based on record review and interview, the facility failed to:
1. Ensure the Quality Assessment and Assurance committee met at least quarterly to identify facility issues and coordinate and evaluate performance improvement projects; and,
2. Ensure the Quality Assessment and Assurance committee included the required members.
Findings:
Review of the facility's Quality Assurance Policy and Procedure revealed, in part, the facility's Quality Assurance committee will meet at least quarterly to identify issues and develop, implement, and/or oversee implementation of appropriate plans of correction for identified quality deficiencies. Further review revealed the Quality Assurance committee will consist of the medical director, the administrator, the director of nursing, and 3 other staff members designated by the facility.
There was no documented evidence and the facility was unable to present any documented evidence the facility's Quality Assessment and Assurance committee met at least quarterly or was composed of the required members.
In an interview on 10/05/2023 at 4:07 p.m., S1Regional Administrator stated he had no evidence to present to show Quality Assurance met on a quarterly basis or was made up of the required members.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a baseline care plan was initiated with 48 hours of admissi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a baseline care plan was initiated with 48 hours of admission for 3 (Resident #21, Resident #74, and Resident #237) of 19 (Resident #1, Resident #5, Resident #6, Resident #7, Resident #9, Resident #11, Resident #12. Resident #14, Resident #19, Resident #21, Resident #27, Resident #36, Resident #49, Resident #69, Resident #72, Resident #74, Resident #82, Resident #235, and Resident #237) sampled residents whose care plan was reviewed in the final investigation sample.
Findings:
Resident #21
Review of Resident #21's electronic medical record (EMR) revealed, in part, Resident #21 was admitted to the facility on [DATE]. Further review revealed Resident #21 had the following admit diagnoses which included, but not limited to, generalized anxiety disorder, depression, bipolar disorder, and schizoaffective disorder.
Review of Resident #21's care plan revealed, in part, a plan of care was not developed related to the above until 10/03/2023.
Resident #74
Review of Resident #74's EMR revealed, in part, Resident #74 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis.
Review of Resident #74's care plan revealed, in part, a care plan was not developed for the above until 10/03/2023.
Resident #237
Review of Resident #237's EMR revealed, in part, Resident #237 was admitted to the facility on [DATE] with a diagnosis of depression.
Review of Resident #237's October 2023 Physician's orders revealed, in part, an order dated 09/20/2023 to administer Alprazolam (a medication used to treat anxiety) 0.25 milligrams (mg) every 24 hours as needed for anxiety. Further review of Resident #237's Physician's ordered revealed, in part, an order dated 09/20/2023 to administer Sertraline Hydrochloride (HCL) (a medication used to treat depression) 50 mg every day.
Review of Resident #237's care plan revealed, in part, a plan of care was not developed for Resident #237's anxiety and antianxiety medication use and/or her depression and antidepressant medication use.
In an interview on 10/05/2023 at 10:23 a.m., S5Minimum Data Set (MDS) Licensed Practical Nurse (LPN) stated a resident's baseline care plan should be initiated in a resident's EMR within 48 hours from admission. S5MDS/LPN further stated the use of hypotonic, antianxiety, antidepressant, and psychotropic medication usage should be addressed in a resident's baseline care plan within 48 hours from admission. S5MDS/LPN further stated a resident's baseline care plan should also address if they have diagnosis of depression, anxiety, dialysis use, bipolar disorder or schizoaffective disorder within 48 hours from admission. S5MDS/LPN confirmed that the above resident's baseline care plans did not address the above mentioned medication usage or diagnoses and should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interviews, the facility failed to administer a resident's water flush per physician orders for 1 (Resident #11) of 1 (Resident #11) sampled residents investig...
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Based on record review, observation, and interviews, the facility failed to administer a resident's water flush per physician orders for 1 (Resident #11) of 1 (Resident #11) sampled residents investigated for enteral feedings.
Findings:
Review of the facility's Care Of Enteral Feeding Tube Policy and Procedure revealed, in part, all enteral tube feedings shall have care according to physician orders.
Review of Resident #11's October 2023 physician orders revealed, in part, an order with a start date of 09/29/2023 for Resident #11 to receive 35 milliliters (ml) of flush of water for 22 hours per day.
Observation on 10/02/2023 at 10:25 a.m. revealed, Resident #11's enteral feeding pump was set to infuse a water flush of 35mL every 4 hours.
Observation on 10/02/2023 at 11:43 a.m. revealed, Resident #11's enteral feeding pump was set to infuse a water flush of 35mL every 4 hours.
Observation on 10/03/2023 at 10:00 a.m. revealed, Resident #11's enteral feeding pump was set to infuse a water flush of 35mL every 4 hours.
Observation on 10/03/2023 at 1:35 p.m. revealed, Resident #11's enteral feeding pump was set to infuse a water flush of 35mL every 4 hours.
In an interview on 10/03/2023 at 1:30 p.m., S4Licensed Practical Nurse (LPN) confirmed Resident #11 had received a water flush of 35mL every 4 hours on 10/02/2023 and 10/03/2023. S4LPN stated she was unaware Resident #11's order changed from 35mL of water flush every 4 hours to 35mL of water flush every hour for 22 hours daily.
In an interview on 10/05/2023 at 3:05 p.m., S7Registered Dietician stated she was in the facility on 09/13/2023 and notified S18Assistant Director of Nursing Resident #11's free water flush rate was incorrect.
In an interview on 10/05/2023 at 3:19 p.m., S18ADON confirmed Resident #11 received the enteral water flush at the wrong rate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 a resident's continuous positive airway pressur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident's continuous positive airway pressure (CPAP) mask was contained for 1 (Resident #6) of 4 (Resident #5, Resident #6, Resident #27, and Resident #237) sampled residents reviewed for respiratory care.
Findings:
Review of Resident #6's record revealed Resident #6 was admitted [DATE] with diagnoses of, in part, Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea (OSA), Chronic Pulmonary Edema, and Legal blindness.
Review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/06/2023 revealed, in part, Resident #6's vision was severely impaired; Brief Interview for Mental Status (BIMS) score of 12 (score of 08-12 indicated moderate cognitive impairment). Further review revealed Resident #6 received fifteen minutes of respiratory therapy for one day.
Review of Resident #6's Physician Orders for October 2023 revealed, in part, Resident #6's CPAP should be applied at bedtime and removed every morning.
In an interview on 10/02/2023 at 10:03 a.m., Resident #6 stated he was blind and relied on staff to handle his respiratory equipment. He further stated he wears his CPAP every night.
Observation on 10/02/2023 at 10:03 a.m. revealed Resident #6's CPAP mask was uncontained with the mask touching the bedside table.
Observation on 10/03/2023 at 10:58 a.m. revealed Resident #6's CPAP mask was uncontained with the mask touching the bedside table.
Observation on 10/04/2023 at 8:38 a.m. revealed Resident #6's CPAP mask was uncontained with the mask touching the bedside table.
In an interview on 10/04/2023 at 8:44 a.m., S17Licensed Practical Nurse (LPN) stated Resident #6 was blind in both eyes and needed staff assistance for respiratory care.
In an interview on 10/05/2023 at 10:13 a.m., Resident #6 stated he used a nebulizer. Resident #6 stated he was blind and needed assistance with changing tubing, filters, oxygen equipment, and cleaning his nebulizer and CPAP.
Observation on 10/05/2023 at 10:15 a.m. revealed Resident #6's CPAP was at the bedside. Resident #6's CPAP mask was uncontained and was visibly soiled with a white colored substance. Further observation revealed Resident #6's nebulizer was on his bed uncontained.
In an interview on 10/05/2023 at 2:10 p.m., S16LPN stated he was not sure if Resident #6's mask should be contained.
In an interview on 10/05/2023 at 4:34 p.m., S8Director of Nursing stated Resident #8's CPAP should have been contained.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure the accurate dispensation of controlled medications for 1 (medication cart c) of 2 medication carts (medication cart a and medicati...
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Based on record review and interviews, the facility failed to ensure the accurate dispensation of controlled medications for 1 (medication cart c) of 2 medication carts (medication cart a and medication cart c) observed and reviewed for accurate dispensation of controlled medications.
Findings:
On 10/03/2022 at 5:35 p.m., a reconciliation was completed of controlled substances on medication cart c, and the controlled substance binder for medication cart c revealed the following:
Review of Resident #27's medication card for Hydrocodone-Acetaminophen 5-325 milligrams (mg) (a medication used to treat pain) revealed Resident #27 had 23 tablets available. Review of Resident #27's Individual Narcotic Record revealed, in part, Resident #27 had 24 Hydrocodone-Acetaminophen 5-325mg tablets available
Review of Resident #28's medication card for Alprazolam 0.25 mg (a medication used to treat anxiety) revealed Resident #28 had 44 tablets available. Review of Resident #28's Individual Narcotic Record revealed, in part, Resident #28 had 45 Alprazolam 0.25 mg tablets available.
Review of Resident #22's medication card for Lorazepam 0.5 mg (a medication used to treat anxiety) revealed Resident #22 had 57 tablets available. Review of Resident #22's Individual Narcotic Record revealed, in part, Resident #22 had 59 Lorazepam 0.5 mg tablets available.
Review of Resident #61's medication card for Alprazolam 0.5 mg revealed Resident #61 had 2 tablets available. Review of Resident #61's Individual Narcotic Record revealed, in part, Resident #61 had 4 Alprazolam 0.5 mg tablets available.
Review of Resident #61's medication card for Hydrocodone-Acetaminophen 10-325 mg revealed Resident #61 had 18 tablets available. Review of Resident #61's Individual Narcotic Record revealed, in part, Resident #61 had 19 Hydrocodone-Acetaminophen 10-325 mg tablets available.
Review of Resident #41's medication card for Xanax 0.25 mg (a medication used to treat anxiety) revealed Resident #41 had 3 tablets available. Review of Resident #41's Individual Narcotic Record revealed, in part, Resident #41 had 4 Xanax 0.25 mg tablets available.
Review of Resident #41's medication card for Tramadol 50 mg (a medication used to treat anxiety) revealed Resident #41 had 36 tablets available. Review of Resident #41's Individual Narcotic Record revealed, in part, Resident #41 had 37 Tramadol 50 mg tablets available.
Review of Resident #56's medication card for Alprazolam 0.25 mg revealed Resident #56 had 4 tablets available. Review of Resident #56's Individual Narcotic Record revealed, in part, Resident #56 had 5 Alprazolam 0.25 mg tablets available.
Review of Resident #56's medication card for Alprazolam 0.25mg had 4 pills in the blister pack, and the documentation in the individual narcotic record count was 5.
In an interview on 10/05/2023 at 4:15 p.m., S21Unit Manager stated when a controlled medication was administered to a resident, the controlled medication should be reconciled on the individual narcotic record by the nurse. S21Unit Manager further stated that the facility's nurses should not wait until the end of their shift to document the administration of a controlled medication on the individual narcotic records.
In an interview on 10/05/2023 at 5:55 p.m., S2Administrator stated the nurses should keep accurate controlled substance records and should document the administration of controlled substances at the time of administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on record reviews, observations, and interviews, the facility failed to ensure expired medications and dressings were not available for residents use.
Findings:
Observation of medication cart a ...
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Based on record reviews, observations, and interviews, the facility failed to ensure expired medications and dressings were not available for residents use.
Findings:
Observation of medication cart a on 10/04/2023 at 5:16 p.m. revealed, in part, a box of 14 Bisacodyl Stimulant Laxative Suppositories (medication administered rectally and used to treat constipation) 10 mg had expired in 09/2023.
In an interview on 10/04/2023 at 5:16 p.m., S4Liscensed Practical Nurse (LPN) confirmed the 14 Bisacodyl Stimulant Laxative Suppositories 10 mg expired in 09/2023. S4LPN further stated the 14 Bisacodyl Stimulant Laxative Suppositories 10 mg should not be in medication cart a and available for resident use.
Observation of treatment cart b on 10/05/2023 at 9:09 a.m., revealed, in part, 1 ManukAhd Super Lite Honey Coated absorbent dressing (a honey impregnated super absorbent gelling fiber dressing) had an expiration date of 09/2023.
In an interview on 10/05/2023 at 9:09 a.m., S3Treatment Nurse (TN) stated the above listed dressings was expired and should not have been in treatment cart b and available for resident use.
In an interview on 10/05/2023 at 5:55 p.m., S2Administrator stated the above expired medications and the expired dressing should not be in medication cart a and treatment cart b and available for resident use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to:
1. Ensure expired food was not available for resident consumption; and
2. Appropriately date and label food that was opened...
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Based on observation, interview, and record review, the facility failed to:
1. Ensure expired food was not available for resident consumption; and
2. Appropriately date and label food that was opened and available for use.
Findings:
Review of the facility's Food Safety And Sanitation Policy And Procedure revealed, in part, foods with expiration dates were to be used by the date on the package.
Observation on 10/02/2023 at 9:21 a.m. of the facility's 3 door refrigerator revealed, in part:
-A half pint whole milk with an expiration date of 09/20/2023;
-Two 32 ounce containers of chopped garlic with expiration dates of 09/17/2023;
-32 ounce container of lemon juice with an expiration date of 02/2023;
-5 pounds of shredded cheese with no open date or expiration date present; and
-One large container of fresh diced tomatoes uncovered with no open date present.
Observation on 10/02/2023 at 9:23 a.m. of the facility's main meat freezer revealed, in part:
- One opened bag of frozen egg rolls with no expiration date or open date present;
- One bag of opened frozen diced chicken with no expiration date or open date present;
- One bag of opened boneless chicken wings with no expiration date or open date present;
- One ziploc bag of opened breaded fish with no open date or expiration date present;
- One bag of opened diced ham with no expiration date or open date present;
- One bag of opened white shredded cheese with no expiration date or open date present;and
- One opened ziploc bag containing 9 frozen hamburger patties with no open date or expiration date present.
Observation on 10/02/2023 at 9:24 a.m. revealed, one opened bag of 15 hamburger buns with no open date and an expiration date of 10/01/2023 with an unknown green powdery substance noted at the bottom of the bag covering one full hamburger bun.
In an interview on 10/02/2023 at 9:25 a.m., S23Dietary Manager confirmed all of the above findings were deficient.
Observation on 10/03/2023 at 2:15 p.m. of the 2 door refrdigerator revealed, a half full gallon of 2% milk with an expiration date of 09/25/2023.
Observation on 10/04/2023 at 11:08 a.m. of the 3 door refrigerator revealed, the following items were not dated or labeled: a 3.53 pound raw chicken, 3.29 pound raw chicken, 3.72 pound raw chicken.
In an interview on 10/05/2023 at 5:16 p.m., S2Administrator stated the above findings were deficient practice.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure staff did not present a medical record as being accurate pri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure staff did not present a medical record as being accurate prior to a resident's death and ensure staff did not alter a medical record after a resident had expired.
This deficient practice was identified for 1 (Resident #74) of 3 (Resident #19, Resident #74, and Resident #82) closed records reviewed.
Findings:
Review of Resident #74's electronic medical record (EMR) revealed, in part, Resident #74 expired on [DATE]. Further review of Resident #74's EMR revealed Resident #74's plan of care was last revised on [DATE].
Review of Resident #74's care plan provided to survey team as Resident #74's accurate care plan revealed, in part, 21 goals and 117 interventions were initiated by S27Corporate Nurse on [DATE] in Resident #74's care plan.
In an interview on [DATE] 2:40 p.m., S5Minimum Data Set (MDS) Licensed Practical Nurse (LPN) stated Resident #74's care plan was revised on [DATE] after Resident #74 was deceased , and the care plan presented to the survey team was not reflective of the care plan that was in place while Resident #74 was a resident at the facility.
In an interview on [DATE] at 2:40 p.m., S2Administrator confirmed Resident #74's care plan had goals and interventions initiated on [DATE].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to:
1. Ensure S26Certified Nurse Assistant (CNA) perf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to:
1. Ensure S26Certified Nurse Assistant (CNA) performed hand hygiene during catheter care for 1 (Resident #234) of 4 residents (Resident #21, Resident #27, Resident #234, and Resident #236) investigated for infection control;
2. Ensure proper use of personal protective equipment (PPE) for 3 Coronavirus Disease 2019 (COVID-19) positive residents (Resident #21, Resident #27, and Resident #236) of 7 (Resident #5, Resident #16, Resident #21, Resident #27, Resident #39, Resident #41, and Resident #236) COVID-19 positive residents;
3. Identify and test residents and staff that were in close contact with COVID-19 positive residents per the facility's COVID-19 Policy; and
4. Ensure signage was placed at the front door to notify family and visitors of the current COVID-19 outbreak.
Findings:
1.
Review of Resident #234's care plan revealed, in part, the facility's staff would provide catheter care to Resident #234 every shift.
Observation on 10/04/2023 at 10:29 a.m., revealed S26CNA put on gloves without first performing hand hygiene, performed catheter care to the head of Resident #234's penis, discarded her gloves, and put on new gloves without first performing hand hygiene. Further observation revealed, S26CNA then cleaned Resident #234's right groin, discarded gloves, and put on new gloves without performing hand hygiene. Further observation revealed S26CNA turned Resident #234's to his side, wiped Resident #234's buttocks, discarded her gloves, put on new gloves, placed a new brief on Resident #234, and pulled Resident #234's pants up without performing hand hygiene. Further observation revealed, S26CNA removed her gloves, put on new gloves and obtained a urinal from Resident #234's bathroom without first performing hand hygiene.
In an interview on 10/05/2023 at 4:39 p.m., S26CNA stated she did not perform hand hygiene before starting Resident #234's catheter care or when changing gloves between steps in Resident #234's catheter care and should have. S26CNA further stated that she did not perform hand hygiene before putting on gloves, putting on Resident #234's brief, or pulling of Resident #234's pants and should have performed hang hygiene.
In an interview on 10/05/2023 at 4:12 p.m., S8Director of Nursing (DON) stated CNAs should perform hand hygiene before starting catheter care, and before putting on new gloves when changing gloves between the steps for catheter care.
2.
Review of the facility's Isolation (Transmission Based Precautions) Policy and Procedure revealed, in part, standard and transmission based precautions (TBP) will be followed to prevent the spread of infection. Further review revealed, a gown and gloves are to be utilized for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment for residents on contact isolation. Further review revealed, in part, droplet precautions include infections that are transmitted by contact via droplets during coughing, sneezing, and talking. Additionally gloves, gown, and mask are to be utilized for all interactions that may involve contact with the resident.
Review of the facility's COVID Tracking Sheet revealed, in part, Resident #21, Resident #27, and Resident #236 tested positive for COVID-19 on 09/27/2023 and placed on TBP.
Observation on 10/02/2023 at 12:02 p.m., revealed S11CNA Coordinator entered Resident #27's room with only a disposable face mask.
Observation on 10/02/2023 at 12:22 p.m., revealed S13CNA entered Resident #236's room with only gloves and a N95 mask (designed to filter airborne particles).
Observation on 10/02/2023 at 12:24 p.m., revealed S13CNA entered Resident #21's room with only gloves and a N95 mask.
In an interview on 10/02/2023 at 12:30 p.m., S13CNA stated she entered Resident #21 and Resident #236's rooms with only gloves and a N95 mask. S13CNA further stated she should have entered Resident #21 and Resident #236's rooms with full PPE which included a disposable gown, gloves, and a N95 mask.
Observation on 10/03/2023 at 12:01 p.m., revealed S11CNA Coordinator entered Resident #236's room wearing only a disposable face mask.
In a telephone interview on 10/03/2023 at 2:32 p.m., S8DON stated any staff member who enters a room who is on droplet isolation they should apply gloves, gowns, and a N95 mask. S8DON further indicated googles were also to be worn if a spatter were involved.
Observation on 10/04/2023 at 12:00 p.m., revealed S15CNA entered Resident #236's room with only a disposable face mask.
In an interview on 10/04/2023 at 12:07 p.m., S15CNA acknowledged she entered Resident #236's room with only a disposable face mask. S15CNA further stated she should have entered Resident #236's room with gloves, a gown, and a N95 mask.
In an interview on 10/05/2023 at 9:10 a.m., S11CNA Coordinator stated on 10/02/2023, when she entered Resident #27, Resident #34, and Resident #72 rooms to deliver lunch, she should have used a gown, gloves, and a N95 mask and did not. S11CNA Coordinator further stated on 10/03/2023 when she entered Resident #21 and Resident #236's room to deliver lunch she should have used a gown, gloves, and a N95 mask and did not.
In an interview on 10/05/2023 at 4:38 p.m., S8DON stated every staff member who entered Resident #5, Resident #16, Resident #21, Resident #27, Resident #39, Resident #41, and Resident #236's room should have applied full PPE which included a gown, gloves, and a N95 mask.
3.
Review of the facility's Coronavirus Disease 2019 (COVID)-19 Testing Policy and Procedure revealed, in part, staff that can identify a high risk exposure with newly identified COVID-19 positive staff members or residents should be included in testing. Further review revealed, in part, residents that have had close contact with a newly identified COVID-19 positive residents or staff members should be tested. Additional review revealed, in part, outbreak testing could be through contact tracing or broad based testing and should include symptomatic individuals, staff with a high-risk exposure to a COVID-19 positive individual, or residents that have had close contact with a COVID-19 positive individual. Further review revealed, a new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation and additional testing. Further review revealed, contact tracing should be completed with newly identified COVID-19 positive staff members or residents if close contacts can be identified. Further review revealed, testing for COVID-19 was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the second negative test. Further review revealed, a facility wide (unit, floor, or other specific area) approach should be considered if all potential contacts cannot be identified, and, if additional cases are identified, strong consideration should be given to shifting to the broad-based approach.
Review of the facility's COVID Tracking Sheet revealed, in part, Resident #21, Resident #27, and Resident #236 tested positive for COVID-19 on 09/27/2023 and placed on TBP.
In an interview on 10/02/2023 at 1:13 p.m., S9Infection Preventionist (IP) stated all residents on Hall d should have been tested on [DATE] (day 1), 09/30/2023 (day 3), and 10/02/2023 (day 5). S9IP further stated I don't know if Hall d was tested on [DATE]. S9IP stated contact tracing was followed for outbreak testing. S9IP stated on 10/01/2023 S8DON and S18Assistant Director of Nursing (ADON) tested positive for COVID-19.
In an interview on 10/03/2023 at 9:10 a.m., S9IP stated I am so overwhelmed and don't know what should be done. S9IP further stated she did not know what the next step for COVID-19 testing should have been to prevent the spread of infection.
In an interview on 10/03/2023 at 12:06 p.m., S28Medical Director stated the facility should have been testing the areas of the facility where there were COVID-19 positive residents.
In a telephone interview on 10/03/2023 at 2:32 p.m., S8DON stated all staff who were in contact with COVID-19 positive residents should have been tested for COVID-19 before returning to work after having several days off or at the onset of symptoms. S8DON further stated she did not have any documentation of staff being tested for COVID-19 before returning to work after several days off. S8DON stated if the facility used the contact tracing method to decide which residents to test, the residents on Hall g should have been tested for COVID-19 when Resident #21 and Resident #236 tested positive. S8DON further stated that residents on Hall g were not tested for COVID-19 as it relates to the facility's contact training procedures.
In an interview on 10/04/2023 at 9:09 a.m., S9IP stated staff were tested for COVID-19 if they presented with any symptoms and before returning to work.
There was no documented evidence and the facility did not present any documented evidence that staff members who were in contact/high exposure with COVID-19 positive staff or residents were tested for COVID-19.
There was no documented evidence and the facility did not present any documented evidence of COVID-19 testing for the residents on Hall g.
There was no documented evidence and the facility did not present any documented evidence of COVID-19 testing on 09/30/2023 for the residents on Hall d.
In an interview on 10/04/2023 at 3:54 p.m., S9IP stated she did not keep a list of staff who had contact with the COVID-19 positive residents and did not test those staff or have any documentation that those staff were tested for COVID-19. S9IP stated all the residents on Hall d were tested for COVID-19 on 09/27/2023 due to several residents testing positive for COVID-19 on 09/23/2023, 09/25/2023, and 09/26/2023. S9IP stated all negative residents on Hall d should have been retested on [DATE] per the facility's policy. S9IP further stated I don't know if all residents on Hall d were tested for COVID-19 on 09/30/2023 because I was not here. S9IP stated she did not have any documentation of any residents being tested for COVID-19 on 09/30/2023. S9IP also stated there were 2 residents (Resident #21 and Resident #236) on Hall g who were COVID-19 positive and on Hall g had not been tested for COVID-19. S9IP stated the residents on Hall g should have been tested for COVID-19 due to coming into close contact with Resident #21 and Resident #236 when they all participated in therapy in the facility's therapy gym.
4.
Review of the facility's Outbreak Policy and Procedure revealed, in part, in the event of an outbreak the facility will place signage at the front door to notify family and visitors.
Observation on 10/02/2023 at 9:00 a.m., revealed no signage noted on the facility's entrance and exit doors indicating the facility's current COVID-19 outbreak.
Observation on 10/03/2023 at 8:45 a.m., revealed no signage noted on the facility's entrance and exit doors indicating the facility's current COVID-19 outbreak.
Observation on 10/04/2023 at 8:52 a.m., revealed no signage noted on the facility's entrance and exit doors indicating the facility's current COVID-19 outbreak.
In an interview on 10/04/2023 at 3:54 p.m., S9IP stated she did not post any signs in the facility that notified visitors of the current COVID-19 outbreak. S9IP further stated she should have posted signs immediately after the start of the COVID-19 outbreak.
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 record review and interviews, the facility failed to provide in-service training for nurse aides to ensure the continuing competence of nurse aides and no less than 12 hours per year for 1 (S...
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Based on record review and interviews, the facility failed to provide in-service training for nurse aides to ensure the continuing competence of nurse aides and no less than 12 hours per year for 1 (S11Certified Nurse Assistant (CNA) Coordinator) of 5 (S11Certified Nurse Coordinator, S12Certified Nurse Assistant, S13Certified Nurse Assistant, S14Certified Nurse Assistant, S24Agency Certified Nurse Assistant) staff training records reviewed for in-service training.
Findings:
Review of S11Certified Nurse Coordinator's personnel record revealed, in part, a hire date of 07/17/2020. Further review revealed, in part, 4 of the 12 hours of training was completed.
There was no documented evidence and the facility did not provide any documented evidence that S11CNA Coordinator completed the required training.
In an interview on 10/05/2023 at 3:23 p.m., S2Administrator stated she did not have the documentation that S11CNA Coordinator completed the required training.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to provide a nutritional supplement as ordered for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, ...
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Based on observations, interviews, and record reviews, the facility failed to provide a nutritional supplement as ordered for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed.
Findings:
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/2023 revealed Resident #1 received a therapeutic diet.
Review of Resident #1's July 2023 Physician Orders revealed, in part, an order for a magic cup (magic cup is a dessert cup that is an option for adding calories and protein for those who experience involuntary weight loss) three times a day for supplement.
Review of Resident #1's Care Plan revealed Resident #1 was at risk for weight loss and had a physician prescribed caloric supplement.
Observation on 07/31/2023 at 12:03 p.m. at lunch revealed Resident #1's magic cup supplement was not provided.
Observation on 08/01/2023 at 12:19 p.m. revealed S3 Certified Nursing Assistant (CNA) served Resident #1 her lunch tray. Resident #1's tray did not include a magic cup.
In an interview on 08/01/23 at 12:40 p.m., S3CNA confirmed a magic cup was not on Resident #1's lunch tray on 08/01/2023.
In an interview on 08/01/23 at 12:44 p.m., S2 Dietary Manager (DM) stated she did not know if Resident #1 had an order for a magic cup with meals. S2DM reviewed Resident #1's diet order and confirmed a magic cup was ordered; however, it was not listed on Resident #1's meal ticket. On 08/01/2023 at 12:42 p.m., S2DM confirmed Resident #1 had not been provided with the magic cup as ordered.
In an interview on 08/01/2023 at 12:45 p.m., S4CNA stated Resident #1 did not have a magic cup with her breakfast on 08/01/2023.
In an interview on 08/01/2023 at 1:15 p.m., S1 Director of Nursing (DON) stated Resident #1 had a physician's order for a magic cup with every meal and a magic cup should have been sent on her tray for each meal.
Mar 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 5 Licensed Practical Nurses (LPN) (S2LPN, S3LPN, S4LPN, S5LP...
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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 5 Licensed Practical Nurses (LPN) (S2LPN, S3LPN, S4LPN, S5LPN, and S6LPN) were certified in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR).
Findings:
Review of the facility's Cardiopulmonary Resuscitation Policy and Procedure revealed, in part, CPR is defined as artificial respiration accompanied by external cardiac compression. Further review revealed nursing staff members must have a current CPR certificate.
Review of S2LPN's personnel record revealed, in part, S2LPN's CPR certification expired in October of 2021. Further review did not reveal nor did the facility present any evidence of S2LPN having a current CPR certification.
Review of S3LPN's personnel record revealed, in part, S3LPN's CPR certification expired on [DATE]. Further review did not reveal nor did the facility present any evidence of S3LPN having a current CPR certification.
Review of S4LPN's personnel record revealed, in part, S4LPN's CPR certification expired in October of 2021. Further review did not reveal nor did the facility present any evidence of S4LPN having a current CPR certification.
Review of S5LPN's personnel record, in part, did not reveal nor did the facility present any evidence of S5LPN having a current CPR certification.
Review of S6LPN's personnel record, in part, did not reveal nor did the facility present any evidence of S6LPN having a current CPR certification.
In an interview on [DATE] at 10:27am S1Director of Nurses (DON) stated she is aware of 5 LPNs not having current CPR certifications for over a year. S1DON confirmed all nurses should have an active CPR certification as per facility policy.
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 safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 harm violation(s), $97,995 in fines, Payment denial on record. Review inspection reports carefully.
- • 33 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $97,995 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Legacy Nursing And Rehabilitation Of Morgan City's CMS Rating?
CMS assigns Legacy Nursing and Rehabilitation of Morgan City an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Legacy Nursing And Rehabilitation Of Morgan City Staffed?
CMS rates Legacy Nursing and Rehabilitation of Morgan City's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 66%, which is 19 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Legacy Nursing And Rehabilitation Of Morgan City?
State health inspectors documented 33 deficiencies at Legacy Nursing and Rehabilitation of Morgan City during 2023 to 2025. These included: 2 that caused actual resident harm, 29 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Legacy Nursing And Rehabilitation Of Morgan City?
Legacy Nursing and Rehabilitation of Morgan City is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LEGACY NURSING & REHABILITATION, a chain that manages multiple nursing homes. With 88 certified beds and approximately 84 residents (about 95% occupancy), it is a smaller facility located in Morgan City, Louisiana.
How Does Legacy Nursing And Rehabilitation Of Morgan City Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Legacy Nursing and Rehabilitation of Morgan City's overall rating (1 stars) is below the state average of 2.4, staff turnover (66%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Legacy Nursing And Rehabilitation Of Morgan City?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Legacy Nursing And Rehabilitation Of Morgan City Safe?
Based on CMS inspection data, Legacy Nursing and Rehabilitation of Morgan City has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Legacy Nursing And Rehabilitation Of Morgan City Stick Around?
Staff turnover at Legacy Nursing and Rehabilitation of Morgan City is high. At 66%, the facility is 19 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Legacy Nursing And Rehabilitation Of Morgan City Ever Fined?
Legacy Nursing and Rehabilitation of Morgan City has been fined $97,995 across 1 penalty action. This is above the Louisiana average of $34,059. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Legacy Nursing And Rehabilitation Of Morgan City on Any Federal Watch List?
Legacy Nursing and Rehabilitation of Morgan City 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.