Chateau Napoleon Caring, LLC
For profit - Limited Liability company
120 Beds
VOLARE HEALTH
Data: November 2025
Trust Grade
33/100
#191 of 264 in LA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Chateau Napoleon Caring, LLC has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #191 out of 264 facilities in Louisiana, placing it in the bottom half, and it is the only option in Assumption County. The trend is improving, as the number of issues found has decreased from 19 to 11 over the last year. Staffing is a concern with a rating of 2 out of 5 stars and a turnover rate of 59%, which is higher than the state average, suggesting challenges in staff retention. Despite $4,233 in fines being average for the state, the facility has faced issues such as failing to properly submit payroll information for care staffing and not ensuring essential medications were available for residents. While there are some strengths, families should be aware of these significant weaknesses when considering care for their loved ones.
- Trust Score
- F
- In Louisiana
- #191/264
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $4,233 in fines. Higher than 55% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 10 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 62 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Bottom 28%
No red flags
19 → 11 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 19 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: 59%
13pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $4,233
Below median ($33,413)
Minor penalties assessed
Chain: VOLARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (59%)
11 points above Louisiana average of 48%
The Ugly 62 deficiencies on record
Jun 2025
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure routine medication was available for administration for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residen...
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Based on interview and record review, the facility failed to ensure routine medication was available for administration for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for medication administration.
Findings:
Review of the facility's Medication Administration policy revised on 03/01/2023 revealed, in part, medications are administered by licensed nurses as ordered by the physician in accordance with professional standards or practice. Further review revealed to correct any discrepancies related to medication orders and report the discrepancies to the nurse manager.
Review of Resident #2's Physician's Orders for May 2025 revealed, in part, an order for Brivaracetam oral tablet 75 milligram (mg) every 12 hours with a start date of 05/03/2025.
Review of Resident #2's May 2025 Medication Administration Record (MAR) revealed the following was documented related to the administration of Resident #2's Brivaracetam 75mg oral tablet:
-9 was documented at 8:00AM and 8:00PM doses on 05/03/2025, 05/04/2025, 05/05/2025, and 05/06/2025;
-2 was documented at 8:00AM on 05/07/2025;
-9 was documented at 8:00PM on 05/07/2025;
-Nothing was documented at 8:00AM on 05/08/2025;
-H was documented at 8:00PM on 05/08/2025;
-H was documented at 8:00AM and 8:00PM on 05/09/2025; and,
-H was documented at 8:00AM on 05/10/2025.
In an interview on 06/17/2025 at 9:40AM, S1Director of Nursing (DON) indicated per Resident #2's medication Brivaracetam 75mg blister pack, the medication was issued to the facility by the pharmacist on 05/07/2025.
In an interview on 06/17/2025 at 1:50PM, S1Director of Nursing (DON) indicated Brivaracetam 75mg was not administered to Resident #2 from 05/3/2025 to 05/07/2025. S2DON further indicated she could not explain why there were 9s and 2s documented on Resident #2's MAR and no documentation of administration on 05/08/2025. S1DON further indicated if the staff held Resident #2's medication for whatever reason, it should have been documented in the progress notes. S1DON confirmed there were no progress notes documented related to Resident #2's Brivaracetam administration.
In an interview on 06/17/2025 at 2:00PM, S2Licensed Practical Nurse (LPN) indicated the 9 documented on Resident #2's MAR indicated other, such as the medication was not available. S2LPN further indicated H documented on Resident #2's MAR indicated Resident #2's Brivaracetam 75mg oral tablet was on hold, since it was not available to be administered.
In an interview on 06/18/2025 at 4:52PM, S1DON indicated she was the nurse manger per the Medication Administration policy, and Resident #2's nurses did not report any discrepancies to her regarding Resident #2's Brivaracetam 75mg oral tablet not being available to administer, but should have.
Feb 2025
10 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure staff notified a physician regarding a change in a resident's skin condition for 1 (Resident #1) of 3 (Resident #1, Resident #2, R...
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Based on interviews and record reviews, the facility failed to ensure staff notified a physician regarding a change in a resident's skin condition for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for notification of change.
Findings:
Review of Resident #1's progress note dated 02/10/2025 at 9:30AM revealed, in part, the Certified Nursing Assistant (CNA) reported a red/purple discoloration to Resident #1's right neck/chest area. Further review revealed, upon assessment, Resident #1 presented with a small red/purple discoloration to Resident #1's right neck/chest area and Resident #1's physician was made aware.
In an interview on 02/20/2025 at 2:10PM S6Former LPN indicated she attempted to notify Resident #1's physician's nurse of Resident #1's skin alteration, but the text message was not sent successfully. S6Former LPN further indicated she had not realized the text message did not send successfully until S5StaffDevelopement Nurse called her later in the day when she (S5Staff Development Nurse) was sending Resident #1 to the emergency room.
In an interview on 02/20/2025 at 9:05AM, S5Staff Developement Nurse indicated S6Former LPN's text message to Resident #1's physician's nurse did not send successfully. S5Staff Development Nurse indicated Resident #1's physician was not notified of the bruise on Resident #1's right chest until around 7:00PM on 02/10/2024 when she sent Resident #1 to the emergency room.
In an interview on 02/21/2025 at 11:46AM, S1Administrator indicated S6Former LPN should have notified the Resident #1's physician on 02/10/2025 when she first noticed the rash/discoloration on Resident #1's chest.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure administrative staff (S2Director of Nursing [DON]) followed the facility's abuse prevention policy and did not indicate to a staff ...
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Based on interviews and record review, the facility failed to ensure administrative staff (S2Director of Nursing [DON]) followed the facility's abuse prevention policy and did not indicate to a staff member (S6Former Licensed Practical Nurse) that she should not have admitted to seeing Resident #1's injury of unknown origin.
Findings:
Review of the facility's undated DON Job Description revealed, in part, the facility's DON was responsible for ensuring the facility's nursing service personnel understood and followed departmental policies and procedures.
Review of the facility's Freedom from Abuse, Neglect, and Exploitation-Preventing and Prohibiting Abuse policy, last revised in 03/2023 revealed, in part, a sign of abuse was a suspicious injury. Further review revealed staff would immediately report allegations or suspicions of abuse to the Administrator, state agency, adult protective services, and other required agencies.
In an interview on 02/20/2025 at 10:32AM, S4Former Admissions Nurse indicated S8LPN had sent her a recording of a conversation between S8LPN and S2DON in which S2DON told S8LPN she should have acted like she did not see the bruise on Resident #1's chest on 02/10/2025.
In an interview on 02/20/2025 at 2:10PM, S6Former LPN indicated the recorded conversation between her (S6Former LPN) and S2DON and had taken place on 02/11/2025. S6Former LPN further acknowledged in the recorded conversation, S2DON told her she should have acted like she did not see the bruise/injury of unknown origin on Resident #1 that she had identified on 02/10/2025.
Review of the above mentioned recorded conversation between S6Former LPN and S2DON regarding Resident #1's bruise/injury of unknown origin, revealed, in part, S2DON stated to S6Former LPN I would have just left it alone. I'm going to be honest with you, as an LPN on the hall, I would have swear to God I didn't see it, I wouldn't do nothing about it. I'm going to be straight up, and I'm not supposed to be telling you this.
In an interview on 02/21/2025 at 11:59AM, S2DON confirmed that it was her (S2DON) speaking to S6Former LPN in the above mentioned conversation. When asked if she had any explanation to dispute the deficient practice at this time, S2DON declined to comment.
In an interview on 02/21/2025 at 1:58PM, S1Administrator indicated S2DON should not have told S6Former LPN to not report a bruise/injury of unknown origin.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to revise a plan of care with an intervention after a fall for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled resident...
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Based on interviews and record reviews, the facility failed to revise a plan of care with an intervention after a fall for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for resident centered care plans.
Findings:
Review of the facility's incident/accident log dated 11/2024 to 02/2025 revealed, in part, Resident #2 had unwitnessed falls on 11/24/2024 12/18/2024, and 02/13/2025.
Review of Resident #2's Minimum Data Set with an Assessment Reference Date of 12/10/2025 revealed, in part, Resident #2 had a Brief Interview for Mental Status assessment score of 9, which indicated moderate cognitive impairment. Further review revealed Resident #2 had one fall with no injury since Resident #2's last assessment.
Review of Resident #2's nursing progress note dated 02/13/2025 at 9:10PM revealed, in part, a Certified Nursing Assistant (CNA) reported to the nurse Resident #2 was found lying on the floor near Resident #2's bed.
Review of Resident #2's Plan of Care with a target date of 03/11/2025 revealed, in part, Resident #2 was at risk for falls related to gait/balance problems and had unwitnessed falls on 11/20/2024, 12/18/2024, and 02/13/2025. Further review of Resident #2's Plan of Care revealed no new intervention was implemented after Resident #2's fall on 02/13/2025.
In an interview on 02/20/2025 at 10:08AM, S2DON confirmed a new intervention was not developed for Resident #2's Plan of Care following Resident #2's fall on 02/13/2025. S2DON indicated Resident #2's Plan of Care should have been updated with an intervention to decrease risk of falls on 02/13/2025.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure a licensed nurse (S7Licensed Practical Nurse [LPN]) did not leave the facility without ensuring another nurse assumed responsibili...
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Based on interviews and record reviews, the facility failed to ensure a licensed nurse (S7Licensed Practical Nurse [LPN]) did not leave the facility without ensuring another nurse assumed responsibility of her resident assignment.
This deficient practice had the potential to affect all 28 residents (Resident #1, Resident #R4, Resident #R5, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R15, Resident #R16, Resident #R17, Resident #R18, Resident #R19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32) who resided on the facility's Hall y and Hall z on 02/09/2025.
Findings:
Review of the facility's LPN schedule dated 02/09/2025 revealed, in part, S7LPN was the scheduled nurse for Hall y and Hall z on the 6:00AM to 6:00PM shift and S18Agency LPN was the scheduled nurse for Hall y and Hall z on the 6:00PM to 6:00AM shift.
Review of the facility's time sheets dated 02/09/2025 revealed, in part, S7LPN clocked out of her shift at 6:15PM on 02/09/2025. Further review revealed S18Agency LPN clocked in for her shift at 9:36PM on 02/09/2025.
In an interview on 02/20/2025 at 9:05AM, S5Staff Development Nurse indicated on 02/09/2025 between 6:00PM and 10:00PM the residents on Hall y and Hall z did not have a scheduled nurse because S7LPN left without ensuring another nurse assumed her resident assignment. S5Staff Development Nurse further indicated she was notified that no nurse was taking care of the residents on Hall y and Hall z by S17Agency LPN and S18Agency LPN's nurse staffing agency. S5Staff Development further indicated she sent a text message to S7LPN to figure out why she had left without ensuring a nurse would be taking her assignment. S5Staff Development Nurse further indicated S7LPN had sent her a text message indicated that she had just left a written report sheet because she was not going to argue with S17Agency LPN.
Review of the text exchange between S5Staff Development Nurse and S7LPN on 02/09/2025 at 8:18PM revealed, in part, S5Staff Development Nurse sent three text messages in a row that asked S7LPN to call her as soon as possible, asked S7LPN if she had left report for Hall y and Hall z and indicated to S7LPN, the nurses are at a standstill and ready to walk out due to you not giving a report! Further review revealed S7LPN replied back with a text message that indicated the other nurse did not want to get off of Hall w, so she left a written report sheet because she was not about to argue with her.
In an interview on 02/21/2025 at 9:21AM, S3Former Assistant Director of Nursing (ADON) indicated on 02/09/2025, S7LPN left the keys to Medication Cart c on the counter and did not ensure S8LPN and/or S17Agency LPN accepted the Hall y and Hall z resident assignment before she left the facility.
Review of the text exchange between S3Former Assistant Director and S7LPN on 02/09/2025 at 7:45PM revealed, in part, S3Former ADON sent a text message that asked S7CNA if she could call S8LPN and give her a report on Hall y and Hall z, as S8LPN was refusing to take the keys to Medication Cart c for Hall y and Hall z without report from S7LPN. Further review revealed S7LPN replied back with a text message that indicated the other nurse did not want to get off of Hall w, so she left a written report sheet because she was not about to argue with her
In an interview on 02/20/2025 at 11:45AM, S17Agency LPN indicated she never took responsibility/report for the residents on Hall y and Hall z from S7LPN on 02/09/2025.
In an interview on 02/21/2025 at 10:15AM, S8LPN indicated that she did not get report from S7LPN or take responsibility of the residents on Hall y and Hall z when S7LPN left the facility. S8LPN further indicated she did not accept the Hall y and Hall z resident assignment until after 8:00PM on 02/09/2025.
In an interview on 02/24/2025 at 9:50AM, S7LPN confirmed she did not ensure another nurse took the Hall y and Hall z assignment before she left on 02/09/2025 because she did not want to deal with S17Agency LPN.
There was no documented evidence, and the facility did not present any documented evidence, the resident's that resided on Hall y and Hall z had an assigned nurse between S7LPN's departure from the facility at 6:15PM on 02/09/2025 until 8:37PM on 02/09/2025 when S8LPN took Medication Cart c and accepted the Hall y and Hall z resident assignment.
In an interview on 02/21/2025 at 11:59AM, S2Director of Nursing indicated S7LPN should not have left the facility without ensuring another nurse assumed the resident assignment for Hall y and Hall z. S2DON further indicated she would consider S7LPNs above actions as resident abandonment.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interviews and records reviews, the facility failed to ensure wound care was completed as ordered for 8 (Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R...
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Based on interviews and records reviews, the facility failed to ensure wound care was completed as ordered for 8 (Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R17, Resident #R28, Resident #R29) of 10 (Resident #R8 and Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R17, Resident #R28, Resident #R29) residents reviewed for completed wound care.
Findings:
Review of the facility's time sheet for 02/09/2025 revealed, S19Wound Care Nurse (WCN) worked on 02/09/2025 from 6:27AM to 2:15PM.
Further review of the facility's time sheet for 02/09/2025 revealed, in part, there was no documented evidence S20WC Nurse worked on 02/09/2025.
In an interview on 02/20/2025 at 11:52AM, S19WC Nurse indicated she did not perform the resident's wound care on 02/09/2025 because she was still in training.
Review of Resident #R10's February 2025 electronic Treatment Administration Report (eTAR) revealed, in part, documentation S20WCN cleaned Resident #R10's right shin non-pressure ulcer with wound cleanser/normal saline, applied calcium alginate (a dressing that absorbs excess moisture to promote wound healing), Santyl (a medication used to remove damaged tissue from chronic skin ulcers), and collagen (a substances used to promote wound healing) to the wound bed, covered the wound with gauze, an abdominal (ABD) pad, and secured the dressing with an ACE wrap (elastic bandage wrap).
Review of Resident #R11's February 2025 eTAR revealed, in part, documentation S20WCN cleaned Resident #R11's lower back surgical site with Betadine (an antiseptic that was used to disinfect wounds, applied an ABD pad, and secured the dressing with tape.
Review of Resident #R12's February 2025 eTAR revealed, in part, documentation S20WCN cleaned Resident #R12's right medial ankle venous ulcer with wound cleanser, patted the wound dry, applied collagen and alginate (and absorbent wound dressing) to the wound, and covered the wound with a border foam dressing. Further review revealed documentation S20WCN had applied skin preparation (prep) to the skin surrounding Resident #R12's left lower leg venous ulcer, applied collagen and alginate to the wound, and secured the dressing with a border foam dressing.
Review of Resident #R13's February 2025 eTAR revealed, in part, documentation S20WCN cleaned Resident #R13's moisture associated dermatitis (MASD) to her sacrum with wound cleanser, patted the wound dry, applied Medihoney (a medical grade honey that assist with wound healing) and alginate to the wound, and covered the wound with a dry dressing.
Review of Resident #R14's February 2025 eTAR revealed, in part, documentation S20WCN applied Betadine soaked gauze to Resident #R14 ruptured right heel blister and covered the wound with a dry dressing.
Review of Resident #R17's February 2025 eTAR revealed, in part, documentation S20WCN cleaned Resident #R17's mid chest surgical site with wound cleanser, patted the surgical site dry, and left the surgical site open to air.
Review of Resident #R28's February 2025 eTAR revealed, in part, documentation S20WCN cleaned Resident #R28's left inner thigh wound with Dakin's solution(a diluted bleach solution used to treat and prevent infections in wounds), patted the wound dry, applied Santyl to the wound, then applied a Dakin's solution moistened gauze, and covered the wound with a dry dressing. Further review revealed documentation S20WCN had cleaned Resident #R28's right inner thigh wound with quarter-strength Dakin's solution, patted the wound dry, applied Santyl to the wound bed, then packed the wound with Dakin's solution moistened gauze, and covered the wound with a dry dressing. Further review revealed documentation S20WCN had cleaned Resident #R28's left medial hip open lesion with quarter-strength Dakin's solution, patted the wound dry, applied metronidazole (a medication used to treat infections) gel then Santyl to the wound bed, applied Dakin's solution moistened gauze to the wound, and covered the wound with a dry dressing.
Review of Resident #R29's February 2025 eTAR revealed, in part, documentation S20WCN cleaned Resident #R29's sacrum wound with wound cleanser, patted the wound dry, applied Santyl and collagen to the wound, covered the wound with a Dakin's solution moistened gauze, and secured the dressing with a border foam dressing.
In an interview on 02/25/2025 at 11:17AM, S20WCN indicated she did not work on 02/09/2025 and had not performed wound care for residents on that day. S20WCN further indicated she must have documented she performed the above mentioned resident's wound care in error.
There was no documented evidence, and the provider did not present any documented evidence the above mentioned wound care was completed on 02/09/2025 for Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R17, Resident #R28, Resident #R29.
In an interview on 02/20/2025 at 1:50PM, S16Medical Director indicated it was not acceptable that resident's required wound care was not completed as per the physicians orders.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure a resident's assistive device was available for a resident's use to decrease the risk of falls for 1 (Resident #1) of 4 (Resident ...
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Based on interviews and record reviews, the facility failed to ensure a resident's assistive device was available for a resident's use to decrease the risk of falls for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, Resident #R4) residents reviewed for accident/hazards.
Findings:
Review of Resident #1's Electronic Medical Record revealed, in part, Resident #1 had diagnoses, which included, unspecified dementia, abnormal posture, difficulty in walking, muscle weakness, and lack of coordination.
Review of S9Former Certified Nursing Assistant (CNA) witness statement dated 02/13/2025 revealed, in part, on 2/8/2025 S9Former CNA indicated she found Resident #1 lying in the bed with Resident #1's upper half of his body in the bed and the lower half of Resident #1's body in his wheelchair. Further review of S9Former CNA witness statement revealed S9Former CNA placed Resident #1 back in the bed and removed Resident #1's wheelchair from the bedside. Resident #1 was upset S9Former CNA removed his wheelchair.
In an interview on 02/21/2025 at 11:46AM, S1Administrator indicated S9Former CNA should not have taken Resident #1's wheelchair from his bedside and away from Resident #1.
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 F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview and record reviews, the provider failed to ensure a Registered Nurse (RN) worked at least 8 hours for 1 (02/09/2025) of 14 (02/02/2025, 02/03/2025, 02/04/2025, 02/05/2025, 02/06/202...
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Based on interview and record reviews, the provider failed to ensure a Registered Nurse (RN) worked at least 8 hours for 1 (02/09/2025) of 14 (02/02/2025, 02/03/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/11/2025, 02/12/2025, 02/13/2025, 02/14/2025, 02/15/2025) days reviewed for staffing requirements.
Findings:
Review of the Nursing/Ancillary Personnel Staffing Pattern Report Form submitted by the facility revealed, in part, there was no documented evidence an RN worked on 02/09/2025.
Review of the facility's time sheets dated 02/09/2025 revealed, in part, there was no documented evidence an RN worked on 02/09/2025.
There was no documented evidence, and the provider was unable to present any documented evidence, an RN worked at least 8 hours as required on 02/09/2025.
In an interview on 02/20/2025 at 1:50PM, S16Medical Director indicated an RN should have worked on 02/09/2025 as required.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to maintain a system to reconcile controlled drugs for 1 (Medication Cart c) of 3 (Medication Cart a, Medication Cart b, Medication Cart c) ...
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Based on interviews and record reviews, the facility failed to maintain a system to reconcile controlled drugs for 1 (Medication Cart c) of 3 (Medication Cart a, Medication Cart b, Medication Cart c) medication carts reviewed for the reconciliation of controlled substances.
Findings:
Review of the facility's surveillance footage on 02/09/2025 from 6:00PM until 8:37PM revealed, in part, Medication Cart c (the medication cart that held the controlled drugs for the residents that resided on Hall y and Hall z) was in view of the surveillance camera. Further review revealed no evidence S7LPN reconciled Medication Cart c's controlled drugs with any nurse before she left the facility at 6:15PM on 02/09/2025.
In an interview on 02/24/2025 at 9:50AM, S7LPN indicated she did not reconcile the controlled drugs in Medication Cart c with another nurse before leaving the facility.
In an interview on 02/25/2025 at 9:15AM, S2Director of Nursing acknowledged the facility's off going and oncoming nurses should reconcile controlled drugs at shift change.
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 F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the facility assessment included active involvement from direct care staff, a governing body member, residents, and residents' repre...
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Based on interview and record review, the facility failed to ensure the facility assessment included active involvement from direct care staff, a governing body member, residents, and residents' representatives in its development.
Findings:
Review of the facility's facility assessment, last updated on 08/26/2024 revealed, in part, there was no documented evidence the facility assessment included a Registered Nurse (RN), a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), and a resident and/or a resident's representative was involved in the development of the facility's facility assessment. Further review revealed there was no documented evidence a member of the facility's governing body was involved in the development of the facility's facility assessment.
The facility was unable to present documented evidence the above mentioned staff, a resident and/or a resident's representative, and a member of the facility's governing body were involved in the development of the facility's assessment.
In an interview on 02/21/2025 at 11:46AM, S1Administrator indicated he was unaware RNs, LPNs, CNAs, resident and/or a resident's representative, and a member of the facility's governing body had to be involved in the development of the facility's facility assessment.
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 F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) received 12 hours of in-service training annually for 1 (S12CNA) of 5 (S11CNA, S12CNA, S13CNA, S...
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Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) received 12 hours of in-service training annually for 1 (S12CNA) of 5 (S11CNA, S12CNA, S13CNA, S14CNA and S15CNA) CNAs' personnel files reviewed for in-service trainings.
Findings:
Review of S12CNA's personnel file revealed, in part, a date of hire of 07/17/2014. Further review of S12CNA's personnel file revealed no documented evidence, and the facility was unable to present any documented evidence S12CNA completed 12 hours of in-service trainings annually as required.
In an interview on 02/21/2025 at 9:17AM, S2DON indicated the facility did not have any documented evidence S12CNA completed 12 hours of in-service trainings annually as required.
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a baseline care plan within 48 hours of adm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for care planning.
Findings:
Review of the facility's 2023 policy titled, Clinical Services Policy and Guidelines For Implementation, Quality of Care, Skin Integrity, revealed, in part, a resident identified as having risk for developing pressure ulcers would have individualized interventions implemented to attempt to prevent pressure ulcers from developing, interventions would be monitored for effectiveness, and the resident's care plan would reflect the interventions.
Review of Resident #1's Electronic Medical Record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE].
Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024 revealed, in part, Resident #1 was at risk for developing pressure ulcers.
Review of Resident #1's record revealed, in part, Resident #1 did not have a baseline care plan and the facility was unable to present any documented evidence Resident #1 had a baseline care plan developed and implemented.
In an interview on 12/30/2024 at 4:40 p.m., S3Minimum Data Set (MDS) nurse indicated Resident #1 did not have a baseline care plan completed.
In an interview on 12/30/2024 at 4:52 p.m., S2Director of Nursing confirmed a baseline care plan was not developed for Resident #1 and should have been developed and implemented.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure medications were available for use for 2 (Resident #1 and Re...
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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 medications were available for use for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for pharmacy services.
Findings:
Resident #1
Review of Resident #1's clinical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, hypertension (high blood pressure), and gout (a condition that causes swelling and tenderness in joints).
Review of Resident #1's November 2024 physician's orders revealed, in part, orders for potassium chloride 20 milliequivalent (mEq) (a medication used to treat chronic kidney disease) to be administered twice a day; allopurinol 100 milligram (mg) (a medication used to treat swelling and tenderness in joints) to be administered once a day; and, lisinopril-hydrochlorothiazide 10-12.5 mg (a medication used to treat high blood pressure) to be administered once a day with a start date of 11/16/2024 at 8:00 a.m.
Review of Resident #1's November 2024 electronic Medication Administration Record (eMAR) revealed the following was documented, in part:
- On 11/16/2024 at 8:00 a.m. potassium chloride 20mEq was documented as a 9 (9 indicated other and see progress notes);
- On 11/16/2024 at 8:00 a.m. allopurinol 100mg was documented as a 9; and,
- On 11/16/2024 at 8:00 a.m. lisinopril-hydrochlorothiazide 10-12.5mg was documented as a 9.
Review of Resident #1's progress notes dated 11/16/2024 revealed, in part, Resident #1's above mentioned medications would be delivered from the pharmacy on the evening of 11/16/2024.
In an interview on 12/26/2024 at 11:31 a.m., Resident #1's son indicated Resident #1 did not receive his medications as ordered when he was admitted to the facility on [DATE].
In an interview on 12/26/2024 at 4:20 p.m., S2Director of Nursing (DON) reviewed Resident #1's November 2024 eMAR and progress notes on 11/16/2024 and indicated the documentation revealed the above mentioned medications were not available to be administered to Resident #1 on 11/16/2024 at 8:00 a.m. because Resident #1's medications had not arrived from the pharmacy. S2DON indicated any medications ordered by the facility after 3:00 p.m. would arrive from the pharmacy the next day. S2DON indicated the facility did not utilize the on-call pharmacist or another local pharmacy to obtain Resident #1's medications.
Resident #3
Review of Resident #3's clinical record revealed, in part, Resident #3 was admitted to the facility on [DATE].
Review of Resident #3's December 2024 physician's orders revealed, in part, an order for ondansetron hydrochloride (a medication used to treat nausea) 4 mg tablet, give 1 tablet by mouth every 6 hours for nausea starting on 10/07/2024.
Review of Resident #3's December 2024 eMAR revealed, in part, Resident #3's odansetron hydrochloride was not administered at the following times:
-12/09/2024: 12:00 a.m. and 6:00 a.m.;
-12/21/2024: 12:00 a.m. and 6:00 a.m.;
-12/22/2024: 12:00 a.m. and 6:00 a.m.; and,
-12/23/2024: 12:00 a.m.
Review of Resident #3's nursing progress notes written by S4Minimum Data Set (MDS) Nurse revealed a note on 12/09/2024 at 6:56 a.m. and another note on 12/21/2024 at 5:57 a.m. which indicated the facility was waiting to receive Resident #3's ondansetron from the pharmacy.
In an interview on 12/30/2024 at 11:28 p.m., S4MDS Nurse indicated the facility had issues receiving Resident #3's ondansetron from the pharmacy.
In an interview on 12/30/2024 at 12:36 p.m., S2Director of Nursing (DON) indicated the floor nurses and the pharmacist were responsible for ordering medications for residents. S2DON confirmed the above mentioned deficient practice and further indicated Resident #3 should have received his medications as prescribed.
Dec 2024
5 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to immediately ensure a resident's physician was notified of a resident's change of condition in a timely manner 1 (Resident #2) of 3 (Resid...
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Based on interviews and record reviews, the facility failed to immediately ensure a resident's physician was notified of a resident's change of condition in a timely manner 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) residents investigated for Quality of Care.
Findings included:
Review of the facility's policy titled, Resident Rights: Notification of Change of Condition and Room Changes, dated 03/2023, revealed, in part, the facility would promptly inform the resident, consult with the resident's physician, and notify the resident representative, consistent with his or her authority, when there was an accident that involved the resident, which resulted in injury, and had the potential for requiring physician interventions.
Review of the facility's Incident Audit Report, dated 05/02/2024, revealed, in part, on 04/27/2024, Resident #2's wife reported Resident #2 had a blister to his left hand index finger from a cigarette burn.
Review of the facility's electronic facsimile sheet dated 04/27/2024 revealed, in part, a faxed communication was sent to Resident #2's physician on 04/27/2024 that indicated Resident #2 sustained a blister to his left index finger. Resident #2's physician's office was faxed of the above mentioned blister from a cigarette burn on 04/27/2024.
There was no documented evidence and the provider did not present any documented evidence to identify the time the faxed communication was sent to Resident #2's physician's office.
There was no documented evidence and the provider did not present any documented evidence that Resident #2's physician was at the office when the facsimile was sent and read the above mentioned facsimile, and/or followed-up with Resident #2's physician to see if the facsimile was received and/or if there were any new orders.
In an interview on 12/03/2024 at 9:14AM, S5Licensed Practical Nurse (S5LPN) indicated she notified Resident #2's physician by electronic facsimile on 04/27/2024 of Resident #2's above mentioned blister.
In an interview on 12/03/2024 at 3:18PM, the medical receptionist at Resident #2's physician's office indicated the above mentioned facsimile sheet was sent to Resident #2's physician on 04/27/2024 at 7:44PM, but she did not have any documented evidence that Resident #2's physician reviewed the above mentioned facsimile sheet.
In an interview on 12/03/2024 at 3:25PM, S5LPN indicated she called, texted, and faxed Resident #2's physician on 04/27/2024 indicating Resident #2's blister to his left hand index finger and did not receive any orders before the end of her shift.
There was no documented evidence and the facility did not present any documented evidence that S5LPN called and/or texted Resident #2's physician of the blister to his left index finger.
In an interview on 12/03/2024 at 3:32PM, S3Staff Development Coordinator indicated she had not received any orders from Resident #2's physician on her shift and did not call Resident #2's physician to follow-up on Resident #2's blister to the left finger.
In an interview on 12/03/2024 at 3:53PM S2Director of Nursing (S2DON) indicated nursing staff should have notified and followed-up with Resident #2's physician timely.
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 F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, the facility failed to assist a resident and/or provide transpo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, the facility failed to assist a resident and/or provide transportation for a residents podiatry (physician which treats disorders of the feet) appointment for 1 (Resident #1) of 3 sampled residents reviewed for foot care.
Findings included:
Review of the facility's undated Resident [NAME] of Rights Louisiana, revealed, in part, residents have the right to receive adequate and appropriate health care and support services consistent with rules promulgated by the Louisiana Department of Health.
Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed, in part, Resident #1 admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had diagnoses of, in part, chronic osteomyelitis (bone infection) to right ankle/foot and diabetes mellitus with polyneuropathy (high blood sugar levels that can cause nerve damage to feet and toes).
Review of Resident #1's After Visit Summary, dated 08/29/2024 revealed, in part, Resident #1 had a scheduled podiatry appointment for 09/04/2024 at 9:00AM.
Review of Resident #1's nursing Progress Note, dated 08/29/2024 revealed, in part, Resident #1 returned from a physician visit with a podiatry appointment scheduled for 09/04/2024, and the appointment was made with the ward clerk.
Review of the facility's appointment book/calendar for appointments scheduled on 09/04/2024 revealed, in part, no documented evidence Resident #1 had attended the podiatry appointment on 09/04/2024 at 9:00AM.
Review of Resident #1's IDT (interdisciplinary team) Care Plan Conference/Welcome Meeting, dated 11/06/2024 revealed, in part, Resident #1 would attend all scheduled appointments and would be put on the podiatry list.
In an interview on 12/02/2024 at 9:18AM, Resident #1 indicated he had a podiatry appointment scheduled for 09/04/2024 which he did not attended. Resident #1 further indicated he had notified the facility staff that he wanted to be assessed by the podiatrist, but had not been seen by a podiatrist since admission.
In an interview on 12/03/2024 at 11:34AM, S8Social Service Worker (SSW) indicated Resident #1 was not on the podiatry list to be seen when the podiatrist made rounds in the facility on 10/02/2024.
In an interview on 12/03/2024 at 11:36AM, S7Ward Clerk indicated she was responsible for placing appointments for residents in the appointment book/calendar after being reviewed by the nurse. S7Ward Clerk further indicated she had no knowledge of having received Resident #1's After Visit Summary, dated 08/29/2024 and had not documented the appointment in the facility's appointment book/calendar.
In an interview on 12/03/2024 at 1:50PM, S2Director of Nursing (DON) confirmed Resident #1's podiatry appointment scheduled for 09/04/2024 was missed. S2DON indicated after Resident #1 did not attend his scheduled podiatry appointment on 09/04/2024, staff should have rescheduled the appointment and/or had Resident #1 seen by the in house podiatrist who made rounds in the facility on 10/02/2024. S2DON confirmed the facility had not assisted Resident #1 with his foot care as required.
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 F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, facility policy, and record reviews, it was determined facility failed to ensure a resident was seen by a p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, facility policy, and record reviews, it was determined facility failed to ensure a resident was seen by a physician in a timely manner for 1 (Resident #1) of 3 sampled residents reviewed for physician visits.
Findings included:
Review of the facility's policy titled, Physician Services Physician Visits and Physician Delegation of Visits, dated 03/2023 revealed, in part, a physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. Further review revealed the requirement for physician visits can be satisfied in accordance with stated law by a Non Physician Practitioner (NPP).
Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed, in part, Resident #1 admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact.
Review of Resident #1's medical record revealed, in part, Resident #1 was seen by the physician on 08/21/2024, 08/27/2024, 10/08/2024, and 11/05/2024. Further review revealed Resident #1 was seen by the physician on 08/27/2024 and not seen again until 10/08/2024 which was greater than 10 days from the required date.
In an interview on 12/02/2024 at 9:18AM, Resident #1 indicated he was not being seen by his primary physician on a regular basis.
In an interview on 12/03/2024 at 3:55PM, S2Director of Nursing (DON) confirmed the facility had no documented evidence Resident #1 was seen by the physician or NPP no later than 10 days after the date the visit was required (09/26/2024).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined the facility failed to obtain laboratory services per physician's orde...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined the facility failed to obtain laboratory services per physician's order for 1 (Resident #1) of 3 sampled resident's records reviewed for pharmaceutical services.
Findings included:
Resident #1
Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed, in part, Resident #1 was admitted to the facility on [DATE] and had diagnoses of, in part, chronic myeloid leukemia not having achieved remission (blood cancer), chronic osteomyelitis (bone infection) to the right ankle/foot, diabetes mellitus with polyneuropathy (high blood sugar levels that can cause nerve damage to feet and toes), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).
Review of Resident #1's Physician Orders, for the month of 12/2024 revealed, in part, an order dated 09/23/2024, for Complete Blood Count (CBC) (a blood test which measures the number and size of the different cells in your blood) and Comprehensive Metabolic Panel (CMP) (a blood test which gives information on the body's fluid balance, levels of electrolytes, and how well the kidneys and liver are functioning) to be drawn weekly on Mondays.
Review of Resident #1's medical record revealed the facility had no documented evidence and the facility did not present any documented evidence Resident #1's CBC and CMP were drawn on the following dates: 09/23/2024, 09/30/204, 10/14/2024, 10/21/2024, 11/04/2024, 11/18/2024, and 11/25/2024.
In an interview on 12/03/2024 at 3:55PM, S2Director of Nursing (DON) indicated routine laboratory test were drawn on Monday, Wednesday, and Fridays by a laboratory testing company, but the company did not draw the laboratory tests as scheduled. S2DON confirmed the facility's nursing staff should have drawn the laboratory tests when the laboratory testing company did not draw laboratory tests as scheduled. S2DON confirmed the facility had no evidence Resident #1 had a CBC and/or a CMP test drawn on the following Mondays 09/23/2024, 09/30/204, 10/14/2024, 10/21/2024, 11/04/2024, 11/18/2024, and 11/25/2024 per physician orders.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews, it was determined the facility failed to ensure shower rooms were maintained in a clean and sanitary manner for 2 (shower room y and shower room z) of 2 shower ro...
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Based on observations and interviews, it was determined the facility failed to ensure shower rooms were maintained in a clean and sanitary manner for 2 (shower room y and shower room z) of 2 shower rooms reviewed for physical environment.
Findings included:
Observation of shower room y on 12/02/2024 at 8:50 AM revealed, an unknown black/gray substance on the floor and base moldings in all 4 shower stalls. Further observation revealed several cracked tiles had an unknown black/gray substance along the cracked tile on the back wall of shower room y. Further observation revealed and unknown black/gray substance on the tiled floor around the toilet in shower room y. Further observation revealed 4 shower curtains had an unknown black/gray substance on both sides of the bottom of the shower curtains. Further observation of shower room y revealed two areas had missing tile molding which exposed sheet rock. Further observation of shower room y revealed an unknown orange/red substance on the metal ceiling supports.
Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact.
In an interview on 12/02/2024 at 9:18 AM Resident #1 indicated he refused to use the shower room because it was too gross.
Observation of shower room z on 12/02/2024 at 8:20 AM revealed cracked tiles along the left wall of the first stall with a black discoloration noted inside the cracks and around the edges of the tile. Further observation revealed 2 of the 4 shower curtains had smears of a black/gray unknown substance along the bottom of the curtain. Further review of the shower room z revealed in the left corner of the room on the floor and along the baseboard there was black/gray spots of an unknown substance.
In an interview on 12/02/2024 at 8:50 AM, S9Certified Nursing Assistant (S9CNA) indicated the facility's housekeeping staff was responsible for cleaning the facility's shower room y and shower room z every day.
In an interview on 12/02/2024 at 9:05 AM S1Administrator indicated the shower curtains in the shower room y and shower room z should not have an unknown black/gray substance on them, should be removed by housekeeping staff, and washed and/or disposed.
In an interview on 12/02/2024 at 10:12 AM S1Administrator confirmed the above mentioned findings in shower room y and shower room z, and had nothing to present to dispute the above mentioned deficient practice.
Oct 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure an allegation of staff to resident verbal abuse was reported to the required State Survey Agency for 1 (Resident #64) of 1 (Reside...
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Based on record reviews and interviews, the facility failed to ensure an allegation of staff to resident verbal abuse was reported to the required State Survey Agency for 1 (Resident #64) of 1 (Resident #64) sampled residents investigated for abuse.
Findings:
Review of the facility's Abuse Policy and Procedure last revised March 2023, revealed, in part, when the facility identified abuse the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately, which included to report the allegation to appropriate authorities within required timeframes, conduct a thorough investigation of the allegation, document and report the result of the investigation of the allegation, and take appropriate corrective action. Further review of the facility's Abuse Policy and Procedure revealed, in part, staff were expected to be in control of their behavior, were to behave professionally, and understood how to work with the facility population.
Review of the facility's Grievance Log dated 09/25/2024 revealed, in part, Resident #64 filed a grievance against a Certified Nursing Assistant (CNA). Further review revealed the grievance was reported to S3Director of Social Services and was to be investigated by S4Certified Nursing Assistant Coordinator.
Review of Resident #64's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2024 revealed, in part, Resident #64 required supervision with toilet transfer.
Review of Resident #64's Plan of Care revealed, in part, Resident #64 required assistance of one staff member with toilet transfer.
In an interview on 09/30/2024 at 9:21 a.m., Resident #64 indicated she had an adult brief on during the night. Resident #64 further indicated she had an episode of diarrhea and when called for assistance S8Certified Nursing Assistant (CNA) responded back by saying, Why you didn't bring you're a** to the bathroom.
In an interview on 10/01/2024 at 9:10 a.m., S3Director of Social Services indicated the allegation of staff to resident verbal abuse was reported to S4Certified Nursing Assistant Coordinator for review.
In an interview on 10/01/2024 at 9:12 a.m., S4Certified Nursing Assistant Coordinator indicated she did not report the allegation of verbal abuse to the Director of Nursing (DON) or the Administrator.
In an interview on 10/01/2024 at 9:45 a.m., S2DON indicated an allegation of verbal abuse was not reported and should have been.
In an interview on 10/01/2024 at 10:23 a.m., S1Administrator indicated an allegation of verbal abuse was not reported and should have been.
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 review, the facility failed to conduct a thorough investigation following an allegation of staff to resident verbal abuse for 1 (Resident #64) of 1 (Resident #64) sample...
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Based on interviews and record review, the facility failed to conduct a thorough investigation following an allegation of staff to resident verbal abuse for 1 (Resident #64) of 1 (Resident #64) sampled residents reviewed for abuse.
Findings:
Review of the facility's Abuse Policy and Procedure last revised March 2023 revealed, in part, when the facility identified abuse, the facility should take the appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. Further review of the facility's Abuse Policy and Procedure revealed the facility should conduct a thorough investigation of the allegation, document, and report the results of the investigation of the allegation.
Review of Resident #64's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2024 revealed, in part, Resident #64 required supervision with toilet transfer.
Review of Resident #64's Plan of Care revealed, in part, Resident #64 required assistance of one staff member with toilet transfer.
In an interview on 09/30/2024 at 9:21 a.m., Resident #64 indicated she had an adult brief on during the night. Resident #64 further indicated she had an episode of diarrhea and when called for assistance S8Certified Nursing Assistant (CNA) responded back by saying, Why you didn't bring you're a** to the bathroom.
In an interview on 10/01/2024 at 9:10 a.m., S3Director of Social Services indicated the allegation of staff to resident verbal abuse was reported to S4Certified Nursing Assistant Coordinator for review.
In an interview on 10/01/2024 at 9:12 a.m., S4Certified Nursing Assistant Coordinator indicated there was no documented evidence, and the facility could not produce any documented evidence of an investigation for the allegation of staff to resident verbal abuse was thoroughly investigated for Resident #64.
In an interview on 10/01/2024 at 9:45 a.m., S2Director of Nursing indicated there was no documented evidence, and the facility could not produce any documented evidence, of an investigation for the allegation of staff to resident verbal abuse was thoroughly investigated for Resident #64.
In an interview on 10/01/2024 at 10:23 a.m., S1Administrator indicated there was no documented evidence, and the facility could not produce any documented evidence, an allegation of staff to resident verbal abuse was thoroughly investigated for Resident #64.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure a resident with a diagnoses of Major Depressive Disorder and...
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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 resident with a diagnoses of Major Depressive Disorder and Bipolar Disorder was referred to the appropriate State Survey Agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #64) of 5 (Resident #17, Resident #21, Resident #50, Resident #62, and Resident #64) sampled residents reviewed for PASARR.
Findings:
Review of Resident #64's Electronic Medical Record (EMR) revealed, in part, Resident #64 was admitted to the facility on [DATE] with a diagnosis that included Major Depressive Disorder. Further review revealed on 05/10/2023 a new diagnosis of Bipolar Disorder. Further review of Resident #64's EMR revealed, in part, no documented evidence that a Level II PASARR evaluation was completed.
In an interview on 10/01/2024 at 12:05 p.m., S3Director of Social Services indicated a Level II PASARR evaluation was not completed on Resident #64. S3Director of Social Services further indicated Resident #64 should have been referred for a Level II PASARR evaluation.
In an interview on 10/01/2024 at 2:20 p.m., S1Administrator indicated there was no documented evidence, and the facility could not present documented evidence, that a Level II PASARR evaluation for Resident #64 was completed. S1Administrator further indicated a Level II PASARR evaluation should have been completed for Resident #64.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on record reviews, observations, interviews the facility failed to ensure privacy was provided for residents during activities of daily living (ADL) care and incontinence care provided in their ...
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Based on record reviews, observations, interviews the facility failed to ensure privacy was provided for residents during activities of daily living (ADL) care and incontinence care provided in their rooms (Room A and Room B) for 4 (Resident #16, Resident #27, Resident #45, and Resident #46) of 4 (Resident #16, Resident #27, Resident #45, and Resident #46) sampled residents investigated for privacy.
Findings:
Review of the facility's Resident [NAME] of Rights revealed, in part, each resident has the right to have privacy in treatment and during care of personal needs. Further review revealed privacy of the resident's body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene.
Room A
Review of the facility's daily census dated 09/30/2024 revealed, in part, Resident #16 and Resident #46 were roommates in Room A.
An observation of Room A on 09/30/2024 at 9:10 a.m. revealed there was no curtain to provide privacy between Resident #16 bed and Resident #46 bed.
Review of Resident #16's Quarterly Minimum Data Set (MDS) and State Optional Assessment (SOA) with an Assessment Reference Date (ARD) of 07/05/2024 revealed, in part, Resident #16 had a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment; required extensive assistance of two or more persons for bed mobility, transfers, toileting, and was always incontinent of bladder and bowel.
Review of Resident #46's Quarterly MDS and SOA with an ARD of 07/09/2024 revealed, in part, Resident #46 had a BIMS of 14 which indicated Resident #46 was cognitively intact; required limited assistance of one person with bed mobility, transfers, and toileting, and was occasionally incontinent of bladder and bowel.
In an interview on 09/30/2024 at 9:10 a.m., Resident #16 indicated he had a roommate, and staff care for performed incontinence care for him and Resident #46 without providing privacy. Resident #16 further indicated he would like to have personal care provided in private.
In an interview on 10/01/2024 at 8:30 a.m., S5Certified Nursing Assistant (CNA) confirmed there was no curtain to provide privacy in Room A, and she did not use any other method to provide privacy while providing ADL and incontinence care to Resident #16 and Resident #46. S5CNA further indicated she should have provided privacy during care.
In an interview on 10/01/2024 at 8:38 a.m., S7Housekeeping Supervisor indicated Room A did not have a curtain to provide privacy between Resident #16 and Resident #46. S7Housekeeping Supervisor further indicated Resident #46 moved into Room A about 3 weeks ago and a privacy curtain was not placed in the room and it should have been.
Room B
Review of the facility's daily census dated 09/30/2024 revealed, in part, Resident #27 and Resident #45 were roommates in Room B.
An observation of Room B on 10/01/2024 at 8:25 a.m. revealed there was no curtain to provide privacy between Resident #27's bed and Resident #45's bed.
Review of Resident #27's Quarterly MDS and SOA with ARD of 08/09/2024 revealed, in part, a BIMS of 01 which indicated severe cognitive impairment; required extensive assistance with bed mobility, transfers, and toileting of two or more persons, and was always incontinent of bladder and frequently incontinent of bowel.
Review of Resident #45's Quarterly MDS and SOA with ARD of 08/07/2024 revealed, in part, a BIMS of 12 which indicated moderate cognitive impairment; and required extensive assistance of two or more persons with bed mobility, transfers, toileting of two or more persons, and was always incontinent of bladder and bowel.
In an interview on 10/01/2024 at 8:38 a.m., S7Housekeeping Supervisor indicated Room B did not have a curtain to provide privacy between Resident #27's bed and Resident #45's bed and there should have been.
In an interview on 10/01/2024 at 3:20 p.m. S6Certified Nursing Assistant (CNA) indicated she provided ADL care and incontinent care for Resident #27 and Resident #45 in Room B on the morning of 10/01/2024 without providing privacy between Resident #27 and Resident #45. S6CNA further indicated privacy should have been provided for each resident during care.
In an interview on 10/01/2024 at 8:40 a.m., S2Director of Nursing (DON) confirmed Room A did not have a privacy curtain to provide privacy between Resident #16 and Resident #46, and Room B did not have a privacy curtain to provide privacy between Resident #27 and Resident #45, and there should have been. S2DON indicated privacy should have been provided to each resident during ADL and incontinence care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected multiple residents
Based on record reviews and an interview, the facility failed to ensure the Certified Nurse Aide (CNA) Registry was verified upon hire for 1 (S11CNA) of 6 (S4CNA Coordinator, S8CNA, S9CNA, S10CNA, S11...
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Based on record reviews and an interview, the facility failed to ensure the Certified Nurse Aide (CNA) Registry was verified upon hire for 1 (S11CNA) of 6 (S4CNA Coordinator, S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA) personnel records reviewed.
Findings:
Review of S11CNA's personnel record revealed, in part, a hire date of 01/09/2024. Further review of S11CNA's timesheet revealed S11CNA worked with residents on 01/09/2024, 01/10/2024, 01/11/2024, 01/12/2024, 01/14/2024, and 01/15/2024.
Review of S11CNA'S personnel record revealed, in part, a CNA Registry verification dated 01/15/2024. Further review of S11CNA's personnel record revealed there was no documented evidence, and the provider did not present any documented evidence a CNA certification check on S11CNA was completed before hire.
In an interview on 10/02/2024 at 2:15 p.m., S13Human Resources (HR) Business Partner confirmed the facility did not complete a CNA certification check on S11CNA before hire to ensure S11CNA was active and should have.
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a resident received adequate assistance with a transfer for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled...
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Based on record review and interview, the facility failed to ensure a resident received adequate assistance with a transfer for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents who were reviewed for the use of mechanical lifts.
Findings:
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/2024 revealed, in part, Resident #1 required extensive assistance from two or more persons with transfers.
Review of Resident #1's Care Plan with an initiation date of 01/05/2024 revealed, in part, Resident #1 required the mechanical lift which required the assistance of 2 staff persons for transfers.
Review of Resident #1's Nurses Notes dated 08/25/2024 revealed, in part, Resident #1 indicated he had an abrasion to his leg which occurred on 08/23/2024 when S4Certified Nursing Assistant (CNA) transferred him without the assistance of a second staff person using the mechanical lift.
In an interview on 09/09/2024 at 10:40 a.m., Resident #1 indicated he hurt his leg on 08/23/2024 when S4CNA transferred him with the mechanical lift. Resident #1 further indicated S4CNA used the mechanical lift alone.
In an interview on 09/09/2024 at 3:15 p.m., S1Administrator indicated during an investigation of the above documented allegation it was determined S4CNA did not follow facility practice on 08/23/2024 when she independently transferred Resident #1 with the mechanical lift.
In an interview on 09/10/2024 at 8:26 a.m., S5CNA indicated on Friday 08/23/2024 S4CNA asked her to help her transfer Resident #1 from the mechanical lift to his gerichair. S5CNA indicated when she entered Resident #1's room he was in the mechanical lift sling attached to the gerichair and was suspended over the gerichair. S5CNA indicated there was no other staff in the room when she entered the room with S4CNA.
In an interview on 09/10/2024 at 12:03 p.m., S2DirectorOfNursing (DON) indicated Resident #1 should have been transferred by two staff persons with the mechanical lift on 08/23/2024. S2DON confirmed Resident #1's care plan indicated two staff persons were required for all transfers.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure a medication was available for resident use as ordered by the physician for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Re...
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Based on record reviews and interviews, the facility failed to ensure a medication was available for resident use as ordered by the physician for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for quality of care.
Findings:
Review of Resident #1's Physicians Order dated 09/03/2024 revealed, in part, Tramadol 50 milligram (mg) (a medication used for pain) to be administered two times a day.
Review of Resident #1's September 2024 electronic Medication Administration Record (eMAR) revealed the following was documented, in part,
09/03/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9 (9 indicated other and see progress notes);
09/04/2024 at 8:00 a.m. Tramadol 50mg was documented as a 9;
09/04/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9;
09/05/2024 at 8:00 a.m. Tramadol 50mg was documented as a 9;
09/05/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9;
09/06/2024 at 8:00 a.m. Tramadol 50mg was documented as a 9;
09/06/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9; and,
09/09/2024 at 8:00 a.m. Tramadol 50mg was documented as a 9.
Review of Resident #1's eMAR progress notes dated 09/03/2024, 09/04/2024, 09/05/2024, 09/06/2024, and 09/09/2024 revealed, in part, Tramadol 50mg was not administered because the medication was not available in the facility.
In an interview on 09/09/2024 at 1:51 p.m., S3LicensedPracticalNurse (LPN) indicated on 09/03/2024 she received a verbal order from Resident #1's physician for Tramadol 50mg to be administered twice a day. S3LPN further indicated Resident #1 had not received Tramadol as ordered because the Tramadol was not available in the facility for administration.
In an interview on 09/09/2024 at 3:40 p.m., S2Director of Nursing (DON) reviewed Resident #1's September 2024 eMAR and confirmed the documentation revealed Tramadol 50mg was not available to be administered to Resident #1 on 09/03/2024, 09/04/2024, 09/05/2024, 09/06/2024, and 09/09/2024. S2DON further indicated the nurse who received the Tramadol 50mg order on 09/03/2024 did not call the pharmacy to acquire the medication and should have.
Feb 2024
5 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 F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure residents received psychiatric evaluations in a timely manner after an incident of resident to resident abuse. This deficient prac...
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Based on record reviews and interviews, the facility failed to ensure residents received psychiatric evaluations in a timely manner after an incident of resident to resident abuse. This deficient practice was identified for 2 (Resident #1 and Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for behavioral healthcare services.
Findings:
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/2023 revealed, in part, Resident #1 had a Brief Interview Mental Status Score (BIMS) of 03 which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 had a diagnosis of Alzheimer's disease.
Review of Resident #2's MDS with a ARD of 12/21/2023 revealed, in part, Resident #2 had a BIMS score of 15 which indicated Resident #2 was cognitively intact.
Review of facility's incident report dated 01/16/2024 at 1:55 p.m. revealed, in part, Resident #1 and Resident #2 were involved in an incident of resident to resident abuse in which Resident #2 approached Resident #1 and they swung at and hit each other. Further review revealed Resident #1 and Resident #2 were added to the list to be seen by psychiatric nurse practitioner on his/her next visit to the facility scheduled on 01/29/2024.
Review of Resident #1's progress notes revealed a note on 01/16/2024 by S3Social Worker indicating Resident #1 called Resident #2 a black b***** and stated she will kick her a**. Further review of the note revealed Resident #2 walked towards Resident #1 and hit her and Resident #1 hit Resident #2 back.
In an interview on 02/27/2024 at 11:15 a.m. S7Occupational Therapist (OT) stated he was walking by the dining room when he saw Resident #2 get up and approached Resident #1. S7OT further stated he separated the 2 residents after Resident #2 grabbed Resident #1 arm.
Review of Resident #1's record revealed a psychiatric progress note dated 01/29/2024. Further review revealed a medication adjustment recommendation.
Review of Resident #2's record revealed a psychiatric progress note dated 01/29/2024. Further review revealed a medication adjustment recommendation.
Review of the facility's incident report dated 01/27/2024 at 11:00 a.m. revealed S2Director of Nursing (DON) was notified by S10Weekend Registered Nurse Supervisor of an incident which occurred between Resident #1 and Resident #2 in the dining room. Further review revealed Resident #2 asked Resident #1 to move out of a chair and Resident #1 stated she was not moving for that black b****. Further review revealed Resident #2 moved towards Resident #1 and at that time Resident #1 swung and hit Resident #2. Further review revealed Resident #1 and Resident #2 were to be seen by the psychiatric nurse practitioner on his/her next visit to the facility scheduled on 01/29/2024.
In an interview on 02/27/2024 at 12:36 p.m., S8Certified Nursing Assistant (CNA) stated during the incident on 01/27/2024, Resident #2 asked her if she could ask Resident #1 to get out of the chair and she told Resident #2 she could not make Resident #1 move. S8CNA added Resident #2 provoked Resident #1 to get out of the chair, and then Resident #1 swung at Resident #2 with a closed fist. S8Certified Nursing Assistant further stated this incident should not have happened.
In an interview on 02/28/2024 at 12:55 p.m., the behavioral health hospital's community liaison (contact person) stated if a resident had increased behaviors or specifically was physically abusive to another resident and needed a psychiatric evaluation, the resident would not have to wait until the nurse practitioner's scheduled visit to the facility. The liaison further stated the nurse practitioner could complete an emergent evaluation through a virtual visit over the telephone to determine if the resident required hospitalization for treatment of behaviors or other immediate interventions such as medication changes.
In an interview on 02/28/2024 at 3:16 p.m., S2Director of Nursing stated she was not aware behavioral health could complete an emergent psychiatric evaluation through a virtual visit over the telephone.
In an interview on 02/29/2024 at 12:26 p.m., S10Weekend Registered Nurse Supervisor stated she heard staff calling for help from the dining room and when she got there Resident #2 was standing against the wall and Resident #1 was hitting her.
In an interview on 02/29/2024 at 1:50 p.m., S3Social Worker stated if a psychiatric evaluation was determined to be necessary due to resident to resident abuse it should be completed the next day.
In an interview on 02/29/2024 at 1:38 p.m., S1Administrator stated he was not aware behavioral health could complete an emergent psychiatric evaluation through a virtual visit over the telephone.
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 F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to:
1.
Ensure staff were provided abuse and neglect training; and
2.
Ensure staff were provided dementia management training.
This deficie...
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Based on record reviews and interviews, the facility failed to:
1.
Ensure staff were provided abuse and neglect training; and
2.
Ensure staff were provided dementia management training.
This deficient practice was identified for 3 (S3Social Worker, S4Activities Director, and S6Cook) of 7 (S3Social Worker, S4Activities Director, S5Certified Nursing Assistant, S6Cook, S7Occupational Therapy, S8Certified Nursing Assistant, and S9Certified Nursing Assistant) personnel records reviewed.
Findings:
Review of S3Social Worker's personnel record revealed, in part, a hire date of 09/08/2023. Further review of S3Social Worker's personnel record revealed no documented evidence and the facility did not present any documented evidence S3Social Worker completed annual dementia training.
Review of S4Activities Director's personnel record revealed, in part, a hire date of 04/06/2022. Further review of S4Activieties Director's personnel record revealed no documented evidence and the facility did not present any evidence S4Activities Director completed annual abuse training.
Review of S6Cook's personnel record revealed, in part, a hire date of 05/09/2019. Further review of S6Cook's personnel record revealed no documented evidence and the facility did not present any documented evidence S6Cook completed annual dementia training or abuse training.
In an interview on 02/27/2024 at 2:10 p.m., S2Director of Nursing (DON) confirmed the above findings on employee personnel records. S2DON further stated the above mentioned employees did not receive abuse and dementia training annually as required.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 4 (...
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Based on interviews and record reviews, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse.
Findings:
Review of the facility's Freedom from Abuse, Neglect and Exploitation Policy revealed, in part, abuse was defined as the willful infliction of injury resulting in physical harm, pain, or mental anguish. Further review revealed, willful was defined as the individual must have acted deliberately, and in determining abuse such action will be considered regardless of whether the individual intended to inflict injury or harm. The policy also revealed physical abuse included but was not limited to, hitting, slapping, punching, biting, and kicking.
Resident #1 and Resident #2
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/2023 revealed, in part, Resident #1 had a Brief Interview Mental Status Score (BIMS) of 03 which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 had a diagnosis of Alzheimer's disease.
Review of Resident #2's MDS with a ARD of 12/21/2023 revealed, in part, Resident #2 had a BIMS score of 15 which indicated Resident #2 was cognitively intact.
Review of the facility's incident report dated 01/16/2024 at 1:55 p.m. revealed, in part, Resident #1 and Resident #2 were waiting for bingo to start in the dining room. Further review revealed Resident #2 approached Resident #1 and they swung at each other.
Review of Resident #1's progress notes revealed a note on 01/16/2024 by S3Social Worker indicating Resident #1 called Resident #2 a black b***** and stated she will kick her a**. Further review of the note revealed Resident #2 walked towards Resident #1 and hit her and Resident #1 hit Resident #2 back.
In an interview on 02/27/2024 at 11:15 a.m. S7Occupational Therapist (OT) stated he was walking by the dining room when he saw Resident #2 get up and approached Resident #1. S7OT further stated he separated the 2 residents after Resident #2 grabbed Resident #1 arm.
Review of the facility's incident report dated 01/27/2024 at 11:00 a.m. revealed S2Director of Nursing (DON) was notified by S10Weekend Registered Nurse Supervisor of an incident which occurred between Resident #1 and Resident #2 in the dining room. Further review revealed Resident #2 asked Resident #1 to move out of a chair and Resident #1 stated she was not moving for that black b****. Further review revealed Resident #2 moved towards Resident #1 and at that time Resident #1 swung and hit Resident #2.
In an interview on 02/27/2024 at 12:36 p.m., S8Certified Nursing Assistant (CNA) stated during the incident on 01/27/2024, Resident #2 asked her if she could ask Resident #1 to get out of the chair and she told Resident #2 she could not make Resident #1 move. S8CNA added Resident #2 provoked Resident #1 to get out of the chair, and then Resident #1 swung at Resident #2 with a closed fist. S8Certified Nursing Assistant further stated this incident should not have happened.
In an interview on 02/29/2024 at 12:26 p.m., S10Weekend Registered Nurse Supervisor stated she heard staff calling for help from the dining room and when she got there Resident #2 was standing against the wall and Resident #1 was hitting her.
Resident #3 and Resident #4
Review of Resident #3's MDS with an ARD of 01/08/2024 revealed, in part, Resident #3 had a BIMS score of 15 which indicated Resident #3 was cognitively intact. Further review revealed Resident #3 had no mental disorders and no behaviors directed towards others.
Review of Resident #4's MDS with an ARD of 01/18/2024 revealed, in part, Resident #4 had a BIMS score 15 which indicated Resident #4 was cognitively intact. Further review revealed Resident #4 had a diagnosis of Alzheimer's disease and no behaviors directed towards others.
Review of Resident #4's care plan revealed, in part, Resident #4 had a mood problem related to dementia.
Review of the facility's incident report dated 01/25/2024 at 12:07 p.m. revealed S1Administrator received a report from S4Activities Director who stated she heard residents arguing in the hallway and went to investigate. S4Activities Director reported she witnessed Resident #4 hit Resident #3 in the back as Resident #4 passed him in the hallway.
Review of Resident #3's progress note dated 01/25/2024 at 11:52 a.m., revealed S3Social Worker spoke to Resident #3 who stated another resident hit him in his back because he could not wait for Resident #3 to move out of the way.
Review of Resident #4's progress note dated 01/25/2024 at 11:55 a.m. Resident #4 stated Resident #3 refused to move out his way; so, he hit him in the back.
In an interview on 02/26/2024 at 1:25 p.m., Resident #4 stated he was involved in an incident with Resident #3 about a month ago. Resident #4 further stated Resident #3 was in front of him and would not get out of his way so he hit Resident #3 with a closed fist in his back.
In an interview on 02/29/2024 at 1:15 p.m., S2DON stated the above mentioned incidents were just altercations and she would not consider them abuse. S2DON further stated she did not agree with the federal regulations definition of abuse because it was too harsh.
In an interview on 02/29/2024 at 1:37 p.m., S1Administrator stated after an investigation was completed the facility confirmed on 01/25/2024 Resident #4 hit Resident #3 in the back because he would not move out of his way. S1Administrator agreed Resident #1, Resident #2, and Resident #3 had the right to be free from abuse; however, further stated in his opinion what occurred was just an altercation and not abuse.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to electronically submit payroll information for direct care staffing as required.
Findings:
Review of the facility's Payroll Based Journal (...
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Based on record review and interview, the facility failed to electronically submit payroll information for direct care staffing as required.
Findings:
Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30) revealed, in part, the facility failed to submit staffing data for Quarter 4.
Review of the facility's record titled CMS (Centers for Medicare and Medicaid Services) Submission Report dated 11/14/2023 revealed, in part, a file was submitted for Fiscal Quarter 4 and the entire file was rejected. Further review revealed the file was not structured properly and therefore could not be processed and the facility should contact the software vendor, make appropriate corrections to the record, and resubmit.
Record review revealed no documented evidence and the facility did not present any documented the facility submitted the PBJ Staffing Data for FY Quarter 4 2023 (July 1 - September 30).
In an interview on 02/27/2024 at 10:00 a.m., S1Administrator stated the facility was unable to submit the PBJ Staffing Data for Fiscal Year Quarter 4 2023 due to an error during submission. S1Administrator further stated he was not aware of the process to correct the file and the facility did not attempt to correct or resubmit the file.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observation and interview, the facility failed to post the required nurse staffing information.
Findings:
Observation on 02/26/2024 at 9:46 a.m. revealed no daily nursing staffing hours were ...
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Based on observation and interview, the facility failed to post the required nurse staffing information.
Findings:
Observation on 02/26/2024 at 9:46 a.m. revealed no daily nursing staffing hours were posted in the facility.
Observation on 02/26/2024 at 1:20 p.m. revealed no daily nursing staffing hours were posted in the facility.
Observation on 02/27/2024 at 9:16 a.m. revealed no daily nursing staffing hours were posted in the facility.
In an interview on 02/27/2024 at 9:30 a.m., S2DON confirmed daily nursing staffing hours were not posted and they should have been posted.
In an interview on 02/27/2024 at 9:40 a.m., S1Administrator confirmed daily staffing hours were not posted on 02/26/2024 and 02/27/2024 as required.
Nov 2023
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on interviews and observations the facility failed to have a have a comfortable mattress for a resident. This deficient practice was for 1 (Resident #34) of 18 (Resident #1, Resident #2, Residen...
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Based on interviews and observations the facility failed to have a have a comfortable mattress for a resident. This deficient practice was for 1 (Resident #34) of 18 (Resident #1, Resident #2, Resident #8, Resident #11, Resident #15, Resident #19, Resident #25, Resident #28, Resident #34, Resident #40, Resident #42, Resident #51, Resident #57, Resident #61, Resident #66, Resident #67, Resident #72, and Resident #73) sampled residents investigated.
Findings:
Resident #34
In an interview on 11/28/2023 at 1:12 p.m., Resident #34 stated that his mattress was sunken down in the middle and was uncomfortable.
Observation on 11/29/2023 at 9:28 a.m. revealed Resident #34's bed was sunken down in the middle towards the head of the bed.
In an interview on 11/29/2023 at 9:35 a.m., S14Licensed Practical Nurse (LPN) confirmed Resident #34's mattress should not be sunken down. S14LPN further stated the bed was changed out about two weeks ago.
In an interview on 11/29/2023 at 9:36 a.m., Resident #34 stated that his mattress was changed out two weeks ago, it was sunken down in the middle.
In an interview on 11/29/2023 at 9:42 a.m., after looking at another similar type of bed, S2Administrator confirmed Resident #34's bed should not be sunken down.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to have a failed to maintain a resident's wheelchair in a sanitary manner. This deficient practice was for 1 (Resident #1) of 18 (Resident #25...
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Based on observations and interviews, the facility failed to have a failed to maintain a resident's wheelchair in a sanitary manner. This deficient practice was for 1 (Resident #1) of 18 (Resident #25, Resident #34, Resident #28, Resident #67, Resident #66, Resident #57, Resident #61, Resident #8, Resident #19, Resident #51, Resident #1, Resident #40, Resident #2, Resident #15, Resident #72, Resident #73, Resident #11, and Resident #42) sampled residents investigated.
Findings:
Observation on 11/28/2023 at 9:41 a.m. revealed Resident #1 was reclined in her wheelchair which had stains of an unknown white substance covered the seat, the back, and the wheels and a wad of hair caught in the right and left front wheels.
Observation on 11/28/2023 at 11:45 a.m. revealed Resident #1 was reclined in her wheelchair which had generalized stains of an unknown white substance and a wad of hair caught in the right and left front wheel.
Observation on 11/29/2023 at 9:15 a.m. revealed Resident #1 was reclined in her wheelchair which had stains of an unknown white substance and a wad of hair caught in the right and left front wheel.
Observation on 11/29/2023 at 1:04 p.m. revealed Resident #1 was reclined in her wheelchair which had generalized stains of an unknown white substance which covered the seat, the back, and the wheels and a wad of hair caught in the right and left front wheels.
Observation on 11/30/2023 at 3:58 p.m. revealed Resident #1 was reclined in her wheelchair which had generalized stains of an unknown white substance which covered the seat, the back, and the wheels and a wad of hair caught in the right and left front wheel.
In an interview on 11/30/2023 at 10:14 a.m., S17Certified Nursing Assistant (CNA) Supervisor stated it was the 6:00 a.m. to 10:00 p.m. shift CNA's responsibility to clean wheelchairs, but the facility did not have an actual wheelchair cleaning schedule.
Observation on 11/30/2023 at 10:15 a.m. revealed Resident #1 was reclined in her wheelchair which had generalized stains of an unknown white substance which covered the seat, the back, and the wheels and a wad of hair caught in the right and left front wheel.
In an interview on 11/30/2023 at 10:16 a.m., S8Corporate Nurse confirmed Resident #1's wheelchair needed to be cleaned.
In an interview on 11/30/2023 at 10:17 a.m., S17CNA Supervisor confirmed Resident #1's wheelchair needed to be cleaned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record reviews, interviews, and observation, the facility failed to ensure a resident's injury of unknown origin was reported for 1 (Resident #1) of 18 (Resident #1, Resident #2, Resident #8,...
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Based on record reviews, interviews, and observation, the facility failed to ensure a resident's injury of unknown origin was reported for 1 (Resident #1) of 18 (Resident #1, Resident #2, Resident #8, Resident #11, Resident #15, Resident #19, Resident #25, Resident #28, Resident #34, Resident #40, Resident #42, Resident #51, Resident #57, Resident #61, Resident #66, Resident #67, Resident #72, and Resident #73) sampled residents investigated.
Findings:
Review of the facility's Abuse policy and procedure revealed, in part, an injury was classified as an injury of unknown source when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Further review revealed reporting of an injury of unknown source was required no later than 24 hours after forming the suspicion.
Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 10/25/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. Further review revealed Resident #1 had diagnoses of traumatic brain injury, stroke, and hemiparesis (a condition of weakness or paralysis on one side of the body)/hemiplegia (a condition of paralysis on one side of the body). Review also revealed Resident #1 was documented to be totally dependent on staff for all self-care and mobility.
Review of Resident #1's Nursing Note from 11/19/2023 at 4:02 p.m. revealed, in part, S13Licensed Practical Nurse (LPN) was informed by Certified Nursing Assistant (CNA) of reddened areas on Resident #1's left inner and outer knee. Further review revealed Resident #1's knee was assessed, and Resident #1 denied her knee was bumped during transfers or personal care. Review also revealed Resident #1's physician and S12Director of Nursing (DON) were notified of Resident #1's left knee injury.
Review of Resident #1's physician's progress note dated 11/19/2023 revealed, in part, Resident #1's physician assessed Resident #1 for left knee ecchymosis (bruising) without known trauma. Further review revealed Resident #1's physician documented the physical exam revealed extensive ecchymosis to Resident #1's anterior left knee. Review revealed Resident #1's physician's diagnostic impression of the examination was a contusion (bruise that happens when blood vessels under the skin break due to an injury or a blow) to Resident #1's left knee.
In an interview on 11/28/2023 at 2:17 p.m., S13LPN stated Resident #1's CNA reported that Resident #1 had a reddened area on her left knee. S13LPN stated she then assessed Resident #1's left knee and observed bruising. S13LPN also stated Resident #1 was unable to tell her how the bruising on her left knee occurred. S13LPN further stated she notified Resident #1's physician and S12DON of Resident #1's left knee bruise and the bruise's unknown origin. S13LPN confirmed Resident #1's left knee bruise was considered an injury of unknown origin because Resident #1 and facility staff were unable to determine how the bruising occurred.
Observation on 11/29/2023 at 9:13 a.m. revealed Resident #1 had a yellow and green discoloration to the medial (middle) and lateral (outside) aspect of her left knee.
In an interview on 11/29/2023 at 9:15 a.m., Resident #1 stated she did not know how she obtained the bruise on her left knee.
Review of the facility's list of state agency reports revealed, in part, a report was not completed for Resident #1's injury of unknown origin which was discovered on 11/19/2023.
There was no documented evidence and the facility was unable to present any documented evidence that the state agency was notified of Resident #1's left knee injury of unknown origin.
In an interview on 11/29/2023 at 11:59 a.m., S2Administrator stated he was not informed of Resident #1's bruised left knee which was discovered on 11/19/2023. S2Administrator defined an injury of unknown origin as an injury that could not be explained by the resident or facility staff. S2Administrator confirmed Resident #1's left knee bruise was considered an injury of unknown origin.
In an interview on 11/29/2023 at 1:10 p.m., S2Administrator confirmed the facility had not reported Resident #1's left knee injury of unknown origin discovered on 11/19/2023 to the state agency as required.
In an interview on 11/30/2023 at 10:20 a.m., S8Corporate Nurse confirmed Resident #1's bruise to her left knee was an injury of unknown origin. S8Corporate Nurse stated Resident #1's left knee injury of unknown origin should have been reported to the state agency upon discovery on 11/29/2023.
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 record reviews and interviews, the facility failed to thoroughly investigate a resident's injury of unknown origin for 1 (Resident #1) of 18 (Resident #25, Resident #34, Resident #28, Residen...
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Based on record reviews and interviews, the facility failed to thoroughly investigate a resident's injury of unknown origin for 1 (Resident #1) of 18 (Resident #25, Resident #34, Resident #28, Resident #67, Resident #66, Resident #57, Resident #61, Resident #8, Resident #19, Resident #51, Resident #1, Resident #40, Resident #2, Resident #15, Resident #72, Resident #73, Resident #11, and Resident #42) sampled residents investigated.
Findings:
Review of the facility's Abuse policy and procedure revealed, in part, an injury was classified as an injury of unknown source when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Further review revealed a thorough investigation should be completed within 5 working days of the allegation.
Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 10/25/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. Further review revealed Resident #1 had diagnoses of traumatic brain injury, stroke, and hemiparesis (a condition of weakness or paralysis on one side of the body)/hemiplegia (a condition of paralysis on one side of the body). Review also revealed Resident #1 was documented to be totally dependent on staff for all self-care and mobility.
Review of Resident #1's Nursing Note from 11/19/2023 at 4:02 p.m. revealed, in part, S13Licensed Practical Nurse (LPN) was informed by a certified nursing assistant (CNA) of reddened areas on Resident #1's left inner and outer knee. Further review revealed Resident #1's knee was assessed, and Resident #1 denied her knee was bumped during transfers or personal care. Review also revealed Resident #1's physician and S12Director of Nursing (DON) were notified of Resident #1's left knee injury.
In an interview 11/28/2023 at 2:17 p.m., S13LPN stated Resident #1's CNA informed her that Resident #1 had a reddened area on her left knee. S13LPN stated she then assessed Resident #1's left knee and observed bruising. S13LPN also stated Resident #1 was unable to tell her how the bruising on her left knee occurred. S13LPN further stated she notified Resident #1's physician and S12DON of Resident #1's left knee bruise and the bruise's unknown origin. S13LPN confirmed Resident #1's left knee bruise was considered an injury of unknown origin because Resident #1 and facility staff were unable to determine how the bruising occurred.
Observation on 11/29/2023 at 9:13 a.m. revealed Resident #1 had a yellow and green discoloration to the medial (middle) and lateral (outside) aspect of her left knee.
In an interview on 11/29/2023 at 9:15 a.m., Resident #1 stated she did not know how she obtained the bruise on her left knee.
In an interview on 11/29/2023 at 11:58 a.m., S8Corporate Nurse stated she had no documented evidence of an investigation for Resident #1's left knee injury of unknown origin to present because the S12DON was on leave. S8Corporate Nurse stated S12DON was currently preparing an investigation for Resident #1's bruise that was discovered on 11/19/2023.
In an interview on 11/29/2023 at 11:59 a.m., S2Administrator defined an injury of unknown origin as an injury that could not be explained by the resident or facility staff. S2Administrator confirmed Resident #1's bruise was considered an injury of unknown origin. S2Administrator confirmed he had no investigation of Resident #1's bruised left knee injury of unknown origin to present to the surveyor, but S12DON was currently on leave and typing an investigation at the time of the interview.
In an interview on 11/29/2023 at 1:10 p.m., S2Administrator presented the surveyor with a typed document S1Administrator identified as the investigation S12DON prepared on 11/29/2023 for Resident #1's left knee injury of unknown origin discovered on 11/19/2023. S2Administrator stated he was unaware if the typed document sent to him today (11/29/2023) was a thorough investigation because S2Administrator was not aware of Resident #1's injury of unknown origin until today (11/29/2023).
In an interview on 11/30/2023 at 10:20 a.m., S8Corporate Nurse confirmed Resident #1's bruise to her left knee was an injury of unknown origin that warranted a thorough investigation which was not completed by S12DON.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to develop a plan of care with measureable objectives and timeframes for a resident receiving hospice services.
This deficient practice was id...
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Based on record review and interview, the facility failed to develop a plan of care with measureable objectives and timeframes for a resident receiving hospice services.
This deficient practice was identified for 1 (Resident #28) of 1 (Resident #28) sampled residents reviewed for hospice services.
Findings:
Review of Resident #28 record revealed, in part, an admission date of 10/11/2022.
Review of Resident #28's November 2023 Physician Orders revealed, in part, an order with a start date of 09/22/2023 to admit to hospice care services.
There was no documented evidence and the facility did not present any documented evidence that a plan of care was developed related to Resident #28 receiving hospice services.
In an interview on 11/30/2023 at 10:00 a.m., S25Licensed Practical Nurse (LPN) acknowledged Resident #28 did not have a care plan implemented for Hospice Care when Resident #28 was admitted to Hospice Care on 09/22/2023.
In an interview on 11/30/2023 at 10:05 a.m., S27Corporate Minimum Data Set Nurse stated they were not auditing the current Care Plans to ensure they were correct.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record reviews, observations, and interviews, the facility failed to clarify a physician's order for a nutritional supplement prior to administration for 1 (Resident #57) of 2 (Resident #11 a...
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Based on record reviews, observations, and interviews, the facility failed to clarify a physician's order for a nutritional supplement prior to administration for 1 (Resident #57) of 2 (Resident #11 and Resident #57) sampled residents reviewed for nutrition.
Findings:
Review of the May 2023 Louisiana Administrative Code, Title 46, Part XLVII revealed, in part: the registered nurse retained the accountability for the total nursing care of the individual, and was responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she received, regardless of whether the care was provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. Review also revealed the registered nurse must clarify any order or treatment regimen believed to be inaccurate, or contraindicated by consulting with the appropriate licensed practitioner and by notifying the ordering practitioner when the registered nurse made the decisions not to administer the medication or treatment.
Review of Resident #57's nutrition/dietary note dated 09/26/2023 at 5:17 p.m., revealed, in part, Resident #57 was readmitted to facility on 09/25/2023 with significant weight loss.
Review of Resident #57's Physician Orders dated 11/01/2023 revealed, in part, an order with a start date of 11/01/2023 for Med Pass 2.0 (nutritional supplement) with meals for appetite.
There was no documented evidence and the facility did not resent any documented evidence as to how many ounces of Med Pass 2.0 supplement was to be administered.
In an interview on 11/29/2023 at 4:15 p.m., S28Licesnsed Practical Nurse (LPN) stated that Resident #57 returned from the hospital with a significant weight loss and was on Med Pass 2.0 supplement. S28LPN stated that she gave Resident #57 4 ounces of Med Pass 2.0, because that was the amount that Resident #57 was receiving before being admitted to the hospital.
Observation on 11/29/2023 at 4:17 p.m. revealed S28LPN administered 4 ounces of Med Pass 2.0 to Resident #57. Further observation revealed Resident #57 drank all 4 ounces of the Med Pass 2.0
In an interview on 11/29/2023 at 5:20 p.m., S28LPN confirmed Resident #57's order for Med Pass 2.0 did not have an amount to be administered and should have clarified the amount the physician wanted to be administered prior to administering the nutritional supplement.
In an interview on 11/30/2023 at 11:40 p.m. S8Corporate Nurse confirmed Resident #57's Medpass 2.0 order did not have an amount to be administered and should have. S8Corporate Nurse further stated S28LPN should have clarified the amount with the physician or physician extender prior to administering the Medpass 2.0 to Resident #57.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record reviews, observations, and interview, the facility failed to ensure a dependent resident received nail care for 1 (Resident #1) of 2 (Resident #1 and Resident #42) sampled residents in...
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Based on record reviews, observations, and interview, the facility failed to ensure a dependent resident received nail care for 1 (Resident #1) of 2 (Resident #1 and Resident #42) sampled residents investigated for activities of daily living.
Findings:
Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 10/25/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 04, which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 was dependent on facility staff for all self-care and did not display rejection of care behaviors in the lookback period.
Review of Resident #1's care plan revealed, in part, Resident #1 had impaired cognitive function and contractures to her right upper and lower extremities. Further review revealed interventions included staff were to assist Resident #1 as needed to complete all activities of daily living, including personal hygiene.
In an interview on 11/28/2023 at 9:42 a.m., S5Certified Nursing Assistant (CNA) stated Resident #1 was a totally dependent on staff for all care.
Observation on 11/29/2023 at 1:04 p.m. revealed Resident #1's contracted right hand 3rd and 5th digit fingernails were longer than 3/4 inch and extended past her fingertips.
Observation on 11/30/2023 at 3:58 p.m. revealed Resident #1's contracted right hand 3rd and 5th digit fingernails were longer than 3/4 inch and extended past her fingertips.
Observation on 11/30/2023 at 10:15 a.m. revealed Resident #1's contracted right hand 3rd and 5th digit fingernails were longer than 3/4 inch and extended past her fingertips.
In an interview on 11/30/2023 at 10:16 a.m., S8Corporate Nurse confirmed Resident #1's 3rd and 5th digit fingernails on her contracted right hand needed to be trimmed because it could potentially puncture Resident #1's palm of her right hand due to the contracture.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed:
1. Ensure an indwelling catheter bag was not lying on the floor and/or held above the waistline while emptying the catheter bag...
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Based on observation, interview, and record review the facility failed:
1. Ensure an indwelling catheter bag was not lying on the floor and/or held above the waistline while emptying the catheter bag (Resident #19); and
2. Ensure catheter care was performed correctly (Resident #66).
This deficient practice was identified for 2 (Resident #19 and Resident #66) of 2 (Resident #19 and Resident #66) sampled residents reviewed for catheter care.
Findings:
Resident #19
Review of Resident #19 clinical record revealed, in part, diagnosis of Urinary Tract Infection and Urinary Retention.
Review of Resident #19's Care Plan revealed, in part, Resident #19 had an indwelling catheter.
Observation on 11/27/2023 at 9:58 a.m. revealed Resident #19's catheter bag was held by a Certified Nursing Assistant (CNA) above Resident #19's waistline. Further observation revealed cloudy, yellow, urine with sediments back-flowed towards Resident #19's bladder.
Observation on 11/29/2023 at 9:25 a.m. revealed Resident #19's catheter bag was lying on the floor.
Observation on 11/29/2023 at 11:25 a.m. revealed Resident #19's catheter bag was lying on the floor.
Observation on 11/29/2023 at 1:55 p.m. Resident # 19's drainage bag was held by a Certified Nursing Assistant (CNA) above the Resident #19's waistline. Further observation revealed cloudy, yellow, urine with sediments back-flowed towards Resident #19's bladder.
In an interview on 11/29/23 at 1:55 p.m., S5Certified Nursing Assistant acknowledged Resident #19's catheter bag should not be held above the resident waistline when emptying the drainage bag and the drainage bag should not be lying on the floor.
In an interview on 11/29/23 at 1:59 p.m., S17Certified Nursing Assistant Supervisor acknowledged Resident #19's urinary bag should be held below the resident waistline when emptying the drainage bag and the drainage bag should not be lying on the floor.
Resident #66
Review of Resident #66's Order Summary Report revealed, in part, an order summary for catheter care every shift.
An observation on 11/29/2023 at 10:15 a.m. revealed S21Certified Nursing Assistant (CNA) provided urinary catheter care to Resident #66. S21CNA washed Resident #66's perineum and groin with a clean wash cloth and then with the same wash cloth proceeded to clean the urinary meatus and did not clean the red catheter tubing.
In an interview on 11/29/2023 at 11:00 a.m., S17Certified Nursing Assistant Supervisor stated urinary catheter care should be provided each shift. S17Certified Nursing Assistant Supervisor stated all CNA's and S21CNA had completed a competency checklist on catheter care. S17Certified Nursing Assistant Supervisor further stated a urinary catheter should be cleaned starting at the urinary meatus and clean outward using a clean soapy towel and then rinsed with a clean wet cloth starting at the urinary meatus and continuing outward. She stated the catheter tubing exiting the urinary meatus should be cleaned starting at the urinary meatus progressing distally downward away from the resident in one swipe. S17Certified Nursing Assistant Supervisor further stated the urinary meatus and catheter should be cleaned with an unused wash cloth before cleaning the rest of the resident's perineum. S17Nursing Assistant Supervisor further stated S21CNA did not perform or maintain a clean technique while providing urinary catheter care.
In an interview on 11/29/2023 at 2:30 p.m., S8Corporate Nurse stated S21CNA did not perform or maintain a clean technique while providing urinary catheter care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure a resident's dialysis access site was assessed for a thrill (palpable vibration of blood through access to test patency)...
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Based on observation, interview and record review the facility failed to ensure a resident's dialysis access site was assessed for a thrill (palpable vibration of blood through access to test patency) and a bruit (audible sound of blood passing through access to test patency) on every shift as ordered by the physician for 1 (Resident #11) of 1 (Resident #11) sampled residents reviewed for dialysis.
Findings:
Review of Resident #11's record revealed, in part, diagnoses of chronic kidney disease, end stage renal disease, dependence on renal dialysis.
Review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/27/2023 revealed, in part, Resident #11's Brief Interview Mental Status score was 15, which indicated he was cognitively intact.
Review of Resident #11's November 2023 Physician Orders revealed, in part, monitor dialysis fistula access site every shift for thrill and bruit with a start date of 10/24/2023.
Review of dialysis monitoring documentation revealed, in part, a monitoring order was in place stating monitor dialysis fistula every shift for thrill and bruit and notify nephrologist/doctor if absent. There was no documentation and the provider did not present any documented evidence which indicated Resident #1's dialysis site was assessed on the following shifts; on the day shift or evening shift on 10/24/2023; on the day shift on 10/26/2023; on the night shift on 10/31/2023; on the evening shift on 11/01/2023; on the day shift on 11/04/2023; on the day shift on 11/05/2023; on the evening shift on 11/06/2023; on the night shift on 11/07/2023; on the evening shift on 11/13/2023; and on the day shift on 11/15/2023.
In an interview on 11/28/2023 at 2:25 p.m., Resident #11 stated the nurses do not assess his dialysis shunt upon return from dialysis.
Observation on 11/29/2023 at 12:40 p.m., revealed S19Licensed Practical Nurse (LPN) did not assess Resident #11's dialysis site for bruit or thrill.
In an interview on 11/29/2023 at 1:00 p.m., S19LPN stated she did not assess Resident #11's dialysis site for a thrill or bruit.
In an interview on 11/30/2023 at 10:20 a.m., S19LPN stated she did not assess Resident #11's dialysis site for a thrill or bruit yesterday.
In an interview on 11/30/2023 at 10:49 a.m., S8Corporate Nurse stated the nurse should assess a dialysis site for a thrill and bruit each shift as ordered.
In an interview on 11/30/2023 at 1:00 p.m., Resident #11 stated the nurse used the stethoscope to assess the dialysis site at times, but definitely not every shift. Resident #11 further stated there were days that no one assessed his dialysis site at all.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record reviews and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 2 (S7CNA and S9CNA) of 2 (S7CN...
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Based on record reviews and interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 2 (S7CNA and S9CNA) of 2 (S7CNA and S9CNA) personnel records reviewed.
Findings:
Review of S7CNA's personnel record revealed, in part, a hire date of 08/10/2021. Further review revealed S7CNA's last annual performance review had been completed on 11/02/2022.
Review of S9CNA's personnel record revealed, in part, a hire date of 10/28/2021. Further review failed to reveal evidence an annual performance review had been completed for S9CNA in the last 12 months.
In an interview on 11/28/2023 at 11:26 a.m., S10Human Resources/Payroll confirmed S7CNA and S9CNA did not have an annual performance review completed in the last 12 months. S10Human Resources/Payroll stated the head of the nursing department was responsible for the completion of annual performance reviews for the certified nurse's aides. S10Human Resources/Payroll stated the facility was aware annual performance evaluations had not been completed timely.
There was no documented evidence and the facility did not present any documented evidence of completing the above mentioned annual performance evaluations as required.
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, interview, and record review the facility failed to ensure eye drops were labeled per facility policy. This deficient practice was identified for 1 medication cart (Cart x) of 2 ...
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Based on observation, interview, and record review the facility failed to ensure eye drops were labeled per facility policy. This deficient practice was identified for 1 medication cart (Cart x) of 2 medication carts ( Cart x, and Cart y) observed for medication storage task.
Findings:
Review of the facility's policy titled Pharmacy Services Labeling and Storage of Drugs and Biologicals revealed, in part: for medications designed for multiple administration (inhalers, eye drops), the label identifies the specific resident for whom it was prescribed.
Observation on 11/29/2023 at 10:16 a.m. of Cart x revealed, in part, an opened bottle of Artificial Tears Ophthalmic Solution (eye drops used for dry eye relief and lubricant). Further observation revealed there was no way to identify which resident the eye drops belonged to.
In an interview on 11/29/2023 at 10:16 a.m., S23Agency Nurse acknowledged the opened bottle of Artificial Tears Ophthalmic Solution should have had the resident's name but it was not labeled. S23Agency Nurse further stated she was unable to identify which resident the eye drops belonged to.
In an interview on 11/29/2023 at 1:29 p.m., S8Corporate Nurse acknowledged the opened bottle of the Artificial Tears Ophthalmic Solution should have been labeled with a resident's name.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on record reviews, observations, and interviews, the facility failed to:
1. Ensure staff placed a hand roll in a resident's contracted hand and elbow pads in a resident's contracted arms as orde...
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Based on record reviews, observations, and interviews, the facility failed to:
1. Ensure staff placed a hand roll in a resident's contracted hand and elbow pads in a resident's contracted arms as ordered by the physician for 1 (Resident #1) of 2 (Resident #1 and Resident #61) sampled residents investigated for positioning and mobility; and,
2. Ensure a resident with contractures received restorative nursing services per their plan of care for 1 (Resident #1) of 2 (Resident #1 and Resident #61) sampled residents investigated for positioning and mobility.
Findings:
1.
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. Further review revealed Resident #1 had diagnoses of traumatic brain injury, stroke, and hemiparesis (a condition of weakness or paralysis on one side of the body)/hemiplegia (a condition of paralysis on one side of the body). Review also revealed Resident #1 was documented as total dependent on staff for all self-care and mobility and did not display rejection of care behaviors in the lookback period.
Review of Resident #1's care plan initiated on 04/20/2017 revealed, in part, Resident #1 was care planned for decreased range of motion to bilateral upper and lower extremities with a goal to have no increase in contractures by 02/24/2024 with interventions for the Certified Nursing Assistant (CNA) to apply a hand roll to Resident #1's right hand at all times.
Review of Resident #1's physician's progress note dated 02/01/2023 revealed, in part, Resident #1 did not have hand rolls or hand towels in place. Further review revealed Resident #1 had severe flexion contractures to the right elbow and right hand. Review also revealed Resident #1's physician documented he spoke with a nurse regarding Resident #1's lack of hand rolls or hand towels.
Review of Resident #1's physician's progress note dated 08/02/2023 revealed, in part, Resident #1 had extreme right flexion contracture without hand rolls or towels in place.
Review of Resident #1's physician's progress note dated 11/06/2023 revealed, in part, Resident #1 had severe right side flexion contractures. Further review revealed Resident #1 required towel rolls to the right hand and elbow.
Review of Resident #1's physician's written order dated 11/06/2023 revealed, in part, Resident #1 needed hand rolls and elbow pads in the creases of the elbows constantly.
Review of Resident #1's active physician's orders as of 11/28/2023 revealed, in part, Resident #1 was ordered to have hand rolls placed in bilateral hands and bilateral elbows daily. Further review revealed the order start date was on 11/07/2023.
Observation on 11/28/2023 at 9:41 a.m. revealed Resident #1 had no hand rolls or elbow pads in the creases of either elbow. Observation further revealed Resident #1 had contractures to her right hand, and her right elbow.
Observation on 11/28/2023 at 11:45 a.m. revealed Resident #1 had no hand rolls or elbow pads in the creases of either elbow. Observation further revealed Resident #1 had contractures to her right hand, and her right elbow.
Observation on 11/29/2023 at 9:13 a.m. revealed Resident #1 had no hand rolls or elbow pads in the creases of either elbow. Observation further revealed Resident #1 had contractures to her right hand, and her right elbow.
In an interview on 11/29/2023 at 9:15 a.m., Resident #1 stated the facility staff did not put hand rolls in her bilateral hands or elbow pads in her bilateral elbows. Resident #1 denied refusing the ordered hand rolls and elbow pads, and confirmed she would allow facility staff to apply the hand rolls and elbow pads as ordered.
In an interview on 11/29/2023 at 12:16 p.m., S31Therapy stated Resident #1 had contractures and required bilateral hand rolls.
Observation on 11/29/2023 at 1:04 p.m. revealed Resident #1 had no hand roll present in the left hand and no elbow pad in either elbow crease.
Observation on 11/30/2023 at 3:58 p.m. revealed Resident #1 had no hand roll present in the left hand and no elbow pad in either elbow crease.
Observation on 11/30/2023 at 10:15 a.m. revealed Resident #1 had no hand roll present in the left hand and no elbow pad in either elbow crease.
In an interview on 11/30/2023 at 12:05 p.m., S18Licensed Practical Nurse (LPN) confirmed Resident #1 had a physician order for bilateral hand rolls and elbow pads in. S18LPN further stated Resident #1 did not refuse the application of the ordered hand rolls or elbow pads in the creases of her elbows.
In an interview on 11/30/2023 at 12:10 p.m., S8Corporate Nurse confirmed Resident #1 did not have bilateral hand rolls or bilateral elbow pads in the creased of her elbows in place during an observation with the surveyor on 11/30/2023 at 10:15 a.m. S8Corporate Nurse stated Resident #1 should have devices applied per physician's orders.
2.
Review of Resident #1's MDS with an ARD of 10/25/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. Further review revealed Resident #1 had diagnoses of traumatic brain injury, stroke, and hemiparesis/hemiplegia. Review also revealed Resident #1 was documented to be totally dependent on staff for all self-care and mobility and did not display rejection of care behaviors in the lookback period. Resident #1 also had no restorative nursing services provided in the lookback period.
Review of Resident #1's care plan initiated on 04/20/2017 revealed, in part, Resident #1 was care planned for decreased range of motion to bilateral upper and lower extremities with a goal to have no increase in contractures by 02/24/2024 with an intervention for the restorative nursing assistant to complete passive range of motion exercises by holding Resident #1's straightened knee in position for 10 seconds for 15 repetitions to each knee every day for 15 minutes.
There was no documented evidence and the facility was unable to provide any documented evidence Resident #1 received restorative nursing services per Resident #1's decreased range of motion care plan.
In an interview on 11/29/2023 at 12:13 p.m., S21CNA stated she was the restorative aide for the facility, but she was often removed from her restorative duties to act as a CNA.
In an interview on 11/29/2023 at 12:14 p.m., S20Physical Therapy Assistant (PTA) stated the facility did not have a formal restorative nursing program. S20PTA stated S21CNA was the restorative aide, but she often was removed from her restorative duties to work as a CNA due to low staffing. S20PTA stated the therapy department did not complete restorative nursing services. S20PTA confirmed there were residents in the facility who could benefit from restorative nursing services.
In an interview on 11/29/2023 at 12:15 p.m., S24Therapy confirmed the facility did not have a formal restorative nursing program.
In an interview on 11/29/2023 at 12:25 p.m., S21CNA confirmed the facility did not have a true restorative nursing program.
In an interview on 11/29/2023 at 12:26 p.m., S2Administrator stated the facility did not have a restorative nursing program to provide restorative nursing services to residents.
In an interview on 11/29/23 at 2:33 p.m., S8Corporate Nurse stated the facility did not have a restorative nursing program to provide restorative nursing services to residents.
In an interview on 11/29/2023 at 3:36 p.m., S8Corporate Nurse confirmed there was no documented evidence and was unable to present any documented evidence restorative nursing services were provided to Resident #1.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review the facility failed to:
1. Ensure a resident remained free from falls by failing to develop and/or implement a care plan to prevent falls, and/or f...
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Based on observations, interviews, and record review the facility failed to:
1. Ensure a resident remained free from falls by failing to develop and/or implement a care plan to prevent falls, and/or failed to develop new individualized interventions after following a fall for 1 (Resident #15) of 1 (Resident #15) sampled residents reviewed for falls; and
2. Ensure smoking paraphernalia was secure according the facility's policy and the residents care plan 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for smoking.
Findings:
1.
Review of the facility's Accident Hazards/Supervision/Devices Policy revealed, in part, the facility would initiate and implement a comprehensive, resident-centered fall prevention plan for residents at risk for falls or with a history of falls.
Review of Resident #15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/2023 revealed, in part, Resident #15's Brief Interview of Mental Status (BIMS) score was 5, which indicated severe cognitive impairment.
Review of the facility's incident report log May 2023 through November 2023 revealed, in part, Resident #15 had an unwitnessed fall on 06/13/2023, 06/27/2023, 10/25/2023, and 10/27/2023.
Review of Resident #15's nurse's note dated 06/13/2023 revealed, in part, when the nurse entered Resident #15's room Resident #15 was awake and alert siting on the side of the bed on the mat and stated I fell off the bed.
Review of Resident #15's nurse's note dated 06/27/2023 revealed, in part, Resident #15 was sitting on the floor on the mat. Further review revealed, Resident #15 had a hematoma (an abnormal pooling of blood under the skin) was noted to the right side of the forehead.
Review of Resident #15's nurse's note dated 10/25/2023 revealed, in part, nurse called to Resident #15's room, upon entering the room Resident #15 was found sitting on the right side of the bed wrapped in a blanket. Further review revealed Resident #15 doesn't recall the fall.
Review of resident #15's nurse's note dated 10/27/2023 revealed, in part, Resident #15 was sitting on the floor at the bedside.
Review of Resident #15's care plan revealed, in part, a care plan was developed for risk for falls on 11/06/2023 after Resident #15 was found on the floor on 10/27/2023. Further review revealed interventions initiated were call light within reach, encourage the resident to use call light for assistance, educate the resident about safety reminders, encourage the resident to participate in activities.
In an interview on 11/29/2023 at 2:40 p.m., S26Licensed Practical Nurse (LPN) stated she was called to Resident #15's room by the certified nursing assistant (CNA) about a month ago when Resident #15 slipped out of her bed. S26LPN further stated Resident #15 had a fall several months ago. S26LPN further stated she was unsure what risk factors Resident #15 had for falls or how often Resident #15 was assessed for falls.
In an interview on 11/30/2023 at 8:55 a.m., S18LPN stated she was not aware of Resident #15 had any falls since she started working at the facility on 10/16/2023.
In an interview on 11/30/2023 at 10:10 a.m., S25LPN stated new fall interventions should have been implemented in 24 to 48 hours after a fall. S25LPN further stated the fall interventions for Resident #15's fall on 10/27/2023 were not implemented until 11/06/2023.
In an interview on 11/30/2023 at 11:40 a.m., S8Corporate Nurse confirmed interventions for Resident #15's falls on 06/13/2023, 06/27/2023, 09/21/2023, 10/25/2023, and 10/27/2023 were not added to Resident #15's care plan and should have been.
2.
Review of Resident #2's care plan revealed, in part, a problem that Resident #2 safe to smoke without supervision with an intervention of staff to keep all smoking supplies.
Review of the facility Smoking policy revealed, in part, the following:
1.
Residents deemed safe to be independent in smoking would be provided an individual storage box for their personal smoking paraphernalia. The individual storage box would be maintained in a secure area, not in the resident's room.
2.
Residents who are independent smokers will obtain their box from staff upon request and remove the desired items. Staff will secure the individual storage box once resident has removed needed items. Resident will return items for storage after smoking.
Review of Resident #2's Minimum Data Set with an Assessment Reference Date of 11/15/2023 revealed, in part, a Brief Interview for Mental Status score of 3 (severely cognitively impaired).
In an interview on 11/28/2023 at 10:34 a.m., Resident #2 stated she had her cigarettes and lighter on her. Resident #2 proceeded to get her cigarette case from her bedside table and when opened revealed 4 cigarettes and a lighter. Resident #2 was unsupervised in her room at this time.
An observation on 11/28/2023 at 12:39 p.m. revealed Resident #2 was alone in her room and when asked if Resident #2 had smoking paraphernal Resident #2 removed a red cigarette case from her coat pocket. Resident #2 then opened her cigarette case which revealed 3 cigarettes and a lighter.
In an interview on 11/29/2023 at 9:14 a.m., S23Agency Nurse stated during the day Resident #2 kept her cigarettes and lighter with her. S23Agency Nurse further stated at night Resident #2's cigarettes and lighter should be picked up and kept at the nursing station.
In an interview on 11/29/2023 at 9:40 p.m., Resident #2 stated she had her cigarettes and lighter with her.
An observation on 11/29/2023 at 9:40 a.m. revealed 2 cigarettes and a lighter in a red cigarette case that Resident #2 removed from her coat pocket while she was unsupervised in her room.
An observation on 11/29/2023 at 1:24 p.m. accompanied by S8Corporate Nurse in Resident #2's room revealed Resident #2 removed a red cigarette case from her shirt pocket and opened the case which held 2 cigarettes and a lighter.
In an interview on 11/29/2023 at 1:35 p.m., S8Corporate Nurse stated Resident #2 should not have cigarettes and a lighter in her possession. S8Corporate Nurse further stated smoking supplies should be kept at the nurse's station.The facility failed to prevent accidents and hazard.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on record review and interviews the facility failed to:
1.Ensure a licensed pharmacist completed monthly medication reviews (MMR) for 3 (Resident #2, Resident #8 and Resident #51) of 5 (Resident...
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Based on record review and interviews the facility failed to:
1.Ensure a licensed pharmacist completed monthly medication reviews (MMR) for 3 (Resident #2, Resident #8 and Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications; and,
2.Ensure the attending physician acted upon the pharmacist's identified irregularities for 1 (Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications.
Findings:
Review of the facility's Pharmacy Services policy revealed, in part, residents will have a Medication Regimen Review (MRR) conducted at least monthly by a licensed pharmacist and includes a review of the resident's medical record. Further review revealed the pharmacist will report any irregularities on a separate written report provided to the attending physician, medical director and the director of nursing. Review also revealed irregularities will then be reviewed and a response will be provided in a timely manner.
Resident #2
Review of Resident #2's record revealed, in part, an admit date of 05/09/2023.
Review of the facility's Pharmacy Services policy revealed, in part, the medication regimen will be reviewed at least monthly by a licensed pharmacist.
Review of monthly medication review records revealed, in part, Resident #2 did not have a monthly medication review, and the facility could not provide documentation, for June 2023, July 2023 and August 2023.
Resident #8
Review of Resident #8's record revealed, in part, a readmit date of 02/06/2023.
There was no documented evidence and the facility was unable to present any documented evidence Resident #8 had MMRs completed by a pharmacist for March 2023 and May 2023.
Resident #51
Review of Resident #51's record revealed, in part, an admit date of 04/04/2022.
Review of the facility's Pharmacy Consult binder revealed, in part, no documented evidence and the facility was unable to present any documented evidence Resident #51 had MMRs completed by a pharmacist for March 2023 and April 2023.
Review of Resident #51's Pharmaceutical Consultant Report dated 01/19/2023 revealed, in part, the pharmacist recommended a gradual dose reduction (GDR) for Resident #51's Lexapro 10 milligrams (mg) ordered daily, Lexapro 5mg ordered daily, and Seroquel 25mg ordered every night. Further review revealed no physician's signature or documented evidence Resident #51's irregularity was acted upon.
Review of the facility's September 2023 Pharmacy Log revealed, in part, documentation that Resident #51's pharmacy consult identified Resident #51 had no diagnoses for many medications. Further review revealed Resident #51's pharmacy consult was marked as outstanding.
Review of Resident #51's Consultant Pharmacist Recommendations to Nursing Staff dated 09/25/2023 revealed, in part, the pharmacist identified Resident #51 had no clear or appropriate diagnosis for many drugs listed on the physician's order sheet or medication administration record. Further review revealed no documented evidence and the facility was unable to present any documented evidence Resident #51's pharmacist identified irregularity was acted upon.
Review of the Consultant Pharmacist Report to Physician from 10/31/2023 revealed, in part, the pharmacist recommended a GDR for Resident #51's ordered Seroquel 25mg. Further review revealed no physician's signature or documented evidence Resident #51's irregularity was reviewed and acted upon by the physician.
In an interview on 11/30/2023 at 1:35 p.m., S8Corporate Nurse confirmed Resident #2, Resident #8, and Resident #51 did not have MMRs by a licensed pharmacist as required. S8Corporate Nurse further confirmed there was no evidence Resident #51's pharmacist identified irregularities from 01/19/2023, 09/25/2023, and 10/31/2023 were reviewed and acted upon by a physician.
In an interview on 11/30/2023 at 3:00 p.m. S8Corporate Nurse stated she could not provide further documentation of monthly medication reviews for Resident #2, Resident #8, and Resident #51.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the facility failed to ensure a resident was free from unnecessary medications by failing to:
1. Ensure each resident medication had an adequate indication for ...
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Based on record reviews and interviews, the facility failed to ensure a resident was free from unnecessary medications by failing to:
1. Ensure each resident medication had an adequate indication for use for 1 (Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications; and,
2. Ensure adverse reactions and behavior monitoring was completed for a resident receiving antipsychotic and hypnotic medications for 1 (Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications.
Findings:
1.
Review of the facility's September 2023 Pharmacy Log revealed, in part, documentation that Resident #51's pharmacy consult identified Resident #51 had no diagnoses for medications. Further review revealed Resident #51's pharmacy consult was marked as outstanding.
Review of Resident #51's Consultant Pharmacist Recommendations to Nursing Staff dated 09/25/2023 revealed, in part, the pharmacist identified Resident #51 had no clear or appropriate diagnosis for many drugs listed on the physician's order sheet or medication administration record. Further review revealed no documented evidence and the facility was unable to present any documented evidence Resident #51's this irregularity was acted upon.
Review of Resident #51's November 2023 physician's orders revealed, in part, an order started on 11/02/2023 for Systane (a medication administered into the eye for lubrication) 0.3-0.4% 1 drop in both eyes every 12 hours as needed for dry eyes. Review also revealed an order started on 10/04/2023 for Docusate Sodium (a stool softener) 100 milligram (mg) capsule daily for constipation. Review of Resident #51's orders revealed an order started on 10/04/2023 for Aspirin (medication is used to reduce fever and relieve minor to moderate pain) 81mg tablet daily for pain.
Review of Resident #52's diagnoses revealed, in part, no evidence of a documented diagnosis of constipation, dry eyes, or pain.
Review of Resident #51's November 2023 electronic Medication Administration Record (eMAR) revealed, in part, documentation that Resident #51 was administered Systane eye drops, Docusate Sodium and Aspirin.
In an interview on 11/30/2023 at 1:35 p.m., S8Corporate Nurse confirmed Resident #51 was prescribed medications without an indication for use. S8Corporate Nurse confirmed the facility should have contacted Resident #51's physician to obtain a diagnosis for the medications without an indication for use.
2.
Review of Resident #51's November 2023 physician's order revealed, in part, orders started on 10/04/2023 for Lexapro (an antidepressant medication) 15mg daily for depression, Seroquel (an antipsychotic medication used for mood disorders) 25mg daily for persistent mood disorder, Trazodone (an antidepressant medication) 100mg daily for depression.
Review of Resident #51's November 2023 eMAR revealed, in part, documentation that Resident #51 was administered Lexapro, Seroquel and Trazodone as ordered.
Review of Resident #51's record revealed no documented evidence and the facility was unable to present any documented evidence behavior monitoring and adverse reaction monitoring was completed for Resident #51's Lexapro, Seroquel, and Trazodone medications since the medications were ordered on 10/04/2023.
In an interview on 11/30/2023 at 2:15 p.m., S22Licensed Practical Nurse confirmed Resident #51 did not have documented evidence that adverse reactions and behaviors were monitored every shift related to Resident #51's Lexapro, Seroquel, and Trazodone medication use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to maintain documentation that the resident or resident representatives received education regarding the benefits and potential side effects...
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Based on interviews and record reviews, the facility failed to maintain documentation that the resident or resident representatives received education regarding the benefits and potential side effects of the influenza vaccine for 5 (Resident #28, Resident #40, Resident #42, Resident #56 and Resident #63) of 5 (Resident #28, Resident #40, Resident #42, Resident #56 and Resident #63) sampled residents reviewed for influenza vaccines.
Findings:
Review of the facility's policy titled, Influenza Vaccination, revealed, in part, the following:
1. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination, and
2. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine.
Review of Resident #28's influenza vaccine consent form revealed, in part, Section 3: Consent for vaccination, I have read or had explained to me the vaccine information statement for the seasonal influenza vaccine and understand the risk and benefits was not signed by Resident #28 or Resident #28's representative.
Review of Resident #40's influenza vaccine consent form revealed, in part, Section 3: Consent for vaccination, I have read or had explained to me the vaccine information statement for the seasonal influenza vaccine and understand the risk and benefits was signed by S11Infection Preventionist on 10/18/2023. Further review revealed neither Resident #40 nor Resident #40's resident representative signed the influenza vaccine consent form to acknowledge they were informed of the benefits and potential side effects of the influenza vaccine.
Review of Resident #42's influenza vaccine consent form revealed, in part, Section 3: Consent for vaccination, I have read or had explained to me the vaccine information statement for the seasonal influenza vaccine and understand the risk and benefits was signed by S11Infection Preventionist on 10/18/2023. Further review revealed neither Resident #42 nor Resident #42's resident representative signed the influenza vaccine consent form to acknowledge they were informed of the benefits and potential side effects of the influenza vaccine.
Review of Resident #56's influenza vaccine consent form revealed, in part, Section 3: Consent for vaccination, I have read or had explained to me the vaccine information statement for the seasonal influenza vaccine and understand the risk and benefits was signed by S11Infection Preventionist on 10/18/2023. Further review revealed neither Resident #56 nor Resident #56's resident representative signed the influenza vaccine consent form to acknowledge they were informed of the benefits and potential side effects of the influenza vaccine.
Review of Resident #63's influenza vaccine consent form revealed, in part, Section 3: Consent for vaccination, I have read or had explained to me the vaccine information statement for the seasonal influenza vaccine and understand the risk and benefits was not signed by neither Resident #63 nor Resident #63's resident representative.
In an interview on 11/27/2023 at 3:24 p.m., S11Infection Preventionist (IP) stated she did not obtain Resident #28, Resident #40, Resident #42, Resident #56, and Resident #63 signatures or the representative's signatures.
In an interview on 11/28/2023 at 11:45 a.m., S8Corporate Nurse stated the above mentioned residents or their representative should sign the influenza vaccine consent form. S8Coroporte Nurse further stated if a resident is unable to sign the influenza vaccine consent form then two nurses should witness a verbal consent and both nurses should sign the influenza vaccine consent form.
In an interview on 11/29/2023 at 12:15 p.m., S11IP stated the resident or representative signature on the vaccine consent acknowledge the risks and benefits of the vaccination were provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to electronically submit payroll information for direct care staffing as required.
Findings:
Review of the facility's Payroll Based Journal (...
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Based on record review and interview, the facility failed to electronically submit payroll information for direct care staffing as required.
Findings:
Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 3 2023 (April 1 - June 30) revealed, in part, the facility failed to submit staffing data for Quarter 3.
In an interview on 11/28/2023 at 2:50 p.m., S1Regional Director of Operations stated he was unable to produce documented evidence the facility had submitted the PBJ Staffing Data for FY Quarter 3 2023 (April 1 - June 30).
Aug 2023
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
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to obtain laboratory services for 3 (Resident #1, Resident #3, and Resident #5) of 5 sampled residents (Resident #1, Resident #2, Resident #...
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Based on record reviews and interviews, the facility failed to obtain laboratory services for 3 (Resident #1, Resident #3, and Resident #5) of 5 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5)
Findings:
Resident #1
Review of Resident #1's Physician's Orders with a start date of 05/10/2023 revealed, in part, CBC (complete blood count), CMP (comprehensive metabolic panel), Keppra (a medication used to treat seizures), Dilantin (a medication used to treat seizures), and Valproic Acid (a medication used to treat seizures) level on admit and every 3 months in the morning.
Review of Resident #1's Office Visit Report dated 05/15/2023 and completed by Resident #1's Physician revealed, in part, need Depakote level drawn soon after the patient is administered medication, need Keppra level drawn, need phenytoin level drawn, obtain CBC, CMP, TSH (thyroid stimulating hormone), Lipid Panel and Vitamin D.
Review of Resident #1's record revealed no documented evidence, and the facility did not present any documented evidence, the above documented labs were completed as ordered.
In an interview on 08/10/2023 at 9:14 a.m., S4 Licensed Practical Nurse (LPN) stated when a laboratory order is received the nurse should enter the order into the electronic medical record. S4LPN further stated the lab orders were not always entered into the electronic medical record, and if the order lab was not entered, then the lab will not get obtained as ordered.
In an interview on 08/10/2023 at 10:00 a.m., S1 Director of Nursing (DON) confirmed there was no documented evidence Resident #1's labs were obtained as ordered upon admit and on 05/15/2023.
Resident #3
Review of Resident #3's Physician's Order with a start date of 06/23/2023 revealed, in part, a renal function panel to be obtained once a day every Monday and Friday.
Review of Resident #3's record revealed no documented evidence, and the facility did not present any documented evidence, the above documented labs were completed as ordered on 06/30/2023, 07/03/2023, 07/07/2023, 07/10/2023, 07/14/2023, 07/17/2023, 07/21/2023, 07/31/2023, 08/04/2023, and 08/07/2023.
In an interview on 08/09/2023 at 12:40 p.m., S1DON stated the facility had no documented evidence Resident #1's renal function panel was completed as ordered by the physician on 06/30/2023, 07/03/2023, 07/07/2023, 07/10/2023, 07/14/2023, 07/17/2023, 07/21/2023, 07/31/2023, 08/04/2023, and 08/07/2023.
Resident #5
Review of Resident #5's record revealed a physician's order dated 06/13/2023 for a CMP.
Review of Resident #5's record revealed no documented evidence, and the facility did not present any documented evidence, the CMP ordered on 06/13/2023 was completed as ordered.
In an interview on 08/10/2023 at 1:27 p.m., S1DON stated Resident #5 had a physician's order for a CMP on 6/13/2023; however, Resident #5's CMP was not obtained as ordered by the physician.
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 F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to:
1.Ensure the ordering physician was promptly notified of laborator...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to:
1.Ensure the ordering physician was promptly notified of laboratory results for 1(Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents; and
2.Ensure there was a physician's order for completed labs for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents.
Findings:
1.
Review of Resident #2's July 2023 physician's orders revealed, in part, an order dated 07/05/2023 to obtain a Magnesium (a mineral that helps the heart work properly) level.
Review of Resident #2's lab report revealed, in part, labs that were drawn on 07/05/2023 and reported to facility on 07/06/2023, resulted in a critical Magnesium level of 0.9 mg (milligrams)/dL (deciliter) (Normal Range 1.6 mg/dL-2.3 mg/dL).
Review of Resident #2's progress notes revealed, in part, no documentation that the ordering physician was notified of the critical Magnesium level on 07/06/2023.
In an interview on 08/08/2023 at 3:20 p.m., Resident #2's physician, stated the facility had not notified him of Resident #2's critical Magnesium level that was reported to the facility on [DATE].
In an interview on 08/08/2023 at 2:50 p.m., S1Director of Nursing (DON) stated the facility's policy was, when critical lab values were noted on a lab report, to immediately call the physician and notify them of the critical lab value. S1DON further stated the facility should have reported Resident #2's critical Magnesium level to Resident #2's physician and did not.
In an interview on 08/10/2023 at 9:00 a.m., S5Liscensed Practical Nurse (LPN) stated if a resident had a critical lab result, the nurse should notify the ordering physician immediately by phone. S5LPN stated Resident #2's physician was not notified of the critical magnesium levels reported to the facility on [DATE].
2.
Resident #1
Review of Resident #1's Nurses' notes dated 07/07/2023 revealed, in part, S1Director of Nurses (DON) attempted to perform venipuncture for ordered labs twice without success.
Review of Resident #1's record revealed no documented evidence, and the facility did not present any documented evidence, of an order for a lab to be drawn on 07/07/2023.
In an interview on 08/09/2023 at 12:40 p.m., S1DON reviewed Resident #1's nurses' notes dated 07/07/2023, and confirmed she attempted venipuncture on Resident #1 twice and was not successful. S1DON also stated she could not locate an order for any labs to be drawn on 07/07/2023. S1DON further stated the floor nurses typically request for her to perform venipuncture and she does not verify the order.
Resident #5
Review of Resident #5's record revealed, in part, CBC (complete blood count), CMP (comprehensive metabolic panel) and Magnesium levels were collected on 07/20/2023.
Review of Resident #5's record revealed no documented evidence, and the facility did not present any documented evidence, of an order for labs to be obtained on 07/20/2023.
In an interview on 08/10/2023 at 1:38 p.m., S1DON confirmed a CBC, CMP, and a Magnesium level was collected on 07/20/2023 for Resident #5, and Resident #5 did not have a physician's order for the above labs to be drawn
Jul 2023
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure medications were available for resident use as ordered by the Physician for 2 (Resident #2 and Resident #6) of 7 (Resi...
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Based on observation, interview, and record review, the facility failed to ensure medications were available for resident use as ordered by the Physician for 2 (Resident #2 and Resident #6) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) residents observed during medication administration observations.
Findings:
Resident #2
Review of Resident #2's Physicians Order dated 06/19/2023 revealed Lacosamide Oral Tablet 200 milligrams (mg) (a medication used for seizures) to be administered two times a day. Review of Resident #2's June 2023 electronic Medication Administration Record (eMAR) revealed, in part, on 06/19/2023 at 8:00 p.m. Lacosamide Oral Tablet 200mg was documented as a 9 (9 indicated other and see progress notes). Review of Resident #2's progress notes dated 06/19/2023 at 9:12 p.m. revealed Lacosamide Oral Tablet 200mg was not administered to Resident #2 because the medication was not in the facility.
On 07/20/2023 at 8:34 a.m., S1Director of Nursing (DON) reviewed Resident #2's June 2023 eMAR and confirmed the documentation revealed Lacosamide Oral Tablet 200mg was not available to be administered to Resident #2 on 06/19/2023 at 8:00 p.m.
Resident #6
Review of Resident #6's Physician Order dated 07/18/2023 revealed Depakote ER (extended release) 250mg by mouth three times a day for seizures.
Observation of medication administration on 07/19/2023 at 12:08 p.m. revealed S2Licensed Practical Nurse (LPN) administered Resident #6's medications. S2LPN stated Resident #6 had an order for Depakote ER (extended release) 250mg (medication used to treat seizures) due at 12:00 p.m.; however, Resident #6 did not have Depakote ER 250mg in the medication cart. S2LPN stated she would get Resident #6's Depakote ER 250mg from the medication room. On 07/19/2023 at 12:26 p.m. the surveyor accompanied S2LPN to the medication room and S2LPN stated Resident #6's Depakote ER 250mg was not available in the medication room. S2LPN stated Resident #6's Depakote ER 250mg was scheduled to be administered no later than 1:00 p.m. on 07/19/2023.
In an interview on 07/19/2023 at 2:15 p.m., S2LPN stated Resident #6 did not receive her 12:00 p.m. dose of Depakote ER 250mg because it was not available in the facility.
On 07/20/2023 at 8:15 a.m., S1Director of Nursing (DON) confirmed Resident #6's Depakote ER 250mg had not been administered on 07/19/2023 at 12:00 p.m. as ordered.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater by having a medication error rate of 8%. This deficient practice wa...
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Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater by having a medication error rate of 8%. This deficient practice was identified for 1 of 3 nurses (S2Licensed Practical Nurse/LPN) who were observed during medication administration.
Findings:
Resident #6
Review of Resident #6's Physician Order dated 07/18/2023 revealed an order for Depakote ER 250 milligrams(mg) Oral Tablet (a medication used to treat seizures) tid (three times a day) at 8:00 a.m., 12:00 p.m., and 8:00 p.m.
Observation of Resident #6's medication administration on 07/19/2023 at 12:08 p.m. revealed S2Licensed Practical Nurse (LPN) failed to administer Depakote ER 250mg.
In an interview on 07/19/2023 at 12:08 p.m., S2LPN stated Resident #6's Depakote ER 250mg was not available on the medication cart and she would have to get the Depakote ER 250mg from the medication room. On 07/19/2023 at 12:26 p.m. the surveyor accompanied S2LPN to the medication room and S2LPN stated Resident #6's Depakote ER 250mg was not available in the medication room.
In an interview on 07/19/2023 at 2:15 p.m., S2LPN stated she had not administered Resident #6's Depakote ER 250mg tablet due at 12:00 p.m. on 07/19/2023.
Resident #7
Review of Resident #7's Physician Order dated 04/19/2023 revealed an order for Diclofenac Sodium External Gel 3% (a gel used to treat pain and inflammatory disease) to be applied topically to the knee, ankle and foot four times a day at 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m.
Observation of medication administration on 07/19/2023 at 11:58 a.m. revealed S2LPN applied Diclofenac Sodium External Gel 1% gel to Resident #7.
In an interview on 07/19/2023 at 1:00 p.m., S2LPN confirmed Resident #7's order was for Diclofenac Sodium External Gel 3% and she had used Diclofenac Sodium External Gel 1%.
There were 25 opportunities for medication administration with 2 medication errors which resulted in a 8% medication error rate.
In an interview on 07/20/2023 at 8:00 a.m., S1Director of Nursing(DON) confirmed Resident #6's Depakote ER 250mg tablet due at 12:00 p.m. on 07/19/2023 had not been administered. S1DON further confirmed Resident #7's order was for Diclofenac Sodium External Gel 3%; however, Dicolfenac Sodium External 1% Gel was used on 07/19/2023 at 11:58 a.m.
May 2023
6 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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure the nurse administered a resident's insulin per physician orders for 1 (Resident #R1) of 4 (Resident #R1, Resident #R2...
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Based on observation, record review, and interview, the facility failed to ensure the nurse administered a resident's insulin per physician orders for 1 (Resident #R1) of 4 (Resident #R1, Resident #R2, Resident #1, and Resident #2) residents observed during medication administration observations.
Findings:
Review of Resident #R1's May 2023 Physician Orders revealed orders of, in part: Accuchecks (finger stick to check for capillary blood glucose levels) three times a day before meals for diabetes; Humalog Kwikpen 100unit/ml inject 7 units SQ before meals for diabetes inject 5 units SQ before meals. Further review of Resident #R1's May 2023 Physician's Orders revealed Humalog Kwikpen 100unit/ml inject per sliding scale of, in part, capillary blood glucose of 301-350 milligrams/deciliters (mg/dl) give 8 units SQ, two times a day for diabetes check record and administer per sliding scale.
Observation on 05/08/2023 at 9:40 a.m. of medication administration revealed S6Registered Nurse (RN)/Social Services Director administered Resident #R1 Humalog (insulin) 100units/milliliter (ml) 15 units subcutaneously (SQ) (in the fat area of the skin) to the right lower abdomen. Resident #R1 acknowledged he had already had breakfast.
Review of Resident #R1's May 2023 electronic Medication Administration Record (eMAR) revealed, in part: Humalog Kwikpen 100 unit/ml inject 7 units SQ before meals for diabetes inject 5 units SQ before meals was scheduled for 7:30 a.m. Further review of Resident #R1's May 2023 eMAR revealed accucheck was documented as 334 mg/dl for 05/08/2023 morning check; and Humalog Kwikpen 100unit/ml inject per sliding scale was scheduled for 8:00 a.m.
In an interview on 05/08/2023 at 4:14 p.m., S6RN/Social Services Director stated she had administered 15 units to Resident #R1 due to Resident #R1 had not received the 7 units of Humalog prior to his meal, and then received the 8 units of Humalog due to the accucheck of 334mg/dl. S6RN/Social Services Director further stated she was behind on medication administration.
In an interview on 05/10/2023 at 11:22 a.m., S3Corporate Compliance Nurse was informed of the above observations. S3Corporate Compliance Nurse stated the nurse should have contacted the physician for guidance since Resident #R1 did not have the scheduled and sliding scale insulins prior to breakfast.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure the certified nursing assistant (CNA) removed her gloves and performed hand hygiene after cleaning a resident's bowel ...
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Based on observation, record review, and interview, the facility failed to ensure the certified nursing assistant (CNA) removed her gloves and performed hand hygiene after cleaning a resident's bowel movement and prior to performing incontinence care to the genital area for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for incontinence care in a total sample of 6.
Findings:
Review of the facility's Hand Hygiene Policy and Procedure revealed, in part, the use of gloves does not replace hand hygiene, if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.
Observation on 05/10/2023 at 4:07 p.m., revealed S5CNA cleaned stool from Resident #3's buttocks area, then turned Resident #3 over and without having removed her gloves or having perfomed hand hygiene, proceeded to clean Resident #3's groin and genital area.
In an interview on 05/10/2023 at 4:10 p.m., S5CNA stated she should have removed her gloves and performed hand hygiene after she cleaned Resident #3's buttocks and before she cleaned the resident's genital area.
In an interview on 05/11/2023 at 4:30 p.m., S2Director of Nursing (DON) stated the CNA should have cleaned Resident #3's genital area first then provide incontinence care for the bowel movement. S2DON further stated once the CNA provided incontinence care for the bowel movement the CNA should have removed her gloves and performed hand hygiene.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to promptly inform the resident's physician of medication refusals for 2 (Resident #3 and Resident #5) of 6 (Resident #1, Resident #2, Resident...
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Based on record review and interview the facility failed to promptly inform the resident's physician of medication refusals for 2 (Resident #3 and Resident #5) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents reviewed for quality of care.
Findings:
Resident#3
Review of Resident #3's Care Plan revealed a problem of, in part, Resident #3 was at risk for complications due to resisting care, refusal of dialysis, and refusal of insulin with a target date of 07/03/2023. Further review revealed approaches of, in part: medications administered as ordered
Review of Resident #3's April 2023 and May 2023 Physician Orders revealed, in part: Basaglar (long-acting insulin for glucose control) 25 units inject subcutaneously (SQ)once daily; Dulaglutide (for Diabetes type 2) Pen injector 1.5mg/0.5ml inject 1.5mg SQ every Tuesday; Humalog (insulin) Pen injector per sliding scale -glucose readings 0-70 = 0 units, 71-150= 0 units, 151-200= 4 units, 201-250= 6 units, 251-300= 8 units, 301-350=10 units, 351-400=12 units, 401-999= 14 units & notify MD, SQ before meals and at bedtime.
Review of Resident #3's Electronic Medication Administration Record (eMAR) dated April 2023 and May 2023 revealed, in part, the following medications were refused: Basaglar 25 units on 04/01/2023, 04/08/2023, 04/09/2023, 04/16/2023, 04/29/2023, 05/06/2023, and 05/07/2023; Dulaglutide 1.5mg on 04/04/2023, 04/04/2023, 04/11/2023, and 05/02/2023; and Humalog per sliding scale every day except 04/12/2023 with recorded blood glucose over 400 in many instances.
In an interview on 05/11/2023 at 1:54 p.m., S3Corporate Compliance Nurse stated insulins were important medications and refusal by a resident should be reported to the physician. S3Corporate Compliance Nurse verified Resident #3's physician was not notified of the above mentioned medication refusals and should have been. S3Corporate Compliance Nurse further acknowledged that medication ordered once daily should be administered or offered at other times of the day if the resident refused.
Resident #5
Review of Resident #5's March 2023 Physician Orders revealed, in part, Aluminium Hydroxide Gel Suspension (used for indigestion) administer 30mililiters (ml) by mouth with meals.
Review of Resident #5's March 2023 eMAR revealed Aluminum Hydroxide Gel was refused on 03/05/2023 at 12:00 p.m.; and at the 5:00 p.m. dose on 03/04/2023, 03/07/2023, 03/13/2023, 03/16/2023, 03/20/2023, 03/21/2023, and 03/23/2023.
Review of Resident #5's Progress Notes revealed no documented evidence and the facility presented no documented evidence of Resident #5's physician having been notified of Resident #5'sabove mentioned medication refusals.
In an interview on 05/11/2023 at 1:01 p.m., S2Director of Nursing (DON) stated the facility did not have documentation of the facility notifying Resident #5's with her medication refusals and the physician should have been notified of any medication refusals.
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 F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on observations, interview, and record reviews, the facility failed to:
1. Ensure communication occurred with the resident's dialysis provider regarding the progress during dialysis (Resident #1...
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Based on observations, interview, and record reviews, the facility failed to:
1. Ensure communication occurred with the resident's dialysis provider regarding the progress during dialysis (Resident #1, Resident #2, Resident #3, and Resident #6);
2. Ensure physician's orders for medication and supplements were coordinated with a resident's dialysis schedule to ensure administration (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6);
3. Ensure residents were weighed after dialysis per physician orders (Resident #3 and Resident #4); and
4. Ensure fluid intake and output was obtained for residents receiving dialysis as ordered (Resident #2, Resident #4, and Resident #5).
This deficient practice was identified for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents reviewed for dialysis services.
Findings:
1. Resident #1
Review of Resident #1's April 2023 and May 2023 Physician Orders revealed, in part, Resident #1 was to receive dialysis on Monday, Wednesday, and Friday.
Review of Resident #1's Care Plan with a target date of 07/30/2023, revealed Resident #1 required dialysis related to kidney failure, and a dialysis communication form was to be completed after each dialysis appointment.
Review of Resident #1's Dialysis Communication Log revealed no documented evidence and the facility presented no documented evidence of Communication Forms and/or any documentation or communication between the dialysis provider and the facility about Resident #1's status/progress during dialysis on 04/25/2023, 04/27/2023, and 04/29/2023.
Resident #2
Review of Resident #2's Care Plan with a target date of 07/21/2023, revealed Resident #2 required dialysis related to ineffective renal perfusion with kidney failure, and a dialysis communication form was to be completed after each dialysis appointment.
Review of Resident #2's April 2023 Physician Orders revealed, in part, Resident #2 was to receive dialysis on Monday, Wednesday, and Friday.
Review of Resident #2's Dialysis Communication Log revealed no documented Communication Forms and/or any documentation or communication between the dialysis provider and the facility about Resident #2's status/progress during dialysis on 04/21/2023 and 04/24/2023.
Resident #3
Review of Resident #3's Care Plan with a target date of 07/03/2023, revealed Resident #3 required dialysis related to ineffective renal perfusion with kidney failure, and a dialysis communication form was to be completed after each dialysis appointment.
Review of Resident #3's Dialysis Communication Log revealed no documented Communication Forms and/or any documentation or communication between the dialysis provider and the facility about Resident #3's status/progress during dialysis on 03/08/2023, 03/22/2023, 04/14/2023, 04/21/2023, 04/28/2023, and 05/01/2023.
Resident #6
Review of Resident #6's Care Plan with a target date of 06/08/2023, revealed Resident #6 required dialysis related to ineffective renal perfusion with kidney failure, and a dialysis communication form was to be completed after each dialysis appointment.
Review of Resident #6's Dialysis Communication Log revealed no documented Communication Forms and/or any documentation or communication between the dialysis provider and the facility about Resident #6's status/progress during dialysis on 03/14/2023, 03/18/2023, 03/23/2023, 04/04/2023, and 04/21/2023.
In an interview on 05/11/2023 at 1:48 p.m., S3Corporate Compliance Nurse acknowledged the nurses should have ensured the completion or the receipt of the Communication Forms from dialysis.
2. Resident #2
Review of Resident #2's April 2023 and May 2023 Physician Orders revealed, in part, to hold blood pressure medications before dialysis. Further review of Resident #2's April 2023 and May 2023 Physician Orders revealed Metoprolol Tartrate (medication used to treat high blood pressure) 25milligrams (mg) give one half of a tablet (12.5mg) by mouth twice a day.
Review of Resident #2's electronic Medication Administration Record (eMAR) dated April 2023 and May 2023 revealed, in part, Metoprolol Tartrate (used for blood pressure) 12.5 milligrams (mg) 8:00 a.m. dose was administered on the following dialysis days 04/03/2023, 04/05/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, 04/24/2023, 04/26/2023, 04/28/2023, 05/01/2023, 05/03/2023, 05/05/2023, and 05/08/2023.
Resident #3
Review of Resident #3's April 2023 Physician Orders revealed, in part, Tradjenta (used to regulate insulin and glucose) 5 mg give once daily by mouth; Dailyvite 800/0.8mg give once daily by mouth; and Basaglar (long-acting insulin for glucose control) 25 units inject subcutaneously once daily.
Review of Resident #3's April 2023 eMAR revealed, in part: Tradjenta 5 mg was not administered on 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, 04/21/2023, and 04/28/2023; Dialyvite 800/0.8mg 1 tablet was not administered on 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, 04/21/2023, and 04/28/2023; Basaglar 25 units was not administered on 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, 04/21/2023, and 04/28/2023.
Review of Resident #3's May 2023 Physician Orders revealed, in part, Tradjenta (used to regulate insulin and glucose for diabetics) 5 mg give once daily by mouth; Dailyvite 800/0.8mg give once daily by mouth; and Basaglar (long-acting insulin for glucose control) 25 units inject subcutaneously once daily.
Review of Resident #3's May 2023 eMAR revealed, in part: Tradjenta 5 mg was not administered on 05/01/2023, 05/03/2023, and 05/08/2023; Dialyvite 800/0.8mg 1 tablet was not administered on 05/01/2023, 05/03/2023, and 05/08/2023; and Basaglar 25 units was not administered on 05/01/2023, 05/03/2023, and 05/08/2023.
Resident #4
Review of Resident #4's April 2023 Physician Orders revealed, in part, Eliquis (used to thin the blood) 5 mg give twice daily by mouth; Isosorbide Mononitrate (used for high blood pressure) 10 mg give twice daily by mouth.
Review of Resident #4's April 2023 eMAR, in part, the following medications were not administered as ordered: Eliquis 5 mg not administered for the 8:00 a.m. dose on 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, 04/21/2023, 04/26/2023, and 04/28/2023; and Isosorbide Mononitrate 10 mg not administered for the 8:00 a.m. dose on 04/10/2023, 04/12/2023, 04/14/2023, 04/19/2023, 04/26/2023, and 04/28/2023.
Review of Resident #4's May 2023 Physician Orders revealed, in part, Eliquis 5 mg give twice daily by mouth; Isosorbide Mononitrate 10 mg give twice daily by mouth.
Review of Resident #4's May 2023 eMAR revealed, in part, the following medications were not administered as ordered: Eliquis 5 mg not administered for the 8:00 a.m. dose on 05/01/2023, 05/03/2023, 05/05/2023, and 05/08/2023; and Isosorbide Mononitrate 10 mg not administered for the 8:00 a.m. dose on 05/01/2023, 05/03/2023, 05/05/2023, and 05/08/2023.
Resident #5
Review of Resident #5's March 2023 Physician Orders revealed, in part, Aspirin 81mg tablet administer one tablet by mouth once a day on day shift
Review of Resident #5's March 2023 eMAR revealed Aspirin 81mg was not administered on dialysis days listed, in part: Aspirin 81mg was not administered on 03/06/2023, 03/08/2023, 03/10/2023, 03/13/2023, 03/15/2023, 03/17/2023, 03/20/2023, and 03/22/2023.
Resident #6
Review of Resident #6's April 2023 Physician Orders revealed, in part, Allopurinol 100mg one tablet by mouth once a day; Aspirin 81mg one tablet by mouth once a day; Cholecalciferol 25 micrograms (mcg) one tablet by mouth once a day; Ciprofloxacin 500mg one tablet by mouth once a day; Gabapentin 300mg one tablet by mouth once a day; Metoprolol Succinate Extended Release (ER) 25mg one tablet once a day.
Review of Resident #6's April 2023 eMAR revealed, in part, the following medications were not administered as ordered on dialysis days: Allopurinol 10mg on 04/04/2023, 04/06/2023, 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, and 04/22/2023; Aspirin 81mg on 04/04/2023, 04/06/2023, 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, and 04/22/2023; Cholecalciferol 25mcg on 04/04/2023, 04/06/2023, 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, and 04/22/2023; Ciprofloxacin 500mg on 04/04/2023, 04/06/2023, and 04/10/2023; Gabapentin 300mg on 04/04/2023, 04/06/2023, 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, and 04/22/2023; and Metoprolol Succinate ER 25mg 04/04/2023, 04/06/2023, 04/10/2023, 04/12/2023, 04/14/2023, 04/17/2023, 04/19/2023, and 04/22/2023.
In an interview on 05/11/2023 at 1:48 p.m., S3Corporate Compliance Nurse stated a clarification order should have been obtained regarding administration of medications on dialysis days. S3Corporate Compliance Nurse confirmed the physician was not notified and a clarification order was not obtained for administration of medications ordered on scheduled dialysis days. S3Corporate Compliance Nurse acknowledged that medication ordered once daily should be administered or offered at other times of the day.
3. Resident #3
Review of Resident #3's Care Plan with a target date of 07/03/2023 revealed, in part Resident #3 needed hemodialysis related to renal failure on Monday, Wednesday, and Friday. Further review revealed an approach of weigh Resident #3 when returned from dialysis.
Review of Resident#3's Weight Log dated April 2023 and May 2023 revealed 04/10/2023 was the only dialysis day with a recorded weight from the facility. There was no documented evidence and the facility presented no documented evidence of the facility having obtained weights for Resident #3 after dialysis other than on 04/10/2023.
Resident#4
Review of Resident #4's Care Plan with a target date of 06/01/2023 revealed, in part Resident #3 needed hemodialysis related to renal failure on Monday, Wednesday, and Friday. Further review revealed an approach of weigh Resident #4 when returned from dialysis.
Review of Resident #4's April 2023 eMAR revealed, in part, there was no documented evidence and the facility presented no documented evidence of the facility having obtained weights on return from dialysis on 04/10/2023, 04/18/2023, 04/21/2023, and 04/24/2023.
Review of Resident #4's May 2023 eMAR revealed, in part, there was no documented evidence and the facility presented no documented evidence of the facility having obtained weights on return from dialysis on 05/03/2023.
In an interview on 05/11/2023 at 1:48 p.m., S3Corporate Compliance Nurse acknowledged all orders to weigh residents upon return from dialysis should documented and completed as ordered.
4. Resident #2
Review of Resident #2's May 2023 Physician Orders revealed, in part, Resident was to have a 1,000 milliliter (ml) per day fluid restriction.
Review of Resident #2's record revealed the only fluid intake recorded was the fluid received during meals.
In an interview on 05/10/2023 at 12:30 p.m., S9Licensed Practical Nurse (LPN) stated she did not record Resident #2's fluid intake at medication pass and no staff was recording Resident #2's output.
Resident #4
Review of Resident #4's April and May 2023 Physician Orders revealed, in part, Resident #4 was to have a 1,000ml per day fluid restriction.
Review of Resident #4's record revealed the only fluid intake recorded was the fluid received during meals.
Resident #5
Review of Resident #5's February 2023 Physician Order reveled, in part, Resident #5 was to have a 1,000ml per day fluid restriction.
Review of Resident #5's February 2023 CNA Fluid Intake documentation revealed no documented evidence and the provider did not present any documented evidence of fluid intake having been assessed on 02/17/2023, 02/18/2023, 02/19/2023, 02/23/2023, and 02/24/2023.
Review of Resident #5's March 2023 Physician Order revealed, in part, Resident #5 was to have a 1,000ml per day fluid restriction.
Review of Resident #5's March 2023 CNA Fluid Intake documentation revealed no documented evidence and the provider did not present any documented evidence of fluid intake having been assessed on 03/02/2023, 03/03/2023, 03/08/2023, 03/09/2023, 03/11/2023, 03/12/2023, 03/14/2023, 03/15/2023, 03/18/2023, and 03/19/2023.
In an interview on 05/11/2023 at 12:31 p.m., S12LPN stated she did not document the fluid intake from medication pass. S12LPN further stated she did not have any place for this documentation.
In an interview on 05/11/2023 at 12:42 p.m., S10CNA stated nursing staff did not provide any information as to how much fluid Resident #5 was allowed during her shift.
In an interview on 05/11/2023 at 12:55 p.m., S11CNA stated she did not document any of Resident #5's fluid intake other than fluids received during meals.
In an interview on 05/09/2023 at 5:35 p.m., S3Corporate Compliance Nurse stated the facility could not provide complete and accurate documented Intake and Outputs (I/O's) for any of the above mentioned dialysis residents.
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
Medical Records
(Tag F0842)
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:
1. Maintain a complete record for documenting Activities of Daily...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to:
1. Maintain a complete record for documenting Activities of Daily Living (ADL) (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6); and,
2. Maintain accurate documentation for Activities of Daily Living (ADL) (Resident #3 and Resident #6).
3. Ensure medication records were accurately documented (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6)
This deficient practice was identified for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) sampled residents whose medical records were reviewed for ADLs.
Findings:
1. Resident #1
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2023 revealed, in part: Resident #1 required extensive assistance of one person for personal hygiene; and total dependence of one person for dressing.
Review of Resident #1's ADL Sheet for April 2023 to 05/11/2023 revealed no documented evidence and the facility did not present any documented evidence of assistance with ADLs were provided to Resident #1 on 04/17/2023-04/20/2023; 04/23/2023; 04/24/2023; 04/30/2023; 05/06/2023 and 05/07/2023.
Resident #2
Review of Resident #2's MDS ARD dated 02/23/2023 revealed Resident #2 required supervision of one person for dressing, locomotion, toilet use, and personal hygiene.
Review of Resident #2's ADL Sheet for April 2023 to 05/11/2023 revealed no documented evidence and the facility did not present any documented evidence of assistance with ADLs were provided to Resident #2 on 05/07/2023; 04/29/2023; 04/25/2023; 04/24/2023; 04/10/2023; 04/09/2023; and 04/02/2023.
Resident #3
Review of Resident #3's MDS ARD dated 02/24/2023 revealed Resident #3 required limited assistance of one person for bed mobility, and transfers. Further review revealed Resident #3 required extensive assistance of one person for locomotion, dressing, toilet use, and personal hygiene.
Review of Resident #3's ADL Sheet for March 2023 to 05/11/2023 revealed no documented evidence and the facility did not present any documented evidence of assistance with ADLs were provided to Resident #3 on 03/01/2023-03/11/2023; 03/14/2023; 03/18/2023; 03/19/2023; 03/25/2023; 03/26/2023; 04/17/2023; 04/19/2023; 04/21/2023; 04/23/2023; 04/29/2023.
Resident #4
Review of Resident #4's MDS ARD dated 02/23/2023 revealed Resident #4 required extensive assistance of one person for bed mobility. Further review revealed Resident #4 required extensive assistance of two persons for transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene.
Review of Resident #4's ADL Sheet for March 2023 to 05/11/2023 revealed no documented evidence and the facility did not present any documented evidence of assistance with ADLs were provided to Resident #4 on 03/19/2023; 03/25/2023; 03/01/2023; 03/09/2023; 03/11/2023-03/15/2023; 04/22/2023; 04/23/2023; 04/29/2023; 04/30/2023; 04/02/2023; 04/09/2023; 04/13/2023; 05/07/2023; and 05/09/2023
Resident #5
Review of Resident #5's MDS ARD dated 03/10/2023 revealed Resident #5 required extensive assistance of one to two persons dressing, toilet use, and personal hygiene.
Review of Resident #5's ADL Sheet for March 2023 revealed no documented evidence and the facility did not present any documented evidence of assistance with ADLs were provided to Resident #5 on 03/18/2023, 03/19/2023; 03/01/2023; 03/02/2023; 03/09/2023; 03/11/2023; 03/14/2023; and 03/15/2023.
Resident #6
Review of Resident #6's MDS ARD dated 03/10/2023 revealed Resident #6 required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Further review revealed Resident #6 required extensive assistance of two persons for transfers.
Review of Resident #6's ADL Sheet for March 2023 revealed no documented evidence and the facility did not present any documented evidence of assistance with ADLs were provided to Resident #6 on 03/03/2023, 03/04/2023, 03/06/2023, 03/07/2023, 03/12/2023, 03/14/2023 03/19/2023, and 03/20/2023.
Review of Resident #6's ADL Sheet for April 2023 revealed no documented evidence and the facility did not present any documented evidence of assistance with ADLs were provided to Resident #6 on 04/22/2023, 04/24/2023, and 04/25/2023.
In an interview on 05/11/2023 at 12:46 p.m., S3Corporate Compliance Nurse confirmed no documentation of ADL care was documented for the above mentioned dates. S3Corporate Compliance Nurse stated there should not be blanks on the documentation.
2. Resident #3
Record review of Resident#3's ADL Sheet revealed documentation of care on: 04/24/2023 after 5:53 a.m. when resident left for dialysis; 04/25/2023 while in the hospital; and 04/26/2023 before 6:01 p.m. when the resident returned to the facility.
Resident #6
Review of Resident #6's Record revealed Resident #6 was admitted to the hospital on [DATE] and returned to the facility on [DATE].
Review of Resident #6's ADL flowsheet for March 2023 revealed documentation of ADL care on 03/29/2023.
In an interview on 05/11/2023 at 1:01 p.m., S2DON (Director of Nursing) stated the facility was aware there was an issue with incomplete documentation for ADLs.
3. Resident #2
Review of Resident #2's May 2023 Physician Orders revealed, in part, Renvela (used for chronic kidney disease) 800 milligrams (mg) give 2 tablets three times daily and Sodium Bicarbonate (used for chronic kidney disease) 650mg give 2 tablets three times daily.
Review of Resident #2's Electronic Medication Administration Record (EMAR) dated April 2023 and May 2023 revealed, in part, no documented evidence and the provider did not present any documented evidence of administration of the following medication: Renvela 800mg for the 11:00 a.m. dose on 04/19/2023, 04/25/2023, 04/26/2023 and the 5:00 p.m. dose on 04/08/2023 and 04/15/2023; Sodium Bicarbonate 650mg for the 12:00 p.m. dose on 04/19/2023 and 04/25/2023.
Resident #3
Review of Resident #3's May 2023 Physician Orders revealed, in part, Rosuvastin (used for High Cholesterol) 10 milligrams (mg) give 1 tablet by mouth at bedtime; Procardia XL (used for High Blood Pressure) 30mg by mouth at bedtime; Remeron (used for Depression) 7.5mg by mouth at bedtime.
Review of Resident #3's Medication Administration Record (EMAR) dated May 2023 revealed, in part, no documented evidence and the facility did not present any documented evidence of administration of the following medication: Rosulvastin10mg at bedtime on 05/05/2023; Procardia XL 30mg by mouth at bedtime on 05/05/2023; Remeron 7.5mg at bedtime on 05/05/2023.
Resident #4
Review of Resident #4's April and May 2023 Physician Orders revealed, in part, Eliquis (used to thin the blood) 5mg give twice daily by mouth; Isosorbide Mononitrate (used for high blood pressure) 10mg give twice daily by mouth; Colace Capsule (used to soften stool) 100mg give twice daily by mouth; Requip (used for restless leg syndrome) 2mg twice daily on Monday, Wednesday, and Friday.
Review of Resident #4's EMAR dated April 2023 and May 2023 revealed, in part, no documented evidence and the provider did not present any documented evidence of administration of the following medication: Colace Capsule 100mg for the 8:00 p.m. dose on 04/06/2023 and 05/05/2023; Eliquis 5mg for the 8:00 p.m. dose on 04/06/2023 and 05/05/2023; Isosorbide Mononitrate 10mg for the 8:00 p.m. dose on 04/06/2023 and 05/05/2023; and Requip 2mg for the 8:00 p.m. dose on 05/05/2023.
Resident #5
Review of Resident #5's February 2023 Physician Orders revealed, in part: Cefdinir (antibiotic used to treat ear infection) 300mg one tablet by mouth once a day; Gabapentin (medication used to treat nerve pain) 300mg one tablet by mouth at bedtime; Melatonin (supplement to assist with sleep) 3mg one tablet by mouth at bedtime; Pro-renal + D (vitamin) one tablet by mouth at bedtime; Sennoside-Docusate Sodium (stool softener) 8.6-50mg one tablet by mouth at bedtime; and Trazodone HCL (hydrochloride) (medication used for depression) 50mg one tablet by mouth at bedtime.
Review of Resident #5's February 2023 EMAR revealed, in part, no documented evidence and the provider did not present any documented evidence of administration of the following medication: Cefdinir 300mg on 02/21/2023 for the 8:00 p.m. dose; Gabapentin 300mg on 02/21/2023 for the 9:00 p.m. dose; Melatonin 3mg on 02/21/2023 for the 9:00 p.m. dose; Pro-renal + D tablet on 02/21/2023 for the 9:00 p.m. dose; Sennoside-Docusate Sodium 8.6-50mg on 02/21/2023 at the 8:00 p.m. dose; and Trazodone HCL 50mg on02/21/2023 at the 9:00 p.m. dose.
Review of Resident #5's March 2023 Physician Orders revealed, in part: Gabapentin 300mg one tablet by mouth at bedtime; Melatonin 3mg one tablet by mouth at bedtime; Pro-renal + D one tablet by mouth at bedtime; and Trazodone HCL 50mg one tablet by mouth at bedtime.
Review of Resident #5's March 2023 EMAR revealed, in part, no documented evidence and the provider did not present any documented evidence of administration of the following medication: Gabapentin 300mg on 03/09/2023 for the 9:00 p.m. dose; Melatonin 3mg on 03/09/2023 for the 9:00 p.m. dose; Pro-renal + D tablet on 03/09/2023 for the 9:00 p.m. dose; and Trazodone HCL 50mg on 03/09/2023 at the 9:00 p.m. dose.
Resident #6
Review of Resident #6's April 2023 Physician Orders revealed, in part: Nystatin (medication used to treat fungal infections) mouth/throat suspension 100,000 unit/milliliter (ml) place and dissolve 5ml buccal (inside of the cheek) three times a day; Renevela 800mg one tablet by mouth with meals; Accuchecks before meals and at bedtime; and Humalog (insulin) Kwikpen Subcutaneous Solution 100 unit/ml per sliding scale.
Review of Resident #6's April 2023 EMAR revealed, in part, no documented evidence and the provider did not present any documented evidence of administration of the following medication: Nystatin mouth/throat suspension 100,000 unit/ml on 04/06/2023 at the 8:00 p.m. dose; Renevela 800mg on 04/16/2023 at the 5:00 p.m. dose; and Accucheck and Humalog Kwikpen subcutaneous Solution 100 unit/ml per sliding scale on 04/05/2023 at the 4:00 p.m. dose and on 04/06/2023 at the 8:00 p.m. dose.
In an interview on 05/11/2023 at 12:30 p.m., S3Corporate Compliance Nurse stated all medications should be documented accurately whether medication was administered or held and why it was held and confirmed there was incomplete/inaccurate documentation of medication administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to implement their policy and procedures to ensure the current COVID-19 vaccination status of all employees was obtained.
This was identified ...
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Based on record review and interview, the facility failed to implement their policy and procedures to ensure the current COVID-19 vaccination status of all employees was obtained.
This was identified for 86 current employees as documented on the facility's Employee Report View.
Findings:
Review of the facility's Employee COVID-19 Vaccination Policy and Procedure revealed the facility will track and securely document the vaccination status of each staff member to include, in part: each staff member's specific vaccine received, the dates of each dose received, or the date of the next scheduled dose for a multi-dose vaccine; staff who have been granted an exemption from vaccination; requirements of the facility; and staff for whom COVID-19 vaccination must be temporarily delayed.
Review of the National Healthcare Safety Network's Recent Facility Resident and Staff Vaccination Rates and Other Data, as reported for week ending 04/23/23 revealed no data was documented for staff vaccinations.
On 05/08/2023 at 3:30 p.m., S4Infecction Control Preventionist presented the facility's COVID-19 Vaccination Employee Tracking Log as current for staff vaccinations, and presented a staff listing labeled Report View of all employed staff as current employees.
Review of the facility's COVID-19 Vaccination Employee Tracking Log as current for staff vaccinations revealed 25 employees were listed with COVID-19 data who were not listed as being current employees on the staff list on the Report View report. Further review revealed S7Laundry Staff and S8Certified Nursing Assistant (CNA) were identified as only had received one dose of the COVID-19 Moderna vaccine (requires two vaccines 28 days apart to complete primary series) on 10/12/2022. There was no documented evidence and the facility did not present any documented evidence that the above mentioned employees was full vaccinated.
Review of the facility's Employee Report View compared to the facility's COVID-19 Vaccination Employee Tracking Log revealed 27 staff were listed as current employees which did not have staff vaccinations data documented.
In an interview on 05/09/2023 at 10:50 a.m., S4Infection Control Preventionist stated she was new to her position and only had the information which had been provided to her. S4Infection Control Preventionist stated the facility did not have a systematic way to record and review staff vaccinations. After reviewing the current staff list and the vaccination matrix
In an interview on 05/09/2023 at 10:51 a.m., S3Corporate Compliance Nurse confirmed, after reviewing the current staff list and the vaccination matrix, that many of the staff on the vaccination matrix are no longer employed by the facility, and there were several newly hired staff who did not have data on the COVID-19 Vaccination Employee Tracking Log; therefore, the facility did not have a systematic way to identify the staff's level of COVID-19 vaccination.
In an interview on 05/09/2023 at 3:17 p.m., S4Infection Control Preventionist stated the facility did not have any documented evidence and the facility was unable to present any documented evidence of S7Laundry Staff and S8CNA having completed the primary series of the COVID-19 vaccination, nor did the facility have evidence of a need to delay the second vaccine or a waiver for the vaccine. S4Infection Control Preventionist further stated both staff were still employed and the facility had no documented evidence of any follow-up with neither S7Laundry Staff nor S8CNA to receive the second COVID-19 vaccine.
Dec 2022
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to ensure that physician orders for medication administration were followed for 1 resident (Resident #5) of 5 sampled residents who were rev...
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Based on interviews and record reviews, the facility failed to ensure that physician orders for medication administration were followed for 1 resident (Resident #5) of 5 sampled residents who were reviewed for medications administered as prescribed. This failed practice had the potential to affect any of the 86 residents residing in the facility as documented on the facility's Resident Census and Conditions of Residents form (CMS-672).
Review of Resident #5's handwritten physician orders for December 2022 revealed in part, an order with a start date of 12/02/2022 for Prednisone 60 mg daily for 3 days, Prednisone 50 mg daily for 3 days, Prednisone 40 mg daily for 2 days, Prednisone 30 mg daily for 2 day, Prednisone 20 mg daily for 2 days, Prednisone 10 mg daily for 2 day, and Prednisone 5 mg daily for two days.
Review of Resident #5's electronic medication administration record (eMAR) revealed, in part, Prednisone 50mg was not started until 12/07/2022 and Prednisone 40mg was not started until 12/11/2022.
In an interview on 12/29/2022 at 10:06 a.m., S3Liscensed Practical Nurse (LPN) stated she placed the order for the Prednisone taper into the system incorrectly, and Resident #5 Prednisone was not administered per the physician's handwritten order.
In an interview on 12/29/2022 at 12:30 p.m., S1Director of Nursing (DON) stated Resident #5's Prednisone was not administered per physician's handwritten orders.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure that physician orders were entered correctly into facility's records for 2 (Resident #4 and Resident #5) of 5 sampled residents.
Fi...
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Based on interviews and record review, the facility failed to ensure that physician orders were entered correctly into facility's records for 2 (Resident #4 and Resident #5) of 5 sampled residents.
Findings:
Resident #4
Review of Resident #4's physician orders for December 2022 revealed, in part, an order dated 09/14/2021 to check Resident #4's fasting blood sugar daily in the morning.
Review of Resident #4's electronic medication administration record (eMAR) dated September, October, November, December 2022 revealed, in part, no documentation of Resident #4's blood glucose levels being checked daily for Resident #4.
In an interview on 12/28/2022 at 1:50 p.m., S4Licensed Practical Nurse (LPN) stated the nurses are responsible for checking resident's blood glucose levels. S4LPN further stated, she did not realize there was an order to check Resident #4's fasting blood glucose level every morning because, it was not being placed onto the eMAR. S4LPN also stated that she had never checked Resident #4's fasting blood glucose. S4LPN was unable to produce any documentation Resident #4's blood glucose was checked.
In an interview on 12/28/22 at 4:40 p.m., S1Director of Nursing (DON) stated Resident #4 had an order for fasting blood glucose levels to be checked every morning, and that Resident #4 blood glucose levels were not checked as ordered.
Resident #5
Review of Resident #5's physician orders dated December 2022 revealed in part, an order dated 12/14/2022 for Basic Metabolic Panel (BMP) (a blood test that measures several basic aspects of your blood) to be drawn one time only for 1 week. Further review revealed a physicians' handwritten order with a start date of 12/02/2022 for Prednisone 60 mg daily for 3 days, Prednisone 50 mg daily for 3 days, Prednisone 40 mg daily for 2 days, Prednisone 30 mg daily for 2 day, Prednisone 20 mg daily for 2 days, Prednisone 10 mg daily for 2 day, and Prednisone 5 mg daily for two days.
Review of Resident #5's electronic medication administration record (eMAR) revealed in part, Basic Metabolic Panel (BMP) (a blood test that measures several basic aspects of your blood) was not obtained as ordered between 12/14/2022 to 12/21/2022. Further reviewed revealed Resident #5's Prednisone 50 mg was not started until 12/07/2022 and Prednisone 40mg was not started until 12/11/2022.
In an interview on 12/29/2022 at 10:06 a.m., S3Liscensed Practical Nurse (LPN) stated she placed the order for the Prednisone taper into the system incorrectly regarding the start and stop date of each dose, and that was why Resident #5 did not receive medication as ordered on 12/06/2022 and 12/10/2022. S3LPN further stated she had not included the order for the BMP to populate to the lab orders and therefore the order was not obtained. S3LPN confirmed due to the errors inputting the orders the medical record was not accurate or complete.
In an interview on 12/29/2022 at 12:30 p.m., S1DON stated that they could not find any record that the physicians' order for Resident #5's BMP to be obtained was completed by facility between 12/14/2022 and 12/21/2022. S1DON further stated Resident #5's Prednisone order was not entered correctly into facility's electronic medical record (EMR), and that Resident #5's Prednisone was not given as ordered on 12/06/2022 and 12/10/2022. S1DON further stated the due to the errors placing the orders into the system the resident's record was not complete and accurate.
Dec 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure a resident with a surgical incision received w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure a resident with a surgical incision received wound care in accordance with professional standards of practice for 1 of 1 sampled residents reviewed for skin conditions (#241) in a total sample of 18.
Findings:
Review of the facility's policy, Wound Treatment Management revised on 12/01/2021 revealed, in part, In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders which may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse, and treatments will be documented on the Treatment Administration Record.
Review of Resident #241's medical record revealed, in part, Resident #241 was admitted to the facility on [DATE] from the hospital.
Resident #241's Nursing admission note, dated 12/02/2022, revealed, in part, Resident #241 had a dressing to a midline abdominal surgical incision that was intact with no drainage.
During an interview on 12/05/2022 at 8:03 a.m. Resident #241 reported he was admitted to the facility from the hospital on [DATE] late in the evening. Resident #241 further stated he had an abdominal surgical incision, and facility staff had not assessed his wound or changed the wound's dressing while he was a resident.
Observation on 12/05/2022 at 10:01 a.m. revealed S5Medical Records assessed Resident #241's midline abdominal surgical wound dressing, which was not dated.
Review of Resident #241's Weekly Body Audit, dated 12/05/2022, revealed, in part, Resident #241 had a midline abdominal surgical incision.
Review of Resident #241's December 2022 Electronic Treatment Administration Record revealed, in part, Resident #241 did not receive treatment to the midline abdominal surgical incision until 12/06/2022.
In an interview an on 12/08/2022 at 2:00 p.m. S7Treatment/Infection Control Nurse acknowledged that wound care to Resident #241's midline abdominal surgical incision should have been initiated on admission. S7Treament/Infection Control Nurse stated the registered nurse (RN) supervisor was responsible for completing wound care on the weekends, and Resident #241's wound should have been assessed and the necessary care and treatments initiated on 12/03/2022.
During an interview on 12/08/2022 at 03:48 p.m. S1Director of Nursing confirmed a RN should have assessed Resident #241's midline abdominal surgical incision within 24 hours of being admitted to the facility. S1Director of Nursing additionally stated the RN supervisor was responsible for wound care on the weekends, and the RN supervisor should have assessed Resident #241's midline abdominal surgical incision and obtained orders from a physician for wound care treatment.
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 observation and interview, the facility failed to store dry goods in a manner to prevent the possibility of food contamination. This deficient practice had the potential to effect 80 resident...
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Based on observation and interview, the facility failed to store dry goods in a manner to prevent the possibility of food contamination. This deficient practice had the potential to effect 80 residents who receive meals from the facility's kitchen according to the Resident Census and Condition Forms (CMS-672)
Review of facility's Food Safety Requirements policy, dated 12/01/2022, revealed in part, food should be stored in a manner that helps prevent deterioration or contamination of food.
Observation on 12/05/2022 at 6:05 a.m. revealed a bag of brown rice was open to air. Further observation revealed a box of solid coconut oil open to air and undated.
Observation on 12/05/2022 at 10:28 a.m. revealed a bag of brown rice was open to air. Further Observation revealed a box of solid coconut oil open to air and undated.
Observation on 12/07/2022 at 9:19 a.m. revealed a bag of brown rice was open to air. Further observation revealed a box of solid coconut oil open to air and undated.
In an interview on 12/07/2022 at 9:20 a.m., S18Dietary Manager (DM) confirmed the solid coconut oil and brown rice were being utilized for resident consumption. S17DM further stated that the above mention items were open to air but should have been sealed. S17DM also confirmed the solid coconut oil should have been labeled with the date it was opened.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to:
1. Ensure a resident received bolus tube feedings as ordered based...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to:
1. Ensure a resident received bolus tube feedings as ordered based on the amount of meal consumption for 1 (Resident #6) of 4 sampled residents (Resident #6, Resident #46, Resident #75, and Resident #239) reviewed for weights; and,
2. Ensure residents were weighed as required for 3 (Resident #6, Resident #46, and Resident #75) of 4 sampled residents (Resident #6, Resident #46, Resident #75, and Resident #239) reviewed for weights.
Findings:
Review of the facility's Weight Monitoring policy revealed, in part, the facility will obtain weekly weights on newly admitted residents and residents identified with a weight loss. Further review revealed meal consumption should be documented in the resident's record.
Resident #6
Review of Resident #6's medical record revealed, in part, an admit date of 01/10/2022 with a diagnosis of moderate protein-calorie malnutrition with gastrostomy status.
Review of Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/20/2022 revealed, in part, Resident #6 was identified as having a significant weight loss.
Review of Resident #6's December 2022 Physician's Orders revealed, in part, an order to administer bolus feedings to Resident #6 via feeding tube if Resident #6 consumed less than 25% of meals by mouth.
Review of Resident #6's Comprehensive Care Plan revealed, in part, Resident #6 was at risk for nutritional problems with an intervention for Resident #6 to maintain adequate nutrition as evidenced by stable weight.
Review of Resident #6's Weights and Vitals Summary revealed, in part, the following weights were collected:
08/31/2022 - 151 pounds;
09/19/2022 - 143.8 pounds;
11/06/2022 - 137.4 pounds; and,
12/02/2022 - 138.6 pounds.
In interview on 12/7/2022 S9 Licensed Practical Nurse at 1:00 p.m. indicated Resident #6 had a Physician's Order to administer bolus feedings if Resident #6's meal intake by mouth was less than 25%. S9LPN further indicated Resident #6 has not received any bolus feedings.
Review of Resident's #6 medical records revealed, in part, no documentation evidence and the facility did not present and documented evidence of documentation of Resident #6's meal intakes by mouth, bolus tube feeding administrations, or weekly weights.
In an interview on 12/07/2022 at 1:30 p.m., S1Director of Nursing indicated there was no record of meal consumption to administer bolus feedings as ordered and no weekly weights were completed when weight loss was noted.
In interview on 12/08/2022 at 4:00 p.m., S3Corporate Nurse indicated meal intake documentation was not initiated until 12/08/2022.
Resident #75
Review of Resident #75's medical records revealed, in part, Resident #75 was initially admitted to the facility on [DATE] and readmitted on [DATE].
Review of Resident #75's Registered Dietician's note, dated 11/16/2022, revealed in part, a recommendation to obtain weekly weights for 4 weeks due to being a new admission to the facility.
Review of Resident #75's December 2022 Physician's Orders revealed, in part, an order with a start date of 09/19/2022 to collect weekly weights every Tuesday.
Review of Resident #75's Weights and Vitals Summary revealed, in part, the following weights were collected since admission:
05/13/2022 - 122.6 pounds;
06/02/2022 - 124 pounds;
09/14/2022 - 105.1 pounds;
11/10/2022 - 102.3 pounds; and,
12/02/2022 - 84 pounds.
There was no documented evidence and the facility did not present any documented evidence that weekly weights were obtained as ordered for Resident #75.
Resident #46
Review of Resident #46's medical record revealed, in part, an admission date of 08/25/2022, with diagnoses of Fluid Overload and Hepatic Failure.
Review of Resident #46's December 2022 Physician's Orders revealed, in part, an order, with a start date of 09/19/2022, for weekly weights every Tuesday.
Review of Resident #46's Weights and Vitals Summary revealed, in part, the following weights were collected:
09/19/2022 - 146.5 pounds;
10/05/2022 - 190.5 pounds;
11/06/2022 - 210 pounds; and,
12/02/2022 - 198.4 pounds.
There was no documented evidence and the facility did not present any documented evidence that weekly weights were obtained as ordered for Resident #46.
In an interview on 12/08/2022 at 12:29 p.m., S17Restorative Certified Nursing Assistant stated Resident #46 was a monthly weight. S17Restorative Certified Nursing Assistant further stated if a Resident was a weekly weight the nurse would tell her when to weigh them.
In an interview on 12/08/2022 at 1:38 p.m., S6MDSCoordinator stated Resident #46 should have had weekly weights.
In an interview on 12/08/2022 at 1:50 p.m., S10Licensed Practical Nurse stated Resident #46 was weighed monthly. S10Licensed Practical Nurse confirmed Resident #46 should have been weighed weekly.
In an interview on 12/08/2022 at 1:58 pm S1Director of Nursing verified Resident #46 was not weighed weekly and confirmed Resident #46 should have been weighed weekly.
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
- "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
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • $4,233 in fines. Lower than most Louisiana facilities. Relatively clean record.
Concerns
- • 62 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (33/100). Below average facility with significant concerns.
- • 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Chateau Napoleon Caring, Llc's CMS Rating?
CMS assigns Chateau Napoleon Caring, LLC 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 Chateau Napoleon Caring, Llc Staffed?
CMS rates Chateau Napoleon Caring, LLC's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Chateau Napoleon Caring, Llc?
State health inspectors documented 62 deficiencies at Chateau Napoleon Caring, LLC during 2022 to 2025. These included: 61 with potential for harm and 1 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Chateau Napoleon Caring, Llc?
Chateau Napoleon Caring, LLC 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 VOLARE HEALTH, a chain that manages multiple nursing homes. With 120 certified beds and approximately 90 residents (about 75% occupancy), it is a mid-sized facility located in NAPOLEONVILLE, Louisiana.
How Does Chateau Napoleon Caring, Llc Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Chateau Napoleon Caring, LLC's overall rating (1 stars) is below the state average of 2.4, staff turnover (59%) 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 Chateau Napoleon Caring, Llc?
Based on this facility's data, families visiting should ask: "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?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Chateau Napoleon Caring, Llc Safe?
Based on CMS inspection data, Chateau Napoleon Caring, LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Chateau Napoleon Caring, Llc Stick Around?
Staff turnover at Chateau Napoleon Caring, LLC is high. At 59%, the facility is 13 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 62%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. 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 Chateau Napoleon Caring, Llc Ever Fined?
Chateau Napoleon Caring, LLC has been fined $4,233 across 1 penalty action. This is below the Louisiana average of $33,121. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Chateau Napoleon Caring, Llc on Any Federal Watch List?
Chateau Napoleon Caring, LLC 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.