What is COURTYARD OF NATCHITOCHES's CMS rating?

COURTYARD OF NATCHITOCHES has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does COURTYARD OF NATCHITOCHES have?

COURTYARD OF NATCHITOCHES has 41 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at COURTYARD OF NATCHITOCHES?

COURTYARD OF NATCHITOCHES has a four-star staffing rating from CMS with 0.23 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is COURTYARD OF NATCHITOCHES located?

COURTYARD OF NATCHITOCHES is located in NATCHITOCHES, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does COURTYARD OF NATCHITOCHES have?

COURTYARD OF NATCHITOCHES has 112 certified beds.

Who owns COURTYARD OF NATCHITOCHES?

COURTYARD OF NATCHITOCHES is a government - hospital district facility and operates independently (not part of a chain).

Is COURTYARD OF NATCHITOCHES safe?

COURTYARD OF NATCHITOCHES has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at COURTYARD OF NATCHITOCHES stick around?

COURTYARD OF NATCHITOCHES has low staff turnover at 24%, which means caregivers stay longer and know residents better.

Was COURTYARD OF NATCHITOCHES ever fined?

No, COURTYARD OF NATCHITOCHES has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is COURTYARD OF NATCHITOCHES on any federal watch list?

No, COURTYARD OF NATCHITOCHES is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at COURTYARD OF NATCHITOCHES?

Medicare inspectors have found 41 deficiencies at COURTYARD OF NATCHITOCHES: 41 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting COURTYARD OF NATCHITOCHES?

Families visiting COURTYARD OF NATCHITOCHES should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does COURTYARD OF NATCHITOCHES compare to other nursing homes?

COURTYARD OF NATCHITOCHES has a 2-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

COURTYARD OF NATCHITOCHES | 55/100 (Grade C)

Sept 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of medical records for 1 (Resident R5) of 5 (Resident #1, Resident #2, Resident #3, Re...

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Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentiality of medical records for 1 (Resident R5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident R5) sampled residents.Review of the facility's policy entitled Sanctions for (facility name) to Comply to HIPAA Privacy Standards revised 06/2016 revealed, in part.all workforce members are required to adhere to the HIPPA Privacy Standards and prevent unauthorized disclosure of Protected Health Information (PHI). Workforce members will protect health information from unauthorized disclosure. Leaving PHI in public areas is a violation of HIPPA Privacy Standards.Observation of Hall B on 09/16/2025 at 8:55 a.m. revealed Cart X was unattended, with the electronic medical record (EMR) screen open and Resident R5's PHI visible. The surveyor remained with Cart X until a staff member approached Cart X. The staff member identified herself as S7LPN.Interview with S7LPN on 09/16/2025 at 8:57 a.m. revealed she left Cart X unattended on Hall B, with Resident R5's PHI visible on the computer screen. S7LPN confirmed she did not ensure the privacy and confidentiality of Resident R5's PHI, but should have. Interview with S2DON on 09/16/2025 at 10:45 a.m. revealed staff were to ensure the privacy and confidentiality of resident PHI by locking computer screens when leaving them unattended.

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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure Cart ...

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Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure Cart X was locked and medications were stored in a safe and secure manner.Review of the facility's policy entitled Medication Storage revised 03/2025 revealed, in part.It is the policy of this facility to ensure all medications housed on our premises will be stored to ensure security. All drugs and biologicals will be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Observation of Hall B on 09/16/2025 at 8:55 a.m. revealed Cart X was unattended, and unlocked, with 3 of 8 drawers pulled open. This surveyor remained with Cart X until a staff member approached Cart X. The staff member identified herself as S7LPN.Interview with S7LPN on 09/16/2025 at 8:57 a.m. revealed Cart X was unattended and unlocked on Hall B, with 3 drawers pulled open. S7LPN revealed medication carts were to be locked, with all drawers closed, when left unattended. S7LPN confirmed the medications on Cart X were not stored in a safe a secure manner, but should have been.Interview with S2DON on 09/16/2025 at 10:45 a.m. revealed medication carts were to be locked when unattended to ensure medications were stored in a safe and secure manner.

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 reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure docume...

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Based on interviews, and record reviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices. The facility failed to ensure documentation on the Medication Administration Report (MAR) was accurate for 2 (Resident #2 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident R5) sampled residents. Review of the facility's policy entitled Administration of Medicines revised 03/2025 revealed, in part.the facility is to maintain a record of all medications administered. Staff is to time and initial each medication on the MAR after the medication is given.Review of the facility's policy entitled Medication Administration Electronic Documentation revised 03/2025 revealed, in part.Every resident has an electronic Medication Administration Record (E-MAR) for the purpose of proper administration and recording of all medications. The E-MAR is a permanent, legal document and is a part of the Electronic Health Record. Resident #2Review of Resident #2's medical record revealed an initial admission date of 08/30/2024 with diagnoses including, in part.Repeated Falls, Tremor, Protein-Calorie Malnutrition, Osteoarthritis, Hypothyroidism, Disorder of the Skin and Subcutaneous Tissue, Dementia, Anxiety, Hyperlipidemia and Glaucoma.Review of Resident #2's Annual MDS with ARD of 09/03/2025 revealed a BIMS Score of 03, indicating severe cognitive impairment.Review of Resident #2's current physician's orders revealed, in part. 09/10/2025 Levothyroxine 100mcg po daily r/t Hypothyroidism; 08/08/2025 Donepezil 10mg give 1/2 tablet po in the evening r/t Dementia and Anxiety; 08/05/2025 Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes at bedtime r/t Glaucoma; 11/04/2024 Observe closely for significant side effects of Anti-Depressant medication.every shift; 10/14/2024 Observe closely for significant side effects of Anticoagulant medication.every shift; 10/08/2024 Resident to wear pillow heel boots with heels floated while in bed every shift; 09/09/2024 Naturewell Retinol Cream apply topically to arms, hands, and face daily r/t Disorder of the Skin and Subcutaneous Tissue; 09/09/2024 Overlay on mattress to help prevent pressure points every shift; 09/05/2024 Supplement of choice TID with meals r/t Unspecified Protein-Calorie Malnutrition; 08/31/2024 Atorvastatin 20mg give one tablet po daily r/t Hyperlipidemia; and 08/30/2024 Memantine 10mg give 1/2 tablet po BID r/t Dementia and Anxiety.Review of Resident #2's 09/2025 MAR revealed, in part.on 09/06/2025 time and initials were not recorded on the night shift for: Overlay on mattress to help prevent pressure points every shift; Observe closely for significant side effects of Anticoagulant medication.every shift; Observe closely for significant side effects of Anti-Depressant medication.every shift; and Resident to wear pillow heel boots with heels floated while in bed every shift.On 09/07/2025 at 6:00 a.m. time and initials were not recorded for Levothyroxine.On 09/08/2025 at 6:00 a.m. time and initials were not recorded for Levothyroxine.Review of Resident #2's 08/2025 MAR revealed, in part.on 08/29/2025 time and initials were not recorded on the evening shift for: Overlay on mattress to help prevent pressure points every shift; Observe closely for significant side effects of Anticoagulant medication.every shift; Observe closely for significant side effects of Anti-Depressant medication.every shift; and Resident to wear pillow heel boots with heels floated while in bed every shift.On 08/28/2025 at 5:00 p.m. time and initials were not recorded for Supplement of choice.On 08/29/2025 at 7:00 p.m. time and initials were not recorded for Donepezil.On 08/29/2025 at 8:00 p.m. time and initials were not recorded for Atorvastatin, Latanoprost Ophthalmic Solution, Memantine, or Naturewell Retinol Cream. Resident #4Review of Resident #4's medical record revealed an admission date of 12/17/2014 with diagnoses including, in part.Diabetes and Hypothyroidism.Review of Resident #4's Annual MDS with an ARD of 08/06/2025 revealed a BIMS Score of 15, indicating intact cognition.Review of Resident #4's physician's orders revealed, in part. 08/07/2025 Levothyroxine 25mcg po every day r/t Hypothyroidism; 09/30/2024 Novolin R Injection Solution inject as per sliding scale subcutaneously BID r/t Diabetes; 08/09/2024 Observe closely for significant side effects of Anticoagulant medication every shift; 08/09/2024 Observe closely for significant side effects of Anticonvulsant medication every shift; 07/01/2024 Blood glucose monitoring one time a day; and 06/26/2024 Encourage fluid intake by mouth every shift.Review of Resident #4's 09/2025 MAR revealed, in part.on 09/06/2025 time and initials were not recorded on the night shift for: Encourage fluid intake by mouth every shift; Observe closely for significant side effects of Anticoagulant medication every shift; and Observe closely for significant side effects of Anticonvulsant medication every shiftOn 09/07/2025 at 6:00 a.m. time and initials were not recorded for blood glucose monitoring, Levothyroxine, and Novolin R.On 09/08/2025 at 6:00 a.m. time and initials were not recorded for blood glucose monitoring, Levothyroxine, and Novolin R.Interview with S3ADM on 09/17/2025 at 1:35 p.m. confirmed the facility failed to ensure documentation on Resident #4's 09/2025 MAR, and Resident #2's 08/2025 and 09/2025 MARs was accurate, but should have.Interview with S11LPN on 09/17/2025 at 1:42 p.m. revealed she administered medications and performed all tasks as ordered for Resident #2 and Resident #4 on 09/06/2025, 09/07/2025, and 09/08/2025, but failed to ensure documentation on the MARs. S11LPN confirmed documentation on Resident #2 and Resident #4's 09/2025 MAR was not accurate, but should have been. Interview with S12LPN on 09/17/2025 at 2:00 p.m. revealed she administered medications and performed all tasks as ordered for Resident #2 on 08/29/2025, but failed to ensure documentation on the MAR. S12LPN confirmed documentation on Resident #2's 08/2025 MAR was not accurate, but should have been.

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property/funds for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sam...

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Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property/funds for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for misappropriation. The facility failed to prevent misappropriation of Resident #1's funds by S7 Rehab Tech. Findings: Review of a facility policy on 06/09/2025 at 9:18 a.m. titled, Abuse Protection and Prevention Program with a revision date of 02/2013 revealed the following in part .Our residents have the right to be free from abuse, neglect and misappropriation of resident property. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of Resident #1's medical record revealed a re-entry admission date of 05/07/2024, with diagnoses that included in part . Fusion of Spine of the Cervical Region, Seizures, Quadriplegia, and Depression. Review of Resident #1's Quarterly MDS with an ARD of 04/23/2025 revealed a BIMS score of 15, which indicated intact cognition. Review of Resident #1's care plan with an initiated date of 08/28/2024 revealed the following in part .date initiated (05/22/2025): Focus: Resident gives money to associates to keep for her. Interventions: Staff will encourage resident to give money to appropriate staff member to put up in a safe place. Review of a facility investigation/incident report completed by S1 Administrator on 05/20/2025 at 12:35 p.m. revealed the following in part .Incident Description: S1 Administrator and S2 SSD interviewed Resident #1 regarding allegations of money being taken from Resident #1 by an associate. Resident #1 revealed to S1 Administrator and S2 SSD that she asked S7 Rehab Tech to hold $12,000 dollars for her in 11/2024. Resident #1 told S1 Administrator and S2 SSD in the interview, that weeks after 11/2024, S7 Rehab Tech told Resident #1 the money she was holding for Resident #1 was stolen from S7 Rehab Tech's home. Resident #1 stated S7 Rehab Tech did not report the crime or repay Resident #1's money stolen. Review of Resident #1's statement written on 05/20/2025 revealed the following in part . on 11/06/2024, Resident #1 went to the bank and cashed a check for $12,434.29 dollars. S7 Rehab Tech counted money on Resident #1's bed. S7 Rehab Tech put $7,000 dollars in one envelope to distribute to Resident #1's mother and sister and $5,000 dollars in another envelope to hold for Resident #1. S7 Rehab Tech proceeded to take all the money home to hold for Resident #1. On 12/03/2024, S7 Rehab Tech brought $800.00 dollars of the $5,000.00 dollars for Resident #1 to distribute to her family members as Resident #1 wished. S7 Rehab Tech also agreed to pay Resident #1's monthly cell phone bill since 12/2024. Sometime in 01/2025, S7 Rehab Tech told Resident #1 someone broke into S7 Rehab Tech's house and stole Resident #1's money. S7 Rehab Tech told Resident #1 she would repay her when S7 Rehab Tech filed her income taxes. Since 01/2025, S7 Rehab Tech has blocked Resident #1's phone number and has avoided speaking to Resident #1 regarding the above events. Review of S1 Administrator and S6 Rehab Director's statement written on 05/20/2025 at 12:30 p.m. revealed the following in part . S1 Administrator and S6 Rehab Director interviewed S7 Rehab Tech regarding the events involving Resident #1. S7 Rehab Tech stated she agreed to hold Resident #1's money. S7 Rehab Tech stated the total amount of money was $8,000 dollars and denied it being $12,000 dollars as Resident #1 stated. S7 Rehab Tech stated she told Resident #1 that someone broke into her home and stole the black box where S7 Rehab Tech kept Resident #1's money. S7 Rehab Tech stated she did not file a police report regarding the crime because S7 Rehab Tech did not want to explain why she had Resident #1's money. S7 Rehab Tech stated she told Resident #1 she would repay Resident #1 as soon as she could. S7 Rehab Tech stated she paid for Resident #1's phone bill and bought Resident #1 things she needed. Review of S7 Rehab Tech's statement written on 05/20/2025 at 12:30 p.m. revealed the following part .in 11/2024, Resident #1 asked S7 Rehab Tech to hold money for her and gave S7 Rehab Tech an envelope with $8,000 dollars. S7 Rehab Tech stated two weeks before Christmas, someone broke into S7 Rehab Tech's home and stole the black lock box with Resident #1's money. S7 Rehab Tech stated she would try to purchase items Resident #1 needed and told Resident #1 she would pay Resident #1 back as soon as she could. S7 Rehab Tech stated Resident #1 did not want the facility to know Resident #1 received the money. S7 Rehab Tech did not call anyone when the money was stolen from her home because S7 Rehab Tech did not know how to explain where the money came from and who it was for. S7 Rehab Tech stated it was her own fault, she should have never taken Resident #1's money, and she should have never made these arrangements with Resident #1. In an interview on 06/09/2025 at 10:15 a.m., S1 Administrator revealed the following in part .on 05/20/2025 there was a rumor going around the facility that Resident #1 allowed a staff member to hold money for Resident #1 and now the money was missing. S1 Administrator and S2 SSD interviewed Resident #1 on this day and Resident #1 revealed this rumor to be true. S1 Administrator stated that she and S6 Rehab Director then interviewed the accused, S7 Rehab Tech. S7 Rehab Tech admitted to holding $8,000 cash for Resident #1 and then her house was broken into and Resident #1's money was stolen. In an interview on 06/09/2025 at 1:15 p.m., Resident #1 revealed the following in part . Resident #1 confirmed the events that occurred in her previous written statement on 05/20/2025. Resident #1 stated she was receiving a car accident settlement and she thought if the nursing home knew about the money the facility would take the money, Resident #1's stay at the facility would be jeopardized, and/or Resident #1's insurances would be discontinued. Resident #1 was worried about this, so Resident #1 trusted S7 Rehab Tech to hold the settlement money, distribute the money as Resident #1 wished, and buy certain things for Resident #1. Resident #1 stated that S7 Rehab Tech agreed to these arrangements. Resident #1 stated, in 11/2024, she received the settlement check, cashed it at the bank, and gave $12,000 dollars cash for S7 Rehab Tech to hold for Resident #1. Resident #1 stated that during this time, S7 Rehab Tech would distribute her money as she wished. Resident #1 stated, in 12/2024 before Christmas, S7 Rehab Tech told Resident #1 that her home was broken into and Resident #1's money was stolen. S7 Rehab Tech promised Resident #1 she would repay her when S7 Rehab Tech received her income tax return. Since 12/2024, Resident #1 would attempt to talk to S7 Rehab Tech about when she would pay Resident #1 back. Resident #1 stated S7 Rehab Tech responses were always some excuse. Resident #1 expected to get paid back from S7 Rehab Tech for the remaining money that was stolen from S7 Rehab Tech's home. Resident #1 revealed that S7 Rehab Tech never stated how much money was actually stolen from S7 Rehab Tech's home or speak of the details of the home invasion/theft. Resident #1 stated, S7 Rehab Tech did not file a police report because S7 Rehab Tech told Resident #1 she did not want to explain why she had thousands of dollars. Resident #1 never spoke of the events/arrangements until 05/20/2025 because S7 Rehab Tech was avoiding Resident #1 and still did not repay Resident #1 for the stolen money. On 05/20/2025, Resident #1 stated she spoke to nursing staff, S1 Administrator, S2 SSD, and the police about the events that took place with S7 Rehab Tech. Resident #1 stated she had not seen or heard from S7 Rehab Tech since 05/20/2025 and had not been repaid for the funds stolen from S7 Rehab Tech's home. Resident #1 revealed S7 Rehab Tech had blocked Resident #1's phone number and blocked Resident #1's daughter's phone numbers. In an interview on 06/09/2025 at 3:08 p.m., S2 SSD revealed the following in part .S2 SSD accompanied S1 Administrator to Resident #1's room to be a witness of an interview. S2 SSD revealed Resident #1 stated the same events and arrangements (mentioned above) Resident #1 and S7 Rehab Tech agreed to. In an interview on 06/10/2025 at 11:08 a.m., S6 Rehab Director revealed the following in part .S6 Rehab Director confirmed his previous statement written on 05/20/2025. S6 Rehab Director stated on 05/20/2025 he participated in an interview with S1 Administrator and S7 Rehab Tech. In the interview, S7 Rehab Tech admitted to holding $8,000 dollars for Resident #1 (in 11/2024) and then the money being stolen from S7 Rehab Tech's home (in 12/2024). In an interview on 06/10/2025 at 1:05 p.m., S1 Administrator revealed the following in part .S1 Administrator confirmed her previous statement written on 05/20/2025. S1 Administrator confirmed after S1 Administrator completed Resident #1's investigation, the allegation of misappropriation of funds/property was substantiated by the facility. S1 Administrator confirmed Resident #1's funds were misappropriated by S7 Rehab Tech.

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure an investigation of an allegation of misappropriation of resident property/funds was thoroughly investigated for 1 (Resident #1) of ...

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Based on interview and record review, the facility failed to ensure an investigation of an allegation of misappropriation of resident property/funds was thoroughly investigated for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for misappropriation. Findings: Review of a facility policy on 06/09/2025 at 9:18 a.m. titled, Abuse Protection and Prevention Program with a revision date of 02/2013 revealed the following in part . Our residents have the right to be free from abuse, neglect and misappropriation of resident property. D. Timely and thorough investigations of all reports and allegations of abuse. Misappropriation of property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 10. Upon receiving information concerning a report of abuse, the director of nursing will designate an associate to monitor the resident's emotions concerning the incident as well as the resident's reactions to his/her involvement in the investigation to assure the resident feels he/she is protected from harm during an investigation. Review of Resident #1's medical record revealed a re-entry admission date of 05/07/2024, with diagnoses that included in part . Fusion of Spine of the Cervical Region, Seizures, Quadriplegia, and Depression. Review of Resident #1's Quarterly MDS with an ARD of 04/23/2025 revealed a BIMS score of 15, which indicated intact cognition. Review of Resident #1's care plan with an initiated date of 08/28/2024 revealed the following part .date initiated (05/22/2025): Focus: Resident gives money to associates to keep for her. Interventions: Staff will encourage resident to give money to appropriate staff member to put up in a safe place. Review of a facility investigation/incident report completed by S1 Administrator on 05/20/2025 at 12:35 p.m. revealed the following in part .Incident Description: S1 Administrator and S2 SSD interviewed Resident #1 regarding allegations of money being taken from Resident #1 by an associate. Resident #1 revealed to S1 Administrator and S2 SSD that she asked S7 Rehab Tech to hold $12,000 dollars for her in 11/2024. Resident #1 told S1 Administrator and S2 SSD in the interview, that weeks after 11/2024, S7 Rehab Tech told Resident #1 the money she was holding for Resident #1 was stolen from S7 Rehab Tech's home. Review of a facility investigation/incident report completed by S1 Administrator on 05/20/2025 at 12:35 p.m. revealed the following in part . Incident Investigation: 05/20/2025 at 12:30 p.m.: S7 Rehab Tech, accused, confirmed allegations. 05/21/2025: Education to all staff. 05/21/2025: Interview with four cognitive residents regarding allegations of staff keeping money, asking for money, or taking money from residents. All four residents denied that any staff had ever approached them about money. In an interview on 06/09/2025 at 10:15 a.m., S1 Administrator revealed the following in part .in regards to the investigation of Resident #1 and S7 Rehab Tech's incident, an in-service was completed with the staff on duty regarding misappropriation of property and S8 DON completed random interviews with residents who resided on Resident #1's hall regarding the allegations. S1 Administrator stated on multiple occasions to this surveyor .she did not have to do much of an investigation because S7 Rehab Tech admitted to taking Resident #1's money. Review of S8 DON's statement written on 05/21/2025 revealed the following in part . S8 DON spoke with three residents that resided in the facility regarding issues with staff and money All three residents were asked if any of our staff ever asked for money, if the residents had any money missing, and if staff ever asked to hold money for them .all three residents answered no to all above questions. In an interview on 06/09/2025 at 1:15 p.m., Resident #1 revealed the following in part . Resident #1 reported S7 Rehab Tech to S1 Administrator and S2 SSD on 05/20/2025. Following reporting the incident on 05/20/2025, S2 SSD came to visit her occasionally regarding the incident but no other staff had checked on her regarding the incident. In an interview on 06/09/2025 at 2:40 p.m., S5 CNA Supervisor revealed the following in part .S5 CNA Supervisor could not describe, define, or give an example of misappropriation of resident property/funds. S5 CNA confirmed she did not know what this meant and was unaware this was a form a resident abuse. In an interview on 06/09/2025 at 3:08 p.m., S2 SSD revealed the following in part .S2 SSD stated she was on vacation when S8 DON completed in-servicing regarding the incident on 05/20/2025. S2 SSD confirmed she had not received any in-servicing since returning to work regarding misappropriation of resident funds/property. In an interview on 06/10/2025 at 10:25 a.m., S4 CNA revealed the following in part .S4 CNA was only aware of physical abuse and no other forms of resident abuse. After education provided, S4 CNA confirmed she was not aware of verbal, mental, sexual, misappropriation of resident funds/property and that these were all forms of resident abuse. S4 CNA confirmed she did not have in-servicing following Resident #1's incident on 05/20/2025 and was not educated regarding misappropriation of resident funds/property. In an interview on 06/10/2025 at 11:08 a.m., S6 Rehab Director revealed the following in part .S6 Rehab Director completed an in-service on 05/21/2025 to his therapy staff regarding ethics including misappropriation of resident funds/property. S6 Rehab Director confirmed he did not in-service/educate all of his therapy staff regarding misappropriation of resident funds/property, but should have. In an interview on 06/10/2025 at 1:05 p.m., S1 Administrator revealed the following in part .S1 Administrator was responsible for Resident #1's investigation on 05/20/2025. S1 Administrator stated S8 DON completed three resident interviews on 05/21/2024 and in-serviced the staff on duty regarding ethics including misappropriation of resident funds/property. S1 Administrator stated there was not much of an investigation because S7 Rehab Tech admitted to taking Resident #1's money, the allegation was substantiated by the facility, and S7 Rehab Tech was suspended immediately and then terminated. S1 Administrator closed and completed the investigation. S1 Administrator confirmed that not all cognitive residents were interviewed, not all facility staff and therapy staff were in-serviced, and Resident #1 did not have safety/monitoring checks throughout the investigation. S1 Administration confirmed she and the facility did not complete a thorough investigation and should have provided safety/monitoring rounds to all residents, in-servicing to all facility/therapy staff, and monitored Resident #1 for any negative effects following the incident on 05/20/2025, but did not.

May 2025 2 deficiencies

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 F0604 (Tag F0604)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraint...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 2 (#1, #3) of 3 (#1, #2, #3) residents reviewed for restraints. The facility failed to ensure: 1. A physician's order was obtained, a consent was signed and a risk assessment was completed for a Geri-chair for Resident #1, 2. A physician's order was obtained, a consent was signed and a risk assessment was completed for a pommel cushion for Resident #3, and 3. A restraint policy was developed. Findings: Review of the facility's policy and procedures failed to reveal a policy for restraints and bed rails. Resident #1 Review of Resident #1's medical records revealed an admit date of 01/16/2025 with the following diagnoses, including in part: infection and inflammatory reaction due to internal left knee prosthesis/subsequent encounter, chronic kidney disease stage 2 (mild), and chronic thromboembolic pulmonary hypertension. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderately impaired cognition. Review of Resident #1's care plan revealed - needs assistance with ADLs (activities of daily living) . Assist x 1 staff member for bathing, dressing eating, grooming, mobility and toileting .Resident uses Gerichair for mobility (initiated 01/17/2025 and revised on 05/28/2025). Review of Resident #1's medical record failed to reveal a physician's order, a consent, and a risk assessment for Gerichair. Observation on 05/27/2025 at 2:20 p.m. revealed Resident #1 reclining with feet up in Gerichair. Observation on 05/28/2025 at 11:45 a.m. revealed Resident #1 reclining with feet up in Gerichair. Resident #3 Review of Resident #3's medical records revealed an admit date of 01/13/2021 with the following diagnoses, including in part: unspecified dementia/unspecified severity without behavioral disturbance/psychotic disturbance/mood disturbance and anxiety, difficulty in walking, muscle weakness (generalized), history of falling an and insomnia unspecified. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition. Review of Resident #3's care plan revealed the resident has had a history of falls related to poor balance: Pommel cushion in wheelchair (initiated 05/28/2025). Review of Resident #3's medical record failed to reveal a physician's order, a consent, and a risk assessment for pommel cushion. During an interview on 05/28/2025 at 11:50 a.m. S3 LPN (licensed practical nurse) reported Resident #3 had the pommel cushion in her wheelchair because she willf all asleep and slide out of it. Observation on 05/28/2025 at 11:50 a.m. revealed Resident #3 sitting up in wheelchair in with pommel cushion in place. During an interview on 05/28/025 at 10:00 a.m. S2 Director of Nursing reported the facility had not obtained consents or physician's orders for restraints to include Gerichairs and pommel cushions. During an interview on 05/28/2025 at 10:45 a.m. S1 Administrator acknowledged the facility had not implemented restraint risk assessments, obtained consents or physician's orders. S1 Administrator further acknowledged the facility did not have a policy for restraints.

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 F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to: 1) ensure residents had a physician's order for si...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to: 1) ensure residents had a physician's order for side rails, 2) obtain informed consent from the resident or resident's representative for side rail use, and/or 3) assess residents for the risk of entrapment from bed rails and 4) ensure a policy was developed for the use of bed rails prior to the installation of bed rails for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for bed rails. Findings: Review of the facility's policy and procedures failed to reveal a policy for bed rails. Resident #1 Review of Resident #1's medical records revealed an admit date of 01/16/2025 with the following diagnoses, including in part: infection and inflammatory reaction due to internal left knee prosthesis/subsequent encounter, chronic kidney disease stage 2 (mild), and chronic thromboembolic pulmonary hypertension. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 10 indicating moderately impaired cognition. Review of Resident #1's medical record failed to reveal a physician's order, a consent, care plan problem and approach and a risk assessment for assist rails x 2. Observation on 05/28/2025 at 8:30 a.m. revealed Resident #1 sitting up in bed with assist rails up x 2. Observation on 05/28/2025 at 3:00 p.m. revealed Resident #1 asleep in bed with assist rails up x 2. Resident #2 Review of Resident #2's medical records revealed an admit date of 11/29/2016 with the following diagnoses, including in part: depression unspecified, generalized anxiety disorder, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, overactive bladder and weakness. Review of Resident #2's medical record failed to reveal a physician's order, a consent, care plan problem and approach and a risk assessment for assist rails x 2. Observation on 05/27/2025 at 2:30 p.m. revealed Resident #2 lying in bed with assist rails up x 2. Observation on 05/28/2025 at 8:35 a.m. revealed Resident #2 lying flat in bed with assist rails up x 2. During an interview on 05/28/2025 at 1:10 p.m. S3 LPN (licensed practical nurse) reported Resident #2 had intermittent confusion and would forget to ask for help when going to the bathroom. S3 LPN further reported the resident has had a decline in her cognitive ability. Observation on 05/28/2025 at 3:00 p.m. revealed Resident #2 asleep in bed with assist rails up x 2. Resident #3 Review of Resident #3's medical records revealed an admit date of 01/13/2021 with the following diagnoses, including in part: unspecified dementia/unspecified severity without behavioral disturbance/psychotic disturbance/mood disturbance and anxiety, difficulty in walking, muscle weakness (generalized), history of falling and insomnia unspecified. Review of Resident #3's MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition. Review of Resident #3's medical record failed to reveal a physician's order, a consent, care plan problem and approach and a risk assessment for assist rails x 2. Observation on 05/28/2025 at 8:45 a.m. revealed Resident #3 sitting up in bed asleep with assist rails up x 2. During an interview on 05/28/025 at 10:00 a.m. S2 DON (Director of Nursing) reported the facility had not obtained consents or physician's orders for assist rails. S2 DON further acknowledged residents were not care planned for assist rails. During an interview on 05/28/2025 at 10:45 a.m. S1 Administrator acknowledged the facility had not implemented assist rail risk assessments, obtained consents or physician's orders. S1 Administrator further acknowledged the facility did not have a policy for bed rails.

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure 1 (#1) out of 2 (#1, #2, #3) sampled residents with pressure ulcers received necessary treatment and services, consistent with pro...

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Based on record reviews and interviews, the facility failed to ensure 1 (#1) out of 2 (#1, #2, #3) sampled residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Findings: Review of Facility's Wound Care Documentation (reviewed 01/2025) revealed: .Wound documentation on all other existing and/or new wounds will be made once a week in the resident care notes. Review of Facility's Staging of Pressure Wounds (revised 03/2013 and reviewed 02/2025) revealed: Purpose: To manage impaired skin integrity as it relates to pressure ulcers. Policy: II. Status and condition of pressure ulcers should be assessed upon admission, if pressure ulcer noted, weekly assessment by treatment nurse. Location, stage, type of wound, width, length, depth, exudate, odor, presence of necrotic or granulation tissue, and condition of surrounding skin should be documented. VIII. Chart in patient's record, weekly. Review of Facility's Wound Care Procedure for Major Wounds (revised 03/13) revealed: Procedure: W. Document the treatment in the patient's chart with notation of status of wound, drainage, skin integrity, etc. weekly. Review of Resident #1's medical records revealed an admit date of 12/29/2008 with the following diagnoses, including in part: pressure ulcer of right hip stage 3, pressure ulcer of sacral region stage 2, disorder of the skin and subcutaneous tissue/unspecified, cerebral palsy/unspecified, contracture of muscle/unspecified and arthropathy. Review of Resident #1's Weekly Skin Only Evaluations failed to reveal skin assessments were completed on 02/04/2025 and 02/17/2025. Review of Resident #1's Weekly Wound Measurement/Picture List failed to reveal measurements for right hip and sacrum on 02/04/2025 and 02/17/2025. During an interview on 03/05/2025 at 2:45 p.m. S1 WCN (Wound Care Nurse) acknowledged she was unable to produce documentation of weekly skin evaluations and measurements for Resident #1 on 02/04/2025 and 02/17/2025. During an interview on 03/05/2025 at 3:45 p.m. S2 RN (Registered Nurse) Charge verified and acknowledged documentation of weekly skin evaluations and measurements were not completed for Resident #1 on 02/04/2025 and 02/27/2025 and should have been.

Dec 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's current wishes for 1 (#2) of 3 (#1, #...

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Based on record review and interview, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's current wishes for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for advance directives. Findings: Review of the facility's policy titled, Advance Medical Directives with a review date of 01/2024 read in part: Section II. General: 3) Documentation that addresses advance directives must be placed in the patient's medical record; 6) The physician must inform the patient . and seek agreement on a mutually acceptable plan of care. Section III. A.) At the time of admission via the admitting department or the emergency department, the patient and/or significant other will be: 2) Asked by the hospital personnel if he/she has an AMD (Advanced Medical Directive) . this response will be documented in the medical record . Review of Resident #2's medical record revealed an admission date of 10/21/2024, with diagnoses that included in part . Cerebral Infarction, Urinary Tract Infection, Dysphagia, Aphasia, Essential (Primary) Hypertension, Type II Diabetes Mellitus Without Complications, Metabolic Encephalopathy, and Hyperlipidemia. Review of Resident #2's physician's orders revealed an order with a created/confirmed date of 11/11/2024 that read DNR (Do Not Resuscitate). Review of Resident #2's medical record revealed a form titled, Consent Form Resuscitative Orders. In Section A, the DNR option was initialed by Resident #2. In Section B, Resident #2 signed and dated the form on 10/22/2024 at 9:30 a.m. The form was also signed and dated by the physician on 10/22/2024 at 1:13 p.m. Section A stated in part . it is the policy of the facility to honor the desires of any patient with respect to resuscitative status. It is our policy to honor the desire made by the patient or surrogate decision maker on the patient's behalf and that such expressed desire, should being part of the patient's record. Review of Resident #2's care plan revealed the resident was care planned for Full code status, with a focus initiated and revision date of 10/23/2024. The focus read in part . advanced directive: Full code; a goal of advanced directive will be adhered to by all staff; interventions/tasks included advanced directive: Full code. On 12/02/2024 at 3:35 p.m., a record review and interview was conducted with S6LPN. S6LPN revealed in part . regarding resident code status . she would look at the dashboard on PCC (Point Click Care) to confirm the resident's code status . she would also check the hard chart for the orange DNR sticker, and hard copy of the signed document stating DNR status. S6LPN displayed step-by-step Resident #2's dashboard on PCC, and revealed a DNR status. S6LPN then retrieved Resident #2's hard chart and pointed out the orange DNR sticker. S6LPN found in the hard chart the DNR signed consent which stated DNR status. S6LPN then displayed and confirmed the current physician's order was DNR status for Resident #2. On 12/03/2024 at 9:46 a.m., a record review and interview was conducted with S7MDS Coordinator. S7MDS Coordinator confirmed . the MDS department is responsible for developing and updating all the resident care plans. S7MDS Coordinator confirmed the most up-to-date care plan for Resident #2 would be found in PCC. S7MDS Coordinator confirmed and displayed on her computer monitor that Resident #2's current care plan read Full code status. S7MDS Coordinator reviewed and displayed Resident #2's current physician orders and stated, Oh, he is suppose to be a DNR according to his doctor's orders. S7MDS Coordinator confirmed the current physician orders were valid and stated there were no other code status orders and this DNR order was implemented on 11/11/2024. S7MDS Coordinator confirmed that Resident #2's care plan should have been updated to DNR status when the new order was received and it was not.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's change in condition was immediately reported fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's change in condition was immediately reported for 1 (#1) of 3 (#1, #2, & #3) sampled residents, as evidenced by S4CNA and S5CNA failing to timely notify the nurse when Resident #1's leg made an audible popping sound while being repositioned by staff. Findings: On 12/03/2024, a review of the facility's policy titled Accidents and Incidents last reviewed on 01/2024 revealed in part .Any employee witnessing an accident or incident involving a resident, employee, or visitor, must report such occurrence to the charge nurse as soon as possible regardless of how minor it may be, to include the following: a. Any resident fall, accident or injury . e. Any other unusual or unexpected event involving a resident. Review of Resident #1's medical record revealed an admit date of 03/10/2017 with diagnoses that included: Displaced Spiral Fracture of Shaft of Left Femur, Atrial Fibrillation, Unspecified Dementia, and Osteoporosis. Review of Resident #1's Quarterly MDS with an ARD of 09/04/2024 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required substantial/maximal assistance with eating, toileting hygiene, and lying to sitting on side of bed; supervision or touching assistance with rolling left and right and sitting to lying, and partial/moderate assistance with sit to stand and chair/bed to chair transfer. Review of Resident #1's care plan initiated 08/12/2024 revealed Resident #1 was care planned for osteoporosis. Interventions included: Provide for safety. Assist x 2 with Hoyer lift for all transfers. Administer medication as ordered. Monitor for side effects. Review of Resident #1's nurses' notes revealed the following: 11/19/2024 at 9:45 a.m. Resident sitting up in wheelchair in dining room, complain of pain to left leg, Acetaminophen 650mg given. S4CNA report at this time while transferring resident from bed to wheelchair that she heard a bone pop but Resident did not yell out or complain of pain. Resident was adjusted in wheelchair and continue to complain of pain, to left leg, leg examined, no redness, warmth, or swelling noted, M.D. notified, Daughter notified, S8Charge Nurse notified, order received to send to ER. By S6LPN. Review of Resident #1's left hip x-ray dated 11/19/2024 at 12:21 p.m. revealed findings of There is a spiral fracture through the proximal diaphysis of the left femur. There is mild overlap and angulation and one half shaft width displacement across the fracture site. In an interview on 12/02/2024 at 2:28 p.m., S6LPN explained on 11/19/2024, Resident #1 was sitting at the dining table and she went over to give the resident her medication. S6LPN stated Resident #1 said I'm Hurting and I think it's my leg. S6LPN stated she gave her Tylenol with her routine medication and Resident #1 said she was hurting again and thought it was her left leg. S6LPN stated she and two aides repositioned Resident #1 and the resident said it felt a little better. S6LPN stated a few minutes later Resident #1 said I think it's my hip so she took her Posey [NAME] off and Resident #1 touched her hip area. S6LPN stated she then notified the doctor who said she could get an x-ray. S6LPN stated she notified the charge nurse, S8Charge Nurse, and she and S8Charge Nurse looked at the resident. S6LPN stated they couldn't see any redness or swelling but S8 Charge Nurse decided it would be better to send Resident #1 to the Emergency Room. S6LPN stated the CNAs had not reported anything to her prior to Resident #1 complaining of pain at the dining table. S6LPN stated S4CNA was sitting at the nurses' station near the dining table and overheard Resident #1 complaining of pain. S6LPN stated at that time, S4CNA told her when they were transferring Resident #1 earlier, they heard a pop. S6LPN stated S4CNA told her Resident #1 didn't complain of any pain at that time so they brought her out to the dining table. In an interview on 12/03/2024 at 8:20 a.m., S4CNA stated on 11/19/2024, about 8:30 a.m. or 9:00 a.m., she and S5CNA went into Resident #1's room to get her up. S4CNA said Resident #1 was lying in bed on her lift pad on her left side with her knees bent some. S4CNA stated she and S5CNA turned her from her left side to her back to prepare to get her up with the lift. S4CNA stated when she turned her to her back, she heard a pop, like a knuckle pop. S4CNA stated she asked S5CNA if she heard the pop and she said she did. S4CNA stated Resident #1 did not react and did not holler. S4CNA stated they waited a few seconds and then dressed her and put her in the wheelchair. S4CNA stated they pushed Resident #1 in her wheelchair to the dining table. S4CNA stated about 30 minutes later while sitting at the table she heard Resident #1 say her legs hurt. S4CNA stated she and S6LPN pressed on both legs and they could tell her left side was hurting. S4CNA stated That is when I told S6LPN that we had heard a pop when we turned her over this morning. S4CNA stated she didn't report it earlier because she didn't think anything of it, because it was just a pop and she never hollered out. In a telephone interview on 12/03/2024 at 12:06 p.m., S5CNA stated she and S4CNA went into Resident #1's room to get her up. S5CNA stated while they were rolling her from her side to her back, they heard a pop. S5CNA stated they stopped and waited for a minute after rolling her and hearing the pop. S5CNA stated Resident #1 did not cry, yell, or have any kind of reaction so they put her in the wheelchair and took her to the dining room to the table for breakfast. S5CNA confirmed she and S4CNA did not report to the nurse that they had heard a pop until Resident #1 complained of pain, about 30 minutes later. S5CNA confirmed she should have reported the pop to the nurse as soon as it happened, Just in case. In an interview on 12/03/2024 at 10:21 a.m., S1 Administrator confirmed S4CNA and S5CNA should have reported to the nurse immediately after hearing the pop and should not have waited.

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 use a mechanical lift, as determined necessary by the resident's person centered plan of care, during a transfer from bed to wheelchair for...

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Based on record review and interview, the facility failed to use a mechanical lift, as determined necessary by the resident's person centered plan of care, during a transfer from bed to wheelchair for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: On 12/03/2024, a review of the facility's policy titled Proper Transferring of Non-Weight Bearing Residents last reviewed on 01/2024 revealed in part . In order to properly transfer any non-weight bearing resident (example: from bed to chair, chair to bed, or to whirlpool, etc.) a lift is to be utilized. As a matter of precaution, two people are required in order to safely move the resident. Review of Resident #1's medical record revealed an admit date of 03/10/2017 with diagnoses that include Displaced Spiral Fracture of Shaft of Left Femur, Atrial Fibrillation, Unspecified Dementia, and Osteoporosis. Review of Resident #1's Quarterly MDS with an ARD of 09/04/2024 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required substantial/maximal assistance with eating, toileting hygiene, and lying to sitting on side of bed; supervision or touching assistance with rolling left and right and sitting to lying, and partial/moderate assistance with sit to stand and chair/bed to chair transfer. Review of Resident #1's care plan initiated 08/12/2024 revealed Resident #1 was care planned for Osteoporosis. Interventions included: Provide for safety. Assist x 2 with Hoyer lift for all transfers. Administer medication as ordered. Monitor for side effects. In an interview on 12/03/2024 at 8:20 a.m., S4CNA stated about 8:30 a.m. or 9:00 a.m. on 11/19/2024, she and S5CNA went into Resident #1's room to get her up. S4CNA stated Resident #1 was lying on a blue, lift pad in her bed on her left side with her knees bent. S4CNA stated she and S5CNA turned her to her back and heard a pop. S4CNA stated they waited a few seconds before transferring Resident #1 to her wheelchair. S4CNA stated she and S5CNA picked Resident #1 up by holding the blue lift pad and transferred her to her wheelchair. S4CNA stated they used the lift pad to transfer Resident #1 because it was way quicker and finding a lift is a problem. S4CNA stated the facility has 3 mechanical lifts in the facility but stated you can't find one often because people hide them or the battery is dead. S4CNA confirmed Resident #1 should have been transferred using the mechanical lift. In a telephone interview on 12/03/2024 at 12:06 p.m., S5CNA stated on 11/19/2024 she and S4CNA went into Resident #1's room to get her up. S5CNA stated while they were rolling her from her side to her back, they heard a pop. S5CNA stated they stopped and waited for a minute after rolling her and hearing the pop. S5CNA stated they then put her in the wheelchair. S5CNA confirmed she and S4CNA transferred Resident #1 to her wheelchair by holding the lift pad and moving her in it. S5CNA stated they did not use the mechanical lift to transfer Resident #1 because they could not find one. S5CNA confirmed Resident #1 should have been transferred using the mechanical lift with two person assistance. In an interview on 12/03/2024 at 9:52 a.m., S1Administrator stated she investigated the incident that occurred on 11/19/2024 and interviewed S4CNA, S5CNA, and the nurse. S1Administrator stated the two CNAs did not use the mechanical lift to transfer Resident #1. S1 Administrator stated she watched the facility's camera footage and knew there was no lift in the room at that time. S1 Administrator confirmed both S4CNA and S5CNA stated they used the lift pad to transfer Resident #1 from her bed to her wheelchair that morning. S1Administrator confirmed Resident #1 should have been transferred using the mechanical lift with two person assistance, as care planned.

Sept 2024 10 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or his/her responsible party prior to the discontinuation of Medicare Part A ...

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Based on record review and interview, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or his/her responsible party prior to the discontinuation of Medicare Part A services for 3 (#33, #44, & #197) of 3 residents reviewed for Beneficiary Notification. Findings: Review of the SNF Beneficiary Review forms completed by the facility for Residents #33, #44, and #197 revealed a NOMNC, Form CMS-10123 was not issued prior to their discharge from Medicare Part A services. In an interview at 9:34 a.m. on 09/24/2024, S4 SW (Social Worker) stated she did not issue a NOMNC/Form CMS-10123 to Residents #33, #44, and #197 prior to their discharge from Part A services. S4 SW confirmed the three residents all had benefit days remaining. S4 SW stated she was not aware the NOMNC/Form CMS-10123 needed to be issued to them.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview the facility failed to develop the resident's comprehensive plan of care for 1 (#37) of 44 sampled residents by failing to develop a Hospice Care Pla...

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Based on observation, record review, and interview the facility failed to develop the resident's comprehensive plan of care for 1 (#37) of 44 sampled residents by failing to develop a Hospice Care Plan for Resident #37. Findings: Review of Resident #37's clinical record revealed an admit date of 09/13/2016, with a Hospice admit date of: 07/22/2024. Resident #37's diagnoses included malignant neoplasm of unspecified lower limb, end stage renal disease, heart disease; cerebral infarction; dependence on renal dialysis; age-related physical debility; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of Resident #37's Significant Change MDS with an ARD of 07/31/2024, revealed a BIMS score that was not assessed because the resident was rarely or never understood. Resident #37 had impairment on both sides for lower and upper extremities; used a wheelchair. Resident #37 was dependent for eating, oral hygiene, toileting hygiene; showering/ bathing, upper body and lower body dressing and personal hygiene. Review of Resident #37's physician's order, read in part Admit to hospice, diagnosis cancer, prognosis terminal DNR. Consult Hospice. Notify hospice 24/7 with any concerns. Review of Resident #37's Care Plan revealed that Resident #37 was not care planned for Hospice. Interview with S17 LPN on 09/24/2024 at 11:58 a.m. revealed that Resident #37 received hospice care. Hospice nurse came once a week on Thursdays and Aides came twice a week on Tuesday and Thursday. S17 LPN provided the office phone number and stated that she can contact the hospice nurse at any time with any changes to Resident #37 during office hours or to the on call nurse outside of business hours. Interview with S9 MDS and S19 MDS on 09/25/2024 at 2:59 p.m. revealed that Resident #37 was not Care Planned for Hospice and should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise the care plan to include new fall interventions after a resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise the care plan to include new fall interventions after a resident fell attempting to get in bed for 1 (#54) of 3 (#13, #54 and #59) resident's care plans reviewed. Findings: Review of Resident #54's medical record revealed he was admitted to the facility on [DATE]. Resident #54 had diagnoses that included in part . Dizziness and Giddiness, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Kidney Disease, Anemia in Chronic Kidney Disease, and Pain. Review of Resident #54's Quarterly MDS with ARD of 08/21/2024, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. Review of the MDS revealed Resident #54 used a wheelchair for mobility. Review of Resident #54's current comprehensive care plan with a target date of 11/13/2024, revealed Resident #54 is at moderate risk for falls related to gait and/or balance problems. The care plan included in part .Last fall 1/31/24 without injury**Date initiated: 08/15/2024 .Revision on: 08/20/2024 . Interventions . Anticipate and meet the resident's needs. Date initiated: 08/15/2024 . Educate the resident/family/caregiver about safety reminders and what to do if a fall occurs. Date initiated: 08/15/2024 Review of Resident #54's progress notes revealed that on 09/16/2024 at 12:45 p.m., Resident #54 was found sitting on the floor of his room. Resident #54 stated he was trying to get in the bed without assistance and lost his balance. Interview on 09/23/2024 at 09:48 a.m. with Resident #54 revealed that he fell a couple of weeks ago. He reported that he tried to go to bed and fell. He indicated that he should have waited for staff, but felt like he could have done it with no help. Interview on 09/24/24 at 9:30 a.m. with S9 MDS revealed she was responsible for Resident #54's care plan. S9 MDS was asked about Resident #54's fall that occurred on 09/16/2024 as indicated in the progress notes. S9 MDS indicated she was not aware that Resident #54 fell on [DATE]. S9 MDS indicated it should have been reported in the morning meeting on 09/17/2024, but was not. S9 MDS stated the Care Plan should have been updated with new interventions to assist in preventing further falls.

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 review and interview the facility failed to ensure services were provided to meet professional standards of practice for 1 (#28) of 44 sampled residents. The facility failed to ensure ...

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Based on record review and interview the facility failed to ensure services were provided to meet professional standards of practice for 1 (#28) of 44 sampled residents. The facility failed to ensure physician's orders for Resident #28 were followed. Findings: Review of resident #28's medical record revealed an admit date of 12/20/2022 with diagnoses that included in part .Osteoporosis, Unspecified Fracture of Right Wrist and Hand, Anemia, and Pain. Review of Resident #28's Quarterly MDS with an ARD of 06/26/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of Resident #28's Progress note dated 09/20/2024 by S16 MD revealed in part . Assessment Plan: 1. Back pain/Osteoarthritis: Patient wants to try to increase Duloxetine (Cymbalta) to help with pains. Review of Resident #28's medical record revealed a telephone order dated 09/20/2024 which read: Change Duloxetine to 60mg daily. The order was signed by S16 MD and S15 LPN on 09/20/2024. Review of Resident #28's MAR for September 2024 revealed the resident was not receiving Duloxetine 60 mg by mouth daily, as ordered on 09/20/2024. Further review revealed the resident had not received Duloxetine 30 mg by mouth daily from 09/16/2024 through 09/24/2024. Review of Resident #28's medical record revealed the resident was care planned for: The resident uses antidepressant medication (Cymbalta) related to pain with interventions that included: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date and administer antidepressant medications as ordered by physician. In an interview on 09/24/2024 at 2:20 p.m., S3 ADON confirmed S16 MD wrote the telephone order on 09/20/2024 to change Duloxetine to 60 mg by mouth daily. S3 ADON reviewed Resident #28's medical record and confirmed the order was not entered and the resident did not receive Duloxetine 60 mg by mouth daily but should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

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 that a resident maintained acceptable parameters of nutritio...

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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 that a resident maintained acceptable parameters of nutritional status for 2 (#11, #195) of 5 (#2, #11, #37, #77, & #195) residents reviewed for nutrition by failing to follow or implement registered dietitian's recommendations. Findings: Resident #11 Review of Resident #11's medical record revealed an admit date of 08/19/2022 with diagnoses that included .Chronic kidney disease, Stage 3, COPD, Chronic Non-pressure Ulcers of Lower Legs and Left Foot and Heart Failure. Review of Resident #11's Quarterly MDS with an ARD of 09/02/2024 revealed a BIMS score of 6, which indicated severe cognitive impairment. Resident #11 required set up assistance with eating. Review of Resident #11's medical record revealed the resident was care planned for a heart healthy, regular texture diet. Interventions included: Refer to Dietician as needed, provide diet as ordered, and monitor and record weight per orders and/or policy. Review of Resident #11's progress notes revealed the following: 08/29/2024 at 6:06 p.m.: Nutrition/Dietary Note by S6 RD: Significant change. Resident with recent hospitalization and under care for Metastatic Prostate Cancer. Continues on heart healthy, regular texture diet with usual good appetite. Present weight 219.3 pounds-This is a 23 pound weight loss over last 6 weeks .Encourage supplements for improved nutrition . 09/06/2024 at 12:36 p.m. note by S3 ADON: Resident weights reviewed. Consulted ST for screening due to weight loss along with Dietician .Will continue with encourage resident to eat and accept supplements as tolerated 09/13/2024 at 12:13 p.m.: Weight Change Note by S3 ADON: Resident weight reviewed. He did eat better this week. However, appetite is still down. Will continue to offer supplements . Review of Resident #11's weights revealed the following: 09/20/2024 09:49 213.4 Lbs 09/13/2024 11:37 217.7 Lbs 08/28/2024 14:20 219.3 Lbs 07/11/2024 16:15 242.9 Lbs 05/22/2024 08:00 241.7 Lbs 04/04/2024 07:00 243.2 Lbs 03/12/2024 08:00 246.5 Lbs Review of Resident #11's current physician's orders revealed no orders for dietary supplements. Review of Resident #11's MARs revealed no documentation of providing supplements to the resident. In an interview on 09/24/2024 at 2:25 p.m., S3 ADON confirmed Resident #11 had significant weight loss, and after reviewing the medical record confirmed an order was not entered for Resident #11 to receive dietary supplements as recommended by the RD, but should have been. Resident #195 Review of Resident #195's medical record revealed an admit date of 09/14/2024 with diagnoses that included .Metabolic encephalopathy, Vitamin Deficiency, Type 2 DM, Left Heel DTI, and Pneumonia. Review of Resident #195's medical record revealed she was care planned for: Diet: Low concentrated sweets, regular texture, and thin liquids. Interventions included: Resident will eat at least 50% of meals by review date. Assess resident's food preferences. Monitor and record weight per orders and/or policy. Provide diet as ordered. Refer to dietician as needed. Review of Resident #195's progress notes revealed the following entries: 09/16/2024 at 1:29 p.m.: [AGE] year old female Height 66, weight 125 pounds, IBW: 130 pounds plus or minus 10%, BMI: 20.2 .Feeds self after set up. Resident meets criteria for mild malnutrition with BMI less than 22 and age greater than 65 years .Recommend supplements of choice between meals for increased nutrition .by S6 RD. 09/17/2024 at 1:50 p.m.: Conferred with wound care nurse. Resident with DTI on heel. Receiving care. Orders do not indicate wound care supplements therefore recommend Vitamin C, Zinc for wound healing Supplements previously recommended due to low BMI by S6 RD. Review of Resident #195's current physician's orders revealed no orders for Vitamin C, Zinc, or dietary supplements. Review of Resident #195's MAR revealed no documentation of the resident receiving Vitamin C, Zinc, or dietary supplements. In an interview on 09/25/2024 at 8:36 a.m., Resident #195 stated she had not received any supplements, shakes, Glucerna, etc. while at this facility. Resident #195 stated she had taken Glucerna prior to coming to the facility and liked them. In an interview on 09/25/2024 at 10:24 a.m., S3 ADON reviewed Resident #195's medical record and confirmed orders were not entered for dietary supplements, Vitamin C, or Zinc and should have been. S3 ADON stated the RD would have given the orders to the floor nurse to carry out. S3 ADON stated the floor nurse could have faxed the recommendations to the physician's office or given them to the doctor when he came to the facility, stating this doctor comes every Friday.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills necessary to care for residents' needs, as identified th...

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Based on observation, record review, and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills necessary to care for residents' needs, as identified through observation of delayed call light response for 1 (#67) of 44 sampled residents. The facility failed to ensure timely call light response for Resident #67. Findings: Review of Resident #67's clinical record revealed an admit date of 06/20/2024, with diagnoses which included weakness, Dementia in other diseases; Benign Prostatic Hyperplasia without lower urinary tract symptoms; urinary tract infection; and anemia. Review of Resident #67's Significant Change MDS with an ARD date of 07/22/2024, revealed a BIMS score of 10; moderately impaired. Resident #67 uses a walker and wheelchair. Resident #67 required setup or clean up assistance with eating; Supervision or touching assistance with oral hygiene; substantial/maximal assist with toileting hygiene, shower/bathing; and partial moderate assist with personal hygiene. Resident #67 required Partial/Moderate assist with chair/bed to chair transfer; toilet transfer; sit to stand; lying to sitting; walk 10 feet; and walk 50 feet with two turns. Resident # 67 had frequent Urinary and Bowel Incontinence. Review of Resident #67's Care Plan revealed in part The resident has a History of falling. Interventions included: Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician and Assist with one staff member for all ambulation. The resident is a high fall risk r/t Confusion, Gait/balance problems: Fall without injury on 07/01/2024; 08/05/2024; 08/10/2024; 08/19/2024; 09/03/2024; 09/06/2024 and 09/22/2024. Interventions included: Anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation of Resident #67 on 09/24/2024 at 09:03 a.m., revealed Resident #67 in bed, O2 via nasal cannula and fall mat at left side of the bed. Resident #67 used call light to call for assistance to get up and use the restroom at 09:08 a.m. This surveyor waited in room. At 09:14 a.m., S17 LPN came in and notified Resident #67 that someone would be in to assist him soon. This surveyor left Resident #67's room after hearing S17 LPN notify staff that Resident #67 needed assistance and returned at 09:35 a.m. to see if anyone had assisted Resident #67 to the restroom. Resident #67 stated that they had not. Notified S17 LPN, who then went in to another resident's room to speak with S18 CNA who then exited the other resident's room and entered Resident #67's room at 09:38 a.m. to assist him. Resident #67 waited approximately 35 minutes to be assisted to restroom. S17 LPN stated that S18 CNA had forgotten and went in to the other resident's room to provide toileting care. Interview with S17 LPN on 09/24/2024 at 11:53 a.m. revealed that Resident #67 had some incontinence. S17 LPN stated that when Resident #67 had to go; he needed to go. Interview with S2 DON on 09/25/2024 at 2:51 p.m. revealed that the call light response time for residents' needs is within 15 minutes.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to honor and accommodate resident food allergies, intolerances, and preferences by failing to ensure 1 Resident (#2) was not prov...

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Based on observation, interview and record review, the facility failed to honor and accommodate resident food allergies, intolerances, and preferences by failing to ensure 1 Resident (#2) was not provided a supplement with milk containing products. This deficient practice had the potential to affect the 94 Residents that resided at the facility. Findings: Record Review of Resident #2's electronic medical record revealed an admit date of 04/03/2024. Resident #2 had diagnoses that included in part . Cough, Unspecified Bacterial Pneumonia, Dysphagia, Contracture of Muscle-Unspecified Site, and Cerebral Palsy. Record Review of Resident #2's Quarterly MDS with ARD of 06/19/2024 revealed Resident had impaired memory and severely impaired cognitive skills. Resident #2 was dependent on staff for all ADL's. Record Review of Resident #2's Comprehensive Person Centered Care Plan with initiated date of 07/09/2024 revealed in part . Food intolerance. Lactose/Dairy products with intervention of: provide nondairy alternatives. Record Review of Resident #2's Current Physician Orders revealed in part . 07/01/2024. Give Ensure or Breeze three times daily in between meals. Record Review of Resident #2's Allergy List revealed she was allergic to Milk containing products (Dairy) and was Lactose Intolerant. Record Review of Resident #2's Departmental Progress Notes revealed in part . 09/16/2024 at 2:13 p.m. S6 RD documented: Weight loss of 13 pounds over the last quarter. Continue plan of care. Encourage oral intake of meals and supplements. Milk three times a day. Monitor weight for further changes. Observation on 09/25/2024 at 10:49 a.m. revealed 2 bottles of Ensure- Enlive on Resident #2's bedside table. 1 bottle was opened and labeled 09/25/2024 7:34 a.m. Review of the product label ingredients list revealed the product contained Milk Protein. The bottle read Contains milk and soy ingredients. Interview on 09/25/2024 at 10:50 a.m. with S13 CNA revealed Resident #2 received Ensure three times a day. Interview on 09/25/2024 at 10:57 a.m. with S14 LPN confirmed Ensure supplements were given to Resident #2 three times a day due to weight loss. Interview on 09/25/2024 at 11:13 a.m. with S3 ADON confirmed Resident #2 received Ensure three times daily. S3 ADON stated S6 RD assessed Resident #2 quarterly and as needed and had ordered the Ensure. S3 ADON stated she would assume S6 RD was aware of Resident #2's milk allergy and lactose intolerance. S3 ADON confirmed residents should not be administered anything they had an allergy to. Telephone Interview on 09/25/2024 at 11:58 a.m. with S6 RD confirmed she had recommended Ensure three times daily for Resident #2. S6 RD revealed if a resident had a lactose intolerance, she would still recommend Ensure, as Ensure did not contain lactose. S6 RD revealed if a resident had a milk allergy she would absolutely avoid Ensure, and stated I'd have to do further evaluation to determine which milk protein was the allergy. S6 RD stated it must have slipped by me that she had a milk allergy, and I can only assume I just saw she had a lactose intolerance.

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, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure refrigerated...

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Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure refrigerated food items were covered, labeled, and stored with an open date after opening. This deficient practice had the potential to affect the 92 Residents that received meals served in the kitchen. Findings: Review of the facility policy titled Food Storage dated 01/2024 read in part . Food is stored immediately after receipt and maintained in a manner that prevents damage, spoilage, infestation, and bacterial contamination. Observation of kitchen on 09/23/2024 at 8:45 a.m. accompanied by S7 Kitchen Lead revealed there was an open block of cheese on the refrigerator shelf that was uncovered, open to air, and undated, and a cup of oranges that was uncovered, open to air, and undated. Interview on 09/24/2024 at the time of the observations accompanied by S7 Kitchen Lead, confirmed the above findings. S7 Kitchen Lead confirmed all opened food items should be covered and dated, but had not been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to keep the residents' equipment in good repair. The facility failed to repair wheelchair arm rest cushions for 5 (#19, #40, #47,...

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Based on observation, interview, and record review the facility failed to keep the residents' equipment in good repair. The facility failed to repair wheelchair arm rest cushions for 5 (#19, #40, #47, #49, #67) out of 44 total sampled residents. Findings: Observation of Resident #19 sitting in wheelchair on 09/23/2024 at 10:15 a.m. revealed both wheelchair arm cushions were peeling and in disrepair. Observation of Resident #40 on 09/23/2024 at 11:36 a.m. revealed the resident's wheelchair arm cushions in disrepair. Resident # 40's son stated the wheelchair had been like that for about 6-8 months. Observation of Resident #49's wheelchair on 09/23/2024 at 11:38 a.m. revealed Resident #49's arm chair cushions in disrepair. Observation of Resident #47 on 09/23/2024 at 12:06 p.m. sitting in wheelchair revealed Resident #47's arm cushions of wheelchair in disrepair. Observation of Resident #67's wheelchair on 09/23/2024 at 12:15 p.m. revealed a crack in one arm of Resident # 47's wheelchair cushion. Environmental rounds observed with S2 DON on 09/25/2024 at 2:45 p.m. revealed Residents #40, #47, #49, #67 and #19s' wheelchairs were observed with arm padding in disrepair. Surfaces were noted to be cracked and not intact. Interview with S2 DON at the time of observation confirmed the above residents' equipment were in disrepair and in need of replacement.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the ...

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Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 10 ( #10, #25, #34, #41, #51, #52, #78, #85, #92, and #295) out of 13 (#2, #10, #25, #34, #35, #41, #50, #51, #52, #78, #85, #92, and #295) residents who received pureed meals served by the facility kitchen. Findings: Review of the facility's approved Patient Menu revealed the facility was on week 4, cycle day 23. Lunch menu consisted of: Chicken Spaghetti, [NAME] Beans, Pineapple Tidbits, Honey Wheat Roll, and Unsweetened Iced Tea. Serving size for pureed meal read as follows: Pureed Chicken Spaghetti- ¾ cup (6oz) Ladle/Spoodle. Pureed [NAME] Beans- ½ cup (4oz) Ladle/Spoodle. Pureed Peaches- ½ cup (4oz) Ladle/Spoodle. Observation on 09/23/2024 at 10:45 a.m. of the lunch meal service revealed S7 Kitchen Lead obtained 4oz Ladles/Scoops to serve meal food items. Interview at time of observation with S7 Kitchen Lead revealed the kitchen used gray 4oz scoop for serving all meats and vegetables. S7 Kitchen Lead stated he referred to a document to determine portion size, and that the kitchen did not have a menu with serving sizes to refer to when serving. Review of the posted document titled Standard Scoop Measurements read in part . The number on the scoop equals the number of servings per quart. The document was not specific to the menu/meal served. Review of the document revealed the gray scoop was 4oz and equaled a level measurement of ½ cup. Observation on 09/23/2024 at 10:50 a.m. revealed S7 Kitchen Lead prepared all Hall X resident's lunch trays. Observation revealed S7 Kitchen Lead prepared the Hall X pureed diets using a gray 4oz scoop. Observation revealed S7 Kitchen Lead did not ensure the scoop was completely full and level when he served the pureed chicken spaghetti and pureed green beans for all Hall X Residents. Observation revealed the scoops were approximately ½ full when S7 Kitchen Lead served the pureed food items. Observation revealed S7 Kitchen Lead served Resident # 34's lunch tray, and placed an incomplete 4oz scoop serving of pureed chicken spaghetti and pureed green beans onto the plate. Review of Resident #34's meal card on tray revealed the resident was to receive double portions. Observation revealed all Hall X resident's trays were served, placed on cart, and sent to Hall X for meal service. Interview on 09/23/2024 at 11:05 a.m. with S10 Kitchen Assistant Manager at time of observation confirmed S7 Kitchen Lead did not serve the proper serving size for pureed diets. S10 Kitchen Assistant Manager confirmed staff should ensure scoops/ladles used for serving should be completely full and level when serving food items to ensure residents receive the entire portion size. S10 Kitchen Assistant Manager confirmed the kitchen did not have menu with serving size posted for staff to refer to for portion size, but should have. Observation on 09/23/2024 at 11:07 a.m. of Resident # 34's prepared lunch tray with S8 Patient Service Supervisor confirmed the resident had not been served double portions as ordered, but should have. Observation on 09/23/2024 at 11:25 a.m. of Hall X dining area revealed Resident # 10 had received a pureed meal and was assisted by S11 CNA. Observation of Resident #10's tray revealed the serving size for the pureed chicken spaghetti and pureed green beans appeared less than ½ cup. S11 CNA stated Residents who received pureed diets often do not have an adequate amount of food on their tray. Observation on 09/23/2024 at 11:27 a.m. of Hall X dining area revealed Resident # 85 had received a pureed meal and was assisted by S12 CNA. Observation of Resident #85's tray revealed the serving size for the pureed chicken spaghetti and pureed green beans appeared less than ½ cup. S12 CNA stated she agreed with S11 CNA, and stated Residents who received pureed diets sometimes do not have enough food on their tray. Interview on 09/24/2024 at 9:07 a.m. with S5 Dietary Manager revealed staff were to utilize serving sizes on the approved menus for each meal. Review of the lunch menu for 09/23/2024 with S5 Dietary Manager revealed residents with pureed diets should have received 3/4cup (6oz) of Chicken Spaghetti, and ½ cup (4oz) of green beans. Interview on 09/24/2024 at 9:20 a.m. with S7 Kitchen Lead confirmed he did not serve the correct serving size of pureed chicken spaghetti and pureed green beans for 09/23/2024 lunch meal service. S7 Kitchen Lead confirmed he used a gray 4oz scoop when he served pureed chicken spaghetti and pureed green beans, and he did not ensure the scoop was completely full when serving. S7 Kitchen Lead revealed at times the kitchen did not prepare and send enough of the pureed food items, so he had to serve a lesser amount to ensure every resident received a meal.

Mar 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

ADL Care (Tag F0677)

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 a resident who was unable to carry out ADLs received the nec...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good oral hygiene for 1 (#1) of 3 (#1, #2, & #3) sampled residents reviewed for ADLs. Findings: Review of Resident #1's medical record revealed an admit date of 12/29/2008 with diagnoses that included in part .Cerebral Palsy, Unspecified Bacterial Pneumonia, Dysphagia, Contracture of Muscle, Altered Mental Status, Convulsions, and Pain. Review of Resident #1's Quarterly MDS with an ARD of 01/31/2024 revealed a BIMS was not conducted because the resident was rarely or never understood. Review of the MDS revealed Resident #1 required extensive assistance by two persons with bed mobility and transferring and was totally dependent on one person with eating and toilet use. Review of the MDS revealed Resident #1 was dependent with oral hygiene, the helper does all of the effort, and the resident does none of the effort to complete the activity. Review of Resident #1's physician's orders revealed the following: 04/27/2018: Monitor oral care with flossing using soft picks for in between teeth three times daily after meals. 05/24/2022: Assess gums three times per day after oral care performed. If bleeding or inflammation present. Apply Hydrogen peroxide 3% solution to affected area then massage with warm salt water. Review of Resident #1's care plan revealed she was care planned for grooming and personal hygiene and required total staff assistance. Interventions included oral hygiene daily and as needed, assess gums daily for bleeding or inflammation, if present apply hydrogen peroxide to affected area then massage with warm salt water, and floss teeth using soft picks for in between teeth after meals. Review of a progress note dated 01/09/2024 by Resident #1's dentist revealed the following: Findings: Plaque and calculus on teeth. Home care needs improvement. In an interview on 03/25/2024 at 2:55 p.m., S2 DON stated she and S1 Administrator had talked with Resident #1's Responsible Party who reported observing Resident #1's poor oral hygiene in the emergency room on [DATE]. S2 DON confirmed oral care was not done for Resident #1 on Sunday, 03/10/2024 and Resident #1 was sent out to the ER on the morning of 03/11/2024. S2 DON confirmed Resident #1 had orders in place for oral care three times per day after meals and said those orders had been put in place by Resident #1's dentist. S2 DON confirmed the oral care was not done as ordered on 03/10/2024 and should have been.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

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, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional and hydration status consistent with the resident's comprehensive assessment and plan of care, for 1 (#1) of 3 (#1, #2, & #3) sampled residents reviewed for hydration and nutrition. The facility failed to: 1. Ensure Resident #1 received nutritional supplements as ordered; 2. Ensure the RD's (Registered Dietician) dietary recommendation to increase Resident #1's calories and protein through a nutritional supplement was implemented; and 3. Ensure Resident #1's meal intake was documented for each meal, as care planned. Findings: Review of Resident #1's medical record revealed an admit date of 12/29/2008, with diagnoses that included in part .Cerebral Palsy, Unspecified Bacterial Pneumonia, Dysphagia, Contracture of muscle, Altered Mental Status, Convulsions, Dehydration, Weight Loss, and Pain. Review of Resident #1's Quarterly MDS with an ARD of 01/31/2024, revealed a BIMS score of 00, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required extensive assistance by two persons with bed mobility and transferring. Review of the MDS revealed Resident #1 was totally dependent on one person with eating and toilet use. Review of Resident #1's physician's orders revealed the following: 04/17/2019: Give Ensure or Breeze three times daily in between meals. 01/31/2023: Diet: Regular, pureed honey thickened liquids with 16 oz water with each meal. Review of the Quarterly RD assessment dated [DATE], and documented by S3 RD read in part . Resident continues on regular diet with pureed texture and honey thick liquids. Fed by staff. Ensure/Breeze supplement three times per day between meals. Oral intake 75-100% when recorded. Often missing amounts. Weight of 111.1# - a show of 11.2# weight loss over last quarter .BMI of 21.7 meeting criteria for moderate malnutrition. Full care resident .concern with weight loss. Supplements appropriate if resident accepts. Recommend supplements of Ensure Plus or Breeze with increased calories and protein. Will note to ADON and nursing staff. Review of Resident #1's current Comprehensive Plan of Care revealed Resident #1 was care planned for a problem of Nutrition - at risk for weight loss, and must be fed by staff. Interventions included total assist for feeding all meals and snacks, give Ensure/Breeze three times per day between meals; thicken all liquids to honey consistency; monitor amount of meal consumed/offer alternate if consumes less than 25%, and supplement if consumes less than 50%, give water with all meals (honey thick); RD to evaluate nutritional status at least quarterly, monitor and record weight, and assess resident's food preferences. A review of Resident #1's weights in the medical record revealed an 11 pound weight loss (9.24%) in the past 6 months, to include 5.35% weight loss in the past month from 02/23/2024 through 03/21/2024: 09/22/2023 - 119 pounds 12/19/2023 - 113.5 pounds 02/23/2024-114.1 pounds 03/21/2024 - 108 pounds Review of meal intake documentation by CNAs on Resident #1's Completed Care Tasks revealed Resident #1's meal intake was not monitored as care planned, for a total of 24 times for the month of 03/2024. Review of Resident #1's 03/2024 MAR revealed Resident #1 was scheduled to receive Ensure or Breeze three times daily in between meals at 10:00 a.m., 2:30 p.m., and 8:00 p.m. Review of the MAR revealed Resident #1 did not receive the 10:00 a.m. or 2:30 p.m. Ensure/Breeze supplements on 03/08/2024, 03/09/2024, and 03/10/24. These missed supplements were initialed as not given by S5 LPN, with a note that the supplements were refused by the resident. In a telephone interview on 03/25/2024 at 10:30 a.m., S5 LPN confirmed she was the nurse assigned to care for Resident #1 on the day shifts of 03/08/2024 - 03/10/2024. S5 LPN stated the Ensure/Breeze supplements were given by the CNAs. S5 LPN stated she documented the supplements on the MAR after asking the CNAs if Resident #1 had consumed them. S5 LPN stated she couldn't remember who (CNA) she worked with on those dates, or if Resident #1 consumed the supplements. In a telephone interview on 03/25/2024 at 10:55 a.m., S6 CNA stated she was assigned to Resident #1 on 03/08/2024 and 03/10/2024. S6 CNA stated it was up to the nurse to give the Breeze/Ensure supplements to Resident #1. S6 CNA stated every once in a while a nurse would ask her to give a resident a supplement and she would. S6 CNA stated she didn't give the Breeze/Ensure supplements to Resident #1 that weekend, and wasn't asked to. In an interview on 03/25/2024 at 10:40 a.m., S7 LPN confirmed she was Resident #1's nurse on today. S7 LPN stated she gives Resident #1 her supplements herself, because she has to sign on the MAR to verify that it was given. S7 LPN stated she does not allow the aides to give supplements. An observation on 03/25/2024 at 1:25 p.m., revealed S7 LPN showed this surveyor the supplement being given to Resident #1: Ensure clear, fat free, 8g protein, 240 calories, 22 vitamins and minerals, mixed berry flavor in an 8 oz container. S7 LPN was unaware of S3 RD's 01/28/2024 supplement recommendations. In an interview on 03/25/2024 at 2:00 p.m., S3 RD confirmed that she recommended Ensure Plus/Complete or Boost with increased calories and protein for Resident #1 on 01/28/2024. S3 RD stated the recommended supplements have more calories and protein. S3 RD stated she gives her recommendations to S9 ADON. S3 RD confirmed staff were not documenting meal intake, and it had been a chronic problem. In an interview on 03/25/2024 at 2:20 p.m., S9 ADON stated when S3 RD made a recommendation, she and the floor nurse received a copy of the recommendation. S9 ADON stated it was the floor nurses' responsibility to contact the physician, put the order in the system, and document it in the nurses' notes. S9 ADON stated she didn't know why the recommendation didn't get put in the system, and confirmed it was not documented in the nurses' notes. S9 ADON stated the floor nurse should have contacted the physician, and if the physician refused the order, it should have been documented in the nurses' notes. In an interview on 03/25/2024 at 2:55 p.m., S2 DON confirmed staff should document meal intake on all residents for all meals, snacks, and fluids. S2 DON acknowledged Resident #1 did not receive her supplements as ordered on 03/08/2024 - 03/10/2024. S2 DON stated she was unaware of S3 RD's supplement recommendations dated 01/28/2024, or that the supplements had not been implemented. S2 DON stated the supplements should have been implemented, and nurses, not the CNAs, were to give Resident #1 her ordered supplements three times daily.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to protect the resident's right to be free from verbal abuse by staff for 2 (#2, #4) of 4 (#1, #2, #3, & #4) residents reviewed for abuse. Fin...

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Based on record review and interview, the facility failed to protect the resident's right to be free from verbal abuse by staff for 2 (#2, #4) of 4 (#1, #2, #3, & #4) residents reviewed for abuse. Findings: Review of the facility's Abuse Reporting Protocol revealed in part . Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods, or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of the facility's policy titled Abuse Identification, Protection, and Reporting revealed in part . 5. b. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Resident #2 Review of Resident #2's medical record revealed an admit date of 05/06/2022 with diagnoses that included in part .Cerebral Infarction, Type 2 Diabetes Mellitus, Vascular Dementia, Alzheimer's Disease, and Hemiplegia. Review of Resident #2's Quarterly MDS with an ARD of 10/18/2023 revealed a BIMS score of 5; which indicated severe cognitive impairment. Review of the MDS revealed Resident #2 required partial to moderate assistance with chair to bed, or bed to chair transferring, and with standing from a sitting position. An interview was attempted with Resident #2 on 10/23/2023 at 2:40 p.m. however, Resident #2 stated she could not remember anything about the incident that occurred on 09/27/2023 with S4 CNA. In an interview on 10/24/2023 at 9:40 a.m., Resident #2's roommate, Resident #4, a cognitively intact resident, stated she heard S4 CNA come in to put Resident #2 to bed on 09/27/2023 at 9:00 p.m. Resident #4 stated the curtain was pulled between her bed and Resident #2's bed; however, she heard S4 CNA fussing and hollering at Resident #2 because she couldn't get up and stand from the wheelchair. Resident #4 stated S4 CNA told Resident #2 to stand up, and that she wasn't going to hurt her back. Resident #4 stated S4 CNA left the room and came back a few minutes later (not sure of time), and when Resident #2 still couldn't get out of the wheelchair, S4 CNA left her in the wheelchair. Resident #4 stated a few minutes later (not sure of time), S8 CNA came in and put Resident #2 to bed. Resident #4 said she told Resident #2 that was not right and she needed to report it, but Resident #2 did not want to report her. Resident #4 stated she told Resident #2 she needed to tell her daughter and Resident #2 said no. Resident #4 stated Resident #2 told her she had cried. Resident #4 stated she would dread when it was time for S4 CNA to come in their room because she was always mean to Resident #2. In an interview on 10/24/2023 at 12:00 p.m., S3 CNA stated on 09/28/2023 at 1:05 p.m., while providing care to Resident #4, she overheard Resident #4 and Resident #2 talking. S3 CNA stated Resident #2 said, That was bad what happened last night. S3 CNA stated she asked what happened, and Resident #4 told her that she heard the 3:00 p.m. - 11:00 p.m. aide talking hostile to Resident #2 the previous night around 9:00 p.m. S3 CNA stated she reported what she overheard to S5 CNA Supervisor, and they went together to report to S6 Charge Nurse. In an interview on 10/24/2023 at 12:24 p.m., S7 CNA stated on 09/28/2023 she brought Resident #4 out to a table in the day room near the front nurses' station. S7 CNA stated Resident #4 started telling her that S4 CNA was being mean to Resident #2. S7 CNA stated Resident #4 told her on 09/27/2023 she heard S4 CNA hollering at Resident #2 because she couldn't stand up from the wheelchair without S4 CNA's help. S7 CNA stated Resident #4 told her S4 CNA was hollering at Resident #2 that she wasn't going to hurt her back getting her out of the wheelchair. S7 CNA stated she reported what she was told to S5 CNA Supervisor who then reported to S2 DON. In an interview on 10/24/2023 at 12:42 p.m., S5 CNA Supervisor stated when S7 CNA told her on 09/28/2023 what had been reported to her, she went down and talked to Resident #4. S5 CNA Supervisor stated Resident #4 told her the curtain was pulled, but she heard S4 CNA hollering at Resident #2. S5 CNA Supervisor stated she reported it to S2 DON. In an interview on 10/24/2023 at 1:10 p.m., S2 DON stated she was notified on 09/28/2023 at 1:05 p.m. about the incident by S6 charge nurse who had been notified by S3 CNA. S2 DON stated she notified S1 Administrator and said they went to talk with Residents #2 and #4 and began their investigation. In an interview on 10/24/2023 at 8:30 a.m., S1 Administrator stated she began her investigation when she was notified on 09/28/2023 shortly after 1:05 p.m. of the abuse allegation involving Resident #2. S1 Administrator stated she and S2 DON interviewed Resident #2. S1 Administrator stated Resident #2 was confused at times, but the resident was able to tell her what happened with S4 CNA. S1 Administrator stated she interviewed Resident #2's roommate, Resident #4. S1 Administrator stated Resident #4 told her she heard S4 CNA talking rough to Resident #2 on 09/27/2023 around 9:00 p.m. S1 Administrator stated S4 CNA was suspended during the investigation. S1 Administrator stated she, S2 DON, and S9 Human Resources interviewed S4 CNA on 10/02/2023. S1 Administrator stated S4 CNA denied ever pinching a resident, slapping a resident, or talking rough or rude to a resident. S1 Administrator stated S4 CNA was not told which resident had complained of abuse. S1 Administrator stated during the interview, S4 CNA began complaining about Resident #2 saying she always makes me do things for her. S1 Administrator stated they called S4 CNA on afternoon of 10/02/2023 and told her she was terminated. S1 Administrator acknowledged S4 CNA had been verbally abusive to Resident #2. Resident #4 Review of Resident #4's medical record revealed an admit date of 06/06/2023 with diagnoses that included in part .Hemiplegia following Cerebral Infarction, Ataxic Gait, Atherosclerotic Heart Disease, and Acute Embolism. Review of Resident #4's Quarterly MDS with an ARD of 09/13/2023 revealed a BIMS of 15, indicating intact cognition. Review of the MDS revealed Resident #4 required extensive assistance by one person with bed mobility, extensive assistance by two persons with transferring, and resident was totally dependent on one person assist with toilet use. Review of Resident #4's physician's orders revealed the following order: 06/07/2023: Turn every 2 hours per posted turn schedule. Review of Resident #4's medical record revealed the resident was care planned for pressure ulcers with an intervention listed to turn every two hours per posted turn schedule. In an interview on 10/24/2023 at 9:40 a.m., Resident #4 stated S4 CNA would talk mean to her in the past (actual dates and times not specified) until she figured out how to roll over on her own. Resident #4 stated S4 CNA told her she wasn't going to do it for her and hurt her back. Resident #4 stated she taught herself how to roll over because she was fearful of S4 CNA. Resident #4 stated she would dread when it was time for S4 CNA to come in their room because she was always mean to Resident #2 and was relieved to have a nice, new aide on the 3:00 p.m.-11:00 p.m. shift. In an interview on 10/24/2023 at 12:24 p.m., S7 CNA stated on 09/28/2023 she dressed Resident #4 and brought her to the table in the day room. S7 CNA stated Resident #4 told her that in the past S4, date and time unspecified, CNA had told her that if she didn't roll herself over, she was going to lay in it because she didn't want to hurt her back. S7 CNA stated Resident #4 was upset and Resident #4 told her she was fearful of S4 CNA. In an interview on 10/24/2023 at 12:42 p.m., S5 CNA Supervisor stated S7 CNA reported to her on 09/28/2023 that Resident #4 had told her that S4 CNA was being mean to Resident #2. S5 CNA Supervisor stated after being made aware of the problem, she went to talk to Resident #4 on 09/28/2023, who told her S4 CNA had been mean to her and her roommate. S5 CNA Supervisor stated Resident #4 said S4 CNA had told her in the past to turn over and don't hurt my back so she taught herself to turn over. Attempts to interview S4 CNA by telephone on 10/24/2023 at 2:03 p.m. and 4:10 p.m. were unsuccessful. In an interview on 10/24/2023 at 8:30 a.m., S1 Administrator confirmed Resident #4 was cognitively intact and had reported the verbal abuse by S4 CNA. S1 Administrator acknowledged S4 CNA was verbally abusive to Resident #2 and Resident #4.

Aug 2023 10 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the resident's right to formulate an advanced directive was p...

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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 the resident's right to formulate an advanced directive was properly reflected in the resident's record for 2 (#19, #57) of 3 (#19, #52,#57) residents reviewed for advance directives. The facility failed to ensure all records regarding code status consistently reflected the resident's wishes. Findings: Resident #19 Review of Resident #19's medical record revealed an admit date of [DATE] with diagnoses which included: Chronic Venous Hypertension, Chronic Obstructive Pulmonary Disease, Benign Prostatic Hyperplasia, Heart Failure, Chronic Kidney Disease, Myopathy, and Essential Hypertension. Review of Resident #19's 08/2023 Physician's orders revealed an order dated [DATE] read Do Not Resuscitate. Review of Resident #19's Face Sheet listed a resuscitation status of Full Code- Cardiopulmonary Resuscitation (CPR). Review of Resident #19's headboard on the Electronic Health Record (EHR) revealed a resuscitation status of CPR. An Interview on [DATE] at 9:40 a.m. with S6 RN stated that according to Resident #19's hard chart the outside spine of the chart reads an advances directive of DNR and the Face Sheet in the hard chart reads Full Code status. S6 RN revealed the headboard in the electronic chart read to initiate CPR. S6 RN stated that Resident #19's face sheet and headboard in the electronic chart was not updated to reflect his new code status as of [DATE]. Interview on [DATE] at 9:50 a.m. with S2 DON confirmed Resident #19's Face sheet and code status on the headboard in the EHR was conflicting and had not been updated in the hard chart or electronic chart once the order was updated in [DATE] and it should have been. Resident #57 Review of Resident #57's medical record revealed an admit date of [DATE] with diagnoses that included Dysphagia, Essential Hypertension, Hypoglycemia, Esophageal Obstruction and Congestive Heart Failure. Review of Resident #57's 08/2023 Physician's Orders revealed an order dated [DATE] with resuscitation status DNR. Review of Resident #57's Face Sheet listed a resuscitation status of Full Code- Cardiopulmonary Resuscitation (CPR). Review of Resident #57's headboard on the Electronic Health Record (EHR) revealed a resuscitation status of CPR. An interview on [DATE] at 9:30 a.m. with S5 LPN stated that if there was a code situation with any resident she would look at their headboard in the EHR and Face sheet on their chart. S5 LPN stated that Resident #57 had a Full Code status according to the Face sheet on his chart. In an interview on [DATE] at 9:50 a.m. with S2 DON confirmed that Resident #57's Face sheet reads Full code and 08/2023 Physician orders read DNR. S2 DON confirmed the new Face Sheet that reflected the DNR status was not placed in the hard chart and the headboard in the EHR had not been updated but should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to consult with the resident's physician timely when there was a change in the resident's physical condition after a recent fall, for 1 (#12) ...

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Based on record review and interview, the facility failed to consult with the resident's physician timely when there was a change in the resident's physical condition after a recent fall, for 1 (#12) of 4 (#12, #18, #33, #93) residents reviewed for accidents. Findings: Review of the facility's policy titled Notification of Physician/Family revealed in part . Courtyard of Natchitoches will in effect notify the resident's physician/resident's legal representative when the following occurs: 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2. A significant change in the resident's physical, mental, or psychosocial status Review of Resident #12's medical record revealed an admit date of 04/27/2022, with diagnoses that included in part . Abnormal weight loss, Fracture of shaft of left femur, Anxiety disorder, Major Depressive Disorder, and Alzheimer's disease. Review of Resident #12's Annual MDS with an ARD of 06/07/2023 revealed a BIMS score of 0, which indicated severe cognitive impairment. Review of the MDS revealed Resident #12 required extensive assistance by one person with bed mobility, was totally dependent on two person physical assist with transferring, and was totally dependent on one person physical assist with toilet use and eating. Review of Resident #12's medical record revealed the resident was care planned for falls with an actual fall on 07/08/2023, a fall in room without apparent injury. On 07/11/2023 swelling noted to left knee, sent for x-rays. Fracture noted to left distal femur. Interventions included: assist up to geri chair as tolerated, 1/2 side rails up for bed mobility, star on communication board to alert staff to fall risk, monitor for changes in condition that may warrant increased supervision/assistance and notify the physician, and use Hoyer lift with transfers. Review of Resident #12's nurses' notes revealed the following entries: 07/09/2023 at 3:10pm: Late entry: 07/08/2023 at 9:00 p.m. This staff nurse entered room to administer night time meds to resident, and observed resident lying on right side on floor beside bed. Fall assessment done with no apparent injuries noted. Resident assisted up x 2 (person) assist and placed back into bed. Neuro observations started and within normal limits. MD and son notified. V/S 157/61, 119, 97.9, 18. By S12 LPN. 07/08/2023 at 1:45 pm: Neuro monitoring in progress without change noted in baseline condition. Husband in at bedside and visiting without complaints voiced. Spoke with Daughter and assured her of no injuries with finding resident on floor during HS hours. Monitoring continues. 07/11/23 at 7:47 pm: 13:15: This nurse placed call to S16 MD throughout shift with Resident noted with increased kicking of her left leg , and CNA unable to reposition. Noted swelling to knee and bruising behind knee. Received new order to x-ray left knee. Placed order and awaiting ambulance to transport. 1830: Ambulance here and resident transferred to stretcher and transferred to Radiology. 1855: Received call from ____ in Radiology with report of left knee fractured, and requesting what she needs to do. This nurse told her to transfer to ER for treatment. New order received per S16 MD to transfer to ER for evaluation and treatment of left knee. By S5 LPN. In an interview on 08/15/2023 at 3:40 p.m., S5 LPN stated on 07/09/2023 Resident #12 had some bruising behind the left knee, but the resident did not show any signs of having a broken leg. S5 LPN stated on 07/10/2023, Resident #12 wasn't acting like herself and was kicking her left leg a lot. S5 LPN stated she tried to call the doctor on 07/10/2023 to get an order for an x-ray, but the doctor never called back. S5 LPN stated on 07/11/2023 she called the doctor and received orders for an x-ray, and sent Resident #12 out to radiology. In an interview on 08/16/2023 at 3:07 p.m., S5 LPN stated she told S17 RN Charge Nurse on 07/10/2023, that she had called the doctor to get an x-ray order and was awaiting a call back from the doctor. S5 LPN stated she gave Resident #12 Tylenol 650mg per standing orders. S5 LPN stated she did not follow up with the charge nurse to let her know she never heard back from the doctor, and should have. Review of Resident #12's MAR for 07/2023 revealed there was no documentation that Tylenol was given for the entire month of 07/2023, although S5 LPN stated she gave Resident #12 Tylenol on 07/10/2023. In an interview on 08/16/2023 at 11:17 a.m., S2 DON stated she found out about Resident #12's fall after the x-ray was obtained, so she investigated it. S2 DON stated she talked with the CNA and nurse who worked with Resident #12 on 07/08/2023. Both said they did range of motion with Resident #12 and nothing was different than normal for the resident. S2 DON stated on 07/09/2023, S5 LPN noted a small bruise, but noted nothing else out of the ordinary. S2 DON stated S17 RN Charge Nurse did the 24 hour follow-up assessment on 07/09/2023, and found nothing that led her to believe there was a fracture, and there was no swelling. S2 DON stated on 07/10/2023, S5 LPN reported Resident #12 was kicking her left leg out, was agitated with the leg, and called S16 MD several times, but she never received a call back from the doctor. S2 DON stated on 07/11/2023, S5 LPN reported Resident #12's left leg was swollen and she called the doctor again, and received an order for an x-ray. S2 DON stated Resident #12 was sent for an x-ray which showed the femur fracture. S2 DON stated if the doctor didn't return her call on 07/10/2023, she should have kept calling him until she reached him. Review of a written statement by S5 LPN revealed the following: On 07/09/2023, this nurse received report of resident being found on floor through previous evening and neuro monitoring in place. This nurse to room for monitoring. No distress noted. No undue issues or concerns noted. Resident known to fight against staff on attempt to reposition, same actions known at this time, normal actions from resident. Bruising started on back of left knee. No swelling noted. Husband in room since before lunch, son at bedside before evening meal. On 7/10/2023, neuro monitoring continues. Increased agitation noted with resident noted kicking left leg, more moaning out, but only with positioning and incontinent care. Resident calm when not providing care. This nurse attempted several times to contact physician with no return call. Husband in before lunch, remaining until after evening meal. Son in room before evening meal. Bruising continues to back of knee. Noted resident kicking left foot. On 07/11/2023, knee was more swollen with same bruising to back of knee, was more agitated with more kicking of left foot than previous day. More moaning out with attempting to move resident. Contact made with physician with new order for left knee x-ray at 1:15pm. Contacted ambulance service for transport. Transport arrived to facility at 6:15pm. Husband and son at bedside. Signed by S5 LPN In an interview on 08/16/2023 at 11:55 a.m., S3 ADON, S4 RN Charge Nurse, and S17 RN Charge Nurse all confirmed S5 LPN never reported to them on 07/10/2023 that she had been unable reach Resident #12's physician. S4 RN Charge Nurse explained the floor nurses are supposed to report any problems to one of the two charge nurses immediately. S4 RN Charge Nurse stated she and S17 RN Charge Nurse work with Resident #12's physician, S16 MD, often and he would likely return a text from them. In an interview on 08/16/2023 at 11:50 a.m., S1 Administrator stated S5 LPN should have reached out to one of the administrative nurses when she couldn't reach the doctor. S1 Administrator stated she should have reported it to one of the two charge nurses, the ADON, the DON, or to the Administrator. S1 Administrator stated that one of the administrative nurse could have tried to reach him, and said he may have responded to them because they know him well, and are often in contact with him. S1 Administrator stated if they were still unsuccessful in reaching the physician, she would have called her VP at the hospital, who would reach out to the MD. S1 Administrator stated the floor nurses should go to the charge nurses or ADON for any problems they encounter on the floor.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to make prompt efforts to document and resolve grievances for 1 (#84) of 1 resident reviewed for grievances. Findings: Review of the facility'...

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Based on record review and interview, the facility failed to make prompt efforts to document and resolve grievances for 1 (#84) of 1 resident reviewed for grievances. Findings: Review of the facility's policy titled Filing Grievances/Complaints revealed in part . Our facility will assist residents, their representatives (sponsors); other interested family members, or resident advocates in filing grievances or complaints when such requests are made. 1. Any resident, his/her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2. . 3. Grievances and/or complaints may be submitted orally or in writing. A grievance log will be kept in the office of the Director of Nursing and all grievances will be recorded in this log. A brief notation of the intervention and the follow-up will also be recorded. 4. The Administrator and the Director of Nursing have the responsibility of grievance and/or complaint investigation. They, then will review the findings of the investigation determine what corrective actions, if any, need to be taken. 5. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Review of Resident #84's medical record revealed an admit date of 05/11/2022 with diagnoses that included in part .Atrial fibrillation, Edema, Alzheimer's, Pressure ulcer, and Anxiety disorder. Review of Resident #84's quarterly MDS with an ARD of 07/12/2023 revealed a BIMS interview was not conducted was rarely/never understood. Review of the MDS revealed Resident #84 required extensive assistance by one person with bed mobility and eating, was totally dependent on one person with toilet use, and transferring did not occur. Review of Resident #84's medical record revealed the resident was care planned for bowel and bladder incontinence. Interventions included provide incontinent care every 2 hours and as needed, provide verbal cueing, assess for abdominal distention, assess skin for irritation and redness, asses for acute behavioral changes that may indicate constipation/discomfort, provide incontinent protection at all times, and monitor skin for redness/open areas during incontinent care. In an interview on 08/14/2023 at 12:12 p.m., Resident #84's wife stated staff do not change him every two hours and he stayed wet. Resident #84's wife stated she comes every day to the facility at about 11:00 a.m., feeds him lunch and supper, and goes home about 7 p.m. Resident #84's wife stated the day shift CNA usually changes the resident before the end of their shift, between 1:30 p.m. and 2:00 p.m. Resident #84's wife stated when she is about to go home around 7:00 p.m., the CNA that comes on at 3:00 p.m. has not changed him most days. Resident #84's wife stated she has to go find a CNA to change him before she leaves at 7:00 p.m. Resident #84's wife stated she had complained to S1 Administrator twice recently. Resident #84's wife stated S1 Administrator said she would talk to S7 CNA Supervisor about the problem but S1 Administrator had not talked with her about a resolution since voicing her complaint. Review of the Grievance log for 2023 revealed no documented grievances for Resident #84. In an interview on 08/15/2023 at 12:40 p.m., Resident #84's wife stated on 08/14/2023 the resident was changed about 2:00 p.m. by the day shift CNA. Resident #84's wife stated she stayed at the facility until 8:00 p.m. and no one had changed him when she left since 2:00 p.m. Resident #84's wife stated she talked to S1 Administrator about this issue twice last week. In an interview on 08/16/2023 at 1:20 p.m., Resident #84's wife stated on 08/15/2023 the resident was changed at 2:00 p.m. and no one came in to change him again until 7:00 p.m. In an interview on 08/16/2023 at 1:34 p.m., S1 Administrator stated Resident #84's wife complained to her last Thursday or Friday about a CNA not changing the resident and having to go find someone to change him. S1 Administrator stated she reported it to S7 CNA Supervisor, who addressed it. S1 Administrator confirmed she did not do a grievance on it because they addressed it right away. S1 Administrator stated she should have followed up with Resident #84's wife but didn't because state was in the building.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services that met professional standards of qualit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services that met professional standards of quality, by failing to promptly assess a resident after she fell and hit her head, for 1 resident (#18) in a total sample of 25 residents. Findings: The Facility's Policy titled Fall Policy/Risk Assessment read in part .Post-fall management: (2) the nurse will notify the physician promptly and note and implement diagnostic or treatment interventions ordered. Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Tremor unspecified, Repeated Falls, Pain in left foot, Chronic Migraine, Retention of Urine, Pain in the right shoulder and Subdural Hematoma. Review of Resident #18's DPE MDS with an ARD of 07/25/2023 revealed a BIMS score of 14 (indicating intact cognition). The MDS revealed Resident #18 was coded as requiring one person physical assistance for transfers, personal hygiene and bed mobility; and extensive assistance for dressing and toilet use. Review of Resident #18's Care Plan with a review date of 06/03/2023 revealed Subdural Hematoma from fall - consult with MD status post fall with bilateral hematomas. Interventions included to assist resident as needed, monitor neurological status every shift for any changes, and report to medical doctor immediately. Interview on 08/14/2023 at 9:39 a.m. with Resident #18 revealed she had a fall in May 2023, which resulted in a Subdural Hematoma. Review of hospital records dated 05/18/2023 read in part .Patient with Subdural Hematoma - will need transfer to higher level of care. Review of an Incident report dated 05/17/2023 at 11:30 p.m. read in part .Resident #18's bathroom light was on and upon entering room observed resident sitting on buttocks in bathroom floor. Stated she slid off the commode. No apparent injuries noted voiced no complaints at this time. Assisted up and into bed. Neurological observations restarted at this time. Instructed resident to call for assistance when needing to get up. Medical Doctor and sister notified. No apparent injuries. Interview on 08/15/2023 at 3:00 p.m. with S2 DON revealed on 05/17/2023 around 11:00 p.m., Resident #18 had fallen in the bathroom and hit her head. S2 DON stated the nurse on duty (S12 LPN) did not assess Resident #18 at the time of the fall. S2 DON stated the next day on 05/18/2023 before lunch, Resident #18 came to her office to report S12 LPN had talked to her rudely, and also of her (Resident #18) having a headache. S2 DON stated at that time she assessed Resident #18's head and saw no bruising, swelling or redness. S2 DON stated the doctor was notified of Resident #18 complaining of a headache, and received orders to send Resident #18 to the emergency room. S2 DON stated Resident #18 was diagnosed with a brain bleed, and was sent to another hospital for a higher level of care. Interview on 08/15/2023 at 3:12 p.m. with S13 CNA revealed she worked the 3:00 p.m. - 11:00 p.m. shift on 05/17/2023. S13 CNA stated she was getting ready to clock out when she noticed Resident #18's bathroom light had come on, so she went to answer the call light. S13 CNA stated when she entered Resident #18's bathroom, she was in an upright position on the floor. S13 CNA stated Resident #18 had a red spot on her right ear. S13 CNA stated she went and told S12 LPN of Resident #18 being on the floor in her bathroom, and went back to the bathroom to stay with Resident #18. S13 CNA stated S14 CNA came to assist her with getting Resident #18 off the floor and back into bed. S13 CNA stated she and S14 CNA reported to S12 LPN again of Resident #18 having a fall in the bathroom, and her complaint that her head was hurting. S13 CNA stated S12 LPN said she could not come right then, and sent another CNA to obtain vital signs on Resident #18. Telephone interview on 08/15/2023 at 3:30 p.m. with S12 LPN revealed she provided care for Resident #18 on 05/17/2023 on the night shift. S12 LPN stated she was reconciling medications with another nurse when S13 CNA reported to her that Resident #18 was on the floor in the bathroom. S12 LPN stated she did not immediately go and assess Resident #18 because she was tied up with another resident. S12 LPN stated she did not remember what time she assessed Resident #18, but she did assess her, and called the doctor and her responsible party. Interview on 08/16/2023 at 8:10 a.m. with S14 CNA revealed she worked 3:00 p.m.-7:00 a.m. on 05/17/2023. S14 CNA stated she assisted S13 CNA with getting Resident #18 off the bathroom floor. S14 CNA stated Resident #18 did not look as if she was hurt, but had complained of having a headache. S14 CNA stated she and S13 CNA had reported to S12 LPN of Resident #18 having fallen in the bathroom, and that she complained of her head hurting. S14 CNA stated S12 LPN did not go and assess Resident #18 at that time. Telephone interview on 08/16/2023 at 8:24 a.m. with S12 LPN revealed she did not remember the exact time she went to Resident #18's room to assess her after a fall in the bathroom on 05/17/2023. S12 LPN stated when she assessed Resident #18, she did not complain of any pain or a headache, and she did not notice any injuries. S12 LPN stated she notified the doctor and the family and continued to monitor Resident #18. Interview on 08/16/2023 at 9:23 a.m. with Resident #18 revealed she could not remember the details from the fall on 05/17/2023. Resident #18 stated she did not remember who helped her, or who provided care for her after the fall. Resident #18's roommate stated she did not know any details of the fall, or who assisted her roommate with care. Interview on 08/16/2023 at 9:30 a.m. with S2 DON revealed Resident #18 was not assessed by S12 LPN for at least 3-4 hours after she fell in the bathroom on 05/17/2023. S2 DON stated she and S1 Administrator looked at video footage and went back as far as 3-4 hours after the time Resident #18 fell in the bathroom on 05/17/2023 and S12 LPN did not enter her room. S2 DON confirmed S12 LPN did not immediately assess Resident #18 after she fell and hit her head in the bathroom on 05/17/2023 and she should have.

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 observations, interviews and record review, the Facility failed to ensure that Residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to main...

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Based on observations, interviews and record review, the Facility failed to ensure that Residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The Facility failed to provide trimmed fingernails to dependent Residents for 1 (Resident #67) of 5 (Resident #67, Resident #1, Resident #39, Resident #21 and Resident #84) Residents sampled for ADL's. Total sample size was 24. Findings: Review of Resident #67's clinical record revealed an admission date of 11/02/2021 with diagnoses which included: Parkinson's Disease, Dementia and repeated falls. Review of Resident #67's Quarterly MDS with an ARD of 07/26/2023 revealed Resident #67 had a BIMS score of 11 (indicating moderately impaired cognition), required one person physical assistance for bathing and one person extensive assistance for personal hygiene. Review of Resident #67's care plan with a review date of 10/26/2023 revealed a need for grooming and personal hygiene and the need for staff to assist with approaches to monitor and clean fingernails/toenails. Cut as needed. Observation and interview on 08/14/2023 at 10:17 a.m. revealed Resident #67 sitting in a wheelchair in the dining room. Resident #67's fingernails were noted to be long (approximately 1 and a half inches). Resident #67 asked the surveyor did she cut fingernails and stated he would like his cut. Observation and interview on 08/15/2023 at 8:35 a.m. revealed Resident #67 in the bed in his room. Resident #67's fingernails were noted to be long (approximately 1 and a half inches). Resident #67 stated he was still waiting to get his fingernails cut. Observation and interview on 08/15/2023 at 9:56 a.m. of Resident #67 with S3 ADON in attendance confirmed Resident #67's fingernails were long and needed to be trimmed. Interview on 08/16/2023 at 3:48 p.m. with S2 DON stated the nurse was responsible for trimming fingernails and toenails. S2 DON stated the CNA is to notify the treatment nurse or floor nurse if a Resident's fingernails/toenails need trimming.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #63) of 1 Residents reviewed for respiratory ca...

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Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #63) of 1 Residents reviewed for respiratory care. The facility failed to ensure Resident #63's respiratory equipment was properly changed, labeled and stored. Total sample size was 24. Findings: Facility's Policy on Oxygen Administration read in part . change nebulizer tubing and delivery device on a weekly basis. Review of Resident #63's medical record revealed a diagnoses of Shortness of Breath and Resident #63 received Budesonide 0.25 MG/2 ML suspension one vial per nebulizer two times a day (breathing treatment). Observation and interview on 08/14/2023 at 9:30 a.m. revealed a nebulizer mouth piece lying in Resident #63's bedside drawer in a cup, uncovered and undated. Resident #63 stated she used the nebulizer daily. Observation on 08/15/2023 at 8:25 a.m. revealed a nebulizer mouth piece lying in Resident #63's bedside drawer in a cup, uncovered and undated. Observation and interview on 08/15/2023 at 9:50 a.m. accompanied by S3 ADON revealed Resident #63's nebulizer mouth piece lying in her bedside drawer in a cup, uncovered and undated. S3 ADON confirmed Resident #63's nebulizer mouth piece should have been in a Ziploc bag with a date on it and it was not. Interview on 08/16/2023 at 3:44 p.m. with S2 DON revealed oxygen tubing and Nebulizer equipment should be stored in a Ziploc bag dated and initialed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions for 1 (#12) of 5 (#12, #18, #47, #84, #93) residents reviewed ...

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Based on record review and interview, the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions for 1 (#12) of 5 (#12, #18, #47, #84, #93) residents reviewed for unnecessary medications. Findings: Review of Resident #12's medical record revealed an admit date of 04/27/2022 with diagnoses that included in part .Abnormal weight loss, Fracture of shaft of left femur, Anxiety disorder, Major Depressive Disorder, and Alzheimer's disease. Review of Resident #12's physician' orders revealed the following: 08/10/2023: Norco 5-325 mg tablet, one tablet by mouth every 6 hours as needed 07/12/2023: Paroxetine HCL 40 mg by mouth every day 07/12/2023: Quetiapine Fumarate 25 mg by mouth daily 07/12/2023: Quetiapine Fumarate 50 mg by mouth at bedtime 07/12/2023: Trazodone 50 mg by mouth every night at bedtime 07/12/2023: Buspar 10 mg by mouth three times a day Review of Resident #12's medical record revealed the resident was care planned for the use of psychotropic drugs. Review of the care plan revealed interventions that included pharmacy consultant to review medications monthly, assess for adverse side effects, document and report, and administer medications as ordered. Review of Resident #12's medical record revealed no gradual dose reduction letters were sent to the physician in the past year by the pharmacist. In an interview on 08/16/2023 at 11:17 a.m., S2 DON confirmed a gradual dose reduction letter had not been sent to the physician by the pharmacist in the past year and no gradual dose attempts were made.

CONCERN (D)

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 each resident was free of significant medication errors for 1 (#86) of 4 residents observed during medication administ...

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Based on observation, record review, and interview, the facility failed to ensure each resident was free of significant medication errors for 1 (#86) of 4 residents observed during medication administration pass. The facility failed to ensure medication administered to Resident #86 was the correct medication as ordered by the physician. The facility had a total census of 97 residents residing in the facility. Findings: Review of the facility's policy titled Administration of Medicines revealed in part . Procedure: B. Administration of medication (5 rights) 1. Check physician's order for medication name, dosage, route, and frequency or time ordered. 2. Check medication label on unit dose pack or medication box for correct name and dosage. 3. Check MAR for time last dose given. 4. Identify patient before administering medication. During an observation of medication administration pass on 08/15/2023 at 8:00 a.m., S5 LPN administered Abiraterone (a hormone based chemotherapy used to treat prostate cancer) 250mg by mouth to Resident #86. Review of Resident #86's medical record revealed an admit date of 11/30/2022. Review of Resident #86's physician's orders revealed no evidence of an order for Abiraterone. In an interview on 08/15/2023 at 8:45 a.m., S5 LPN reviewed Resident #86's medical record and confirmed the resident did not have an order to receive Abiraterone. S5 LPN opened the top drawer of her medication cart and removed the bottle of Abiraterone, looked at the label, and stated the medication belonged to another resident. S5 LPN stated the medication was in the bin with Resident #86's medication by mistake. In an interview on 08/15/2023 at 9:00 a.m., S2 DON confirmed Resident #86 was given the wrong medication because the nurse did not follow the 5 rights of medication administration and should have.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was sufficient staff with appropriate competencies and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure there was sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure that resident calls for help were answered timely, and that the need was met when a resident called for help. This deficient practice had the potential to affect all 97 residents residing in the facility. Findings: An interview on 08/14/2023 at 9:55 a.m. with Resident #90 revealed she had to wait for over an hour at times for help after using the call bell. Resident #90 stated weekend staff call in often and she felt the facility is short staffed at times. Resident #90 stated she had notified management about the call light issues in the past. A review of Resident #90's quarterly MDS dated [DATE] revealed Resident #90 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #90 required assistance with one-person physical assist for dressing and bathing, and required supervision with toilet use and personal hygiene. An interview on 08/14/2023 at 10:13 a.m. with Resident #26 revealed it took staff a long time to answer call bells at times, and that most often happened on the evening and night shift. Resident #26 stated 2 weeks ago, after using the call bell, she waited 2 hours and almost fell out of bed waiting for staff to come and help her. Resident #26 stated she was able to keep track of time by looking at her phone. A review of Resident #26's MDS dated [DATE] revealed Resident #26 had a BIMS score of 8, which indicated the resident had moderately impaired cognition. Resident #26 required extensive assistance with one-person physical assist for bed mobility, transfers, toilet use, bathing, and personal hygiene. An interview on 08/14/23 at 10:37 a.m. with Resident #19 revealed staff did not answer his call light in a timely manner. Resident #19 stated he had waited as long as 6 hours for staff to come help him after using the call bell. A review of Resident #19's MDS dated [DATE] revealed Resident #19 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #19 required extensive assistance with one-person physical assist for bed mobility, transfers, eating, dressing and personal hygiene. An interview on 08/15/2023 at 9:55 a.m., Resident #69 stated most nights staff do not answer the call light from about 9:30 p.m. until morning. Resident #69 stated she cannot walk and calls them if she needs incontinent care, can't reach something, or if she is cold but they do not come at all. A review of Resident #69's MDS dated [DATE] revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #69 required extensive assistance by one person physical assist with toilet use and bed mobility and was totally dependent on one person with transferring. Resident #69 required limited assistance by one person with eating. A review of the Facility's 2023 grievances revealed 4 grievances were filed regarding call light response times. An interview on 08/15/2023 at 1:09 p.m. with S8 CNA revealed there were times she felt they were short staffed due to call ins, and she could not meet the resident's needs in a timely manner. An interview on 08/15/2023 at 1:17 p.m. with S9 CNA revealed there were weekends the facility short staffed with CNA's. S9 CNA stated she had received voiced complaints from residents regarding having to wait long periods of time for staff to respond to the call light. S9 CNA stated she had notified S7 CNA Supervisor. An interview on 08/16/2023 at 8:55 a.m. with S10 LPN revealed there had been times residents have complained to her regarding staff not answering call lights in a timely manner and management was notified. A telephone interview on 08/16/2023 at 9:50 a.m. with S11 CNA revealed she worked the evening shift and often worked short staffed. S11 CNA stated staff split the halls and it took longer times to get work done. S11 CNA stated some residents complained to morning staff regarding how long it took to get things done on the evening shift. An interview on 08/16/2023 at 10:15 a.m. with Resident #R1 revealed residents have complained of slow response times to calls for help during resident council meetings, but she was unaware if the concerns was addressed. An interview on 08/16/2023 at 2:30 p.m. with, S7 CNA Supervisor revealed there were times of call ins and was mostly on the weekends. S7 CNA Supervisor stated the facility recently hired agency staff for weekend coverage. S7 CNA Supervisor stated she had residents complain regarding long call bell wait times and she had educated staff on importance of answering call lights in a timely manner. An interview on 08/16/2023 at 3:00 p.m. with S1 Administrator confirmed the facility had 4 complaints since 01/01/2023 regarding long call bell wait times. S1 Administrator stated the facility hired agency CNA staff to work weekends due to a high influx of CNA's leaving to go back to school.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

FACILITY Based on observation and interview, the facility failed to ensure medications were stored under proper temperature controls for 2 (Medication Refrigerator A, Medication Refrigerator B) of 2 m...

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FACILITY Based on observation and interview, the facility failed to ensure medications were stored under proper temperature controls for 2 (Medication Refrigerator A, Medication Refrigerator B) of 2 medication refrigerators observed out of a total of 3 medication refrigerators. Findings: In an observation on 08/16/2023 at 7:45 a.m. of Medication Refrigerator A with S4 RN Charge Nurse revealed the refrigerator contained resident medications. Observation of Medication Refrigerator A's temperature log at that time revealed the temperatures were not monitored for 7 days in August of 2023. In an interview at that time, S4 RN Charge Nurse stated the night nurses are supposed to monitor the refrigerator temperatures each night and confirmed they had not. In an observation on 08/16/2023 at 7:50 a.m. of Medication Refrigerator B with S4 RN Charge Nurse revealed the refrigerator contained multiple resident medications. Observation and interview with S4 RN Charge Nurse at that time of Medication Refrigerator B's temperature log revealed the temperatures were not monitored for 7 days in August 2023 and should have been. In an interview on 08/16/2023 at 11:25 a.m., S2 DON confirmed the night nurses are supposed to check and record the refrigerator temperatures every night, but had not.

Aug 2022 7 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of h...

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Based on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#20) out of a total of 26 sampled residents by failing to ensure staff did not stand while assisting resident #20 during a meal service. Findings: Review of Resident #20's Clinical Record revealed an admit date of 08/31/2020 with diagnoses which included: Dementia, Pain unspecified, Pressure Ulcer of Sacral Region, Major Depressive Disorder, Edema and Alzheimer's Disease. Review of Resident #20's Care Plan with a review date of 08/18/2022 revealed a potential for weight loss *feeding deficit 03/05/2022* pureed texture related to pocketing food, with interventions to allow resident ample time to consume food and to provide feeding assistance. Observation and interview on 08/01/2022 at 11:26 a.m. revealed S7 CNA standing while feeding Resident # 20. S7 CNA stated Resident #20 was total care and she had to be assisted with meals. Observation on 08/03/2022 at 7:40 a.m. revealed S7 CNA standing while feeding Resident #20. Observation and interview on 08/03/2022 at 7:45 a.m. accompanied by S1 DON revealed S7 CNA standing while feeding Resident #20. S1 DON confirmed S7 CNA should not be standing while feeding Resident #20.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to consult with the Resident's physician and notify the Resident repres...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to consult with the Resident's physician and notify the Resident representative when there was a significant change in the Resident's physical condition for 1 (#1) of 3 (#1, #62, and #71) residents reviewed for nutrition. Findings: Resident #1 Review of the facility policy titled Notification of Changes revealed, in part: Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances that require notification include: 1 . 2. Significant change in resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life threatening conditions, or b. Clinical complications . Review of Resident #1's medical record revealed an admit date of 04/11/2022 with diagnoses that included dementia, generalized anxiety disorder, anorexia, and repeated falls. Review of Resident #1's MDS dated [DATE] revealed a BIMS score of 8, which indicated the resident had moderately impaired cognition. Further review of the MDS revealed the resident required extensive assistance with eating. Review of Resident #1's nurses' notes revealed the following entry: 08/02/2022 at 11:10 a.m.: Resident returned from _________ (inpatient psychiatric facility) with weight of 110 pounds on 07/19/2022 .Present weight of 103 pounds .by S4 RD. Further review of Resident #1's medical record revealed the resident was last seen by her physician on 07/01/2022. Review of the 07/01/2022 progress noted revealed the physician increased the resident's Megace (appetite stimulant) dose, as requested by the resident's family. Further record review revealed no evidence of the facility notifying the resident's physician or the resident's responsible representative about her recent weight loss of 6.36% over a 14 day period. In an interview on 08/03/2022 at 10:58 a.m. S1 DON confirmed Resident #1 returned to the facility from an inpatient hospital stay on 07/19/2022 and weighed 110 pounds on return. S1 DON further confirmed Resident #1's weight was 103 pounds on 08/02/2022. S1 DON acknowledged Resident #1 had not seen her physician since 07/01/2022 and the facility had not notified him of the recent weight loss. S1 DON further confirmed the facility had not reported Resident #1's recent weight loss to her responsible representative.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #72) of 26 sampled residents reviewed for respi...

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Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #72) of 26 sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored and No Smoking signs were present when oxygen was administered. Findings: Review of the facility policy titled: Oxygen Concentrator Use and Care of, revealed in part . 1. Keep delivery devices covered in a plastic bag when not in use. 2. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of Resident #72's Clinical Record revealed an admit date of 01/11/2022 with diagnoses which included: Generalized Anxiety Disorder, Other Specified Cough, Encounter for Screening for Respiratory Tuberculosis, Unspecified Combined Systolic and Diastolic (Congestive) Heart Failure. Review of Resident #72's Physician's Orders dated 08/2022 revealed an order for continuous oxygen at 2 liters via nasal cannula. Observation on 08/01/2022 at 10:21 a.m. revealed Resident #72 was out of her room. Nasal cannula was observed hanging on her left bedrail uncovered. Further observation revealed no signage in Resident #72's room to indicate No Smoking when oxygen is administered Observation and interview on 08/02/2022 at 8:39 a.m. revealed Resident #72 lying in bed. Resident stated she was waiting to go to therapy. Nasal cannula noted to be hanging on her left bedrail uncovered. Resident #72 also had a tank of portable oxygen attached to her wheelchair. Nasal cannula attached to portable oxygen was uncovered. No signage was observed in Resident #72's room to indicate No Smoking when oxygen is administered. Observation and interview on 08/02/2022 at 2:00 p.m. accompanied by S1 DON revealed Resident #72's nasal cannula attached to her concentrator and portable oxygen were uncovered; and no signage in Resident #72's room to indicate No Smoking when oxygen is administered. Interview on 08/02/2022 at 2:30 p.m. with S1 DON confirmed Resident #72's nasal cannula attached to her concentrator and portable oxygen should be covered and they were not. S1 DON further confirmed there were no signage in Resident #72's room to indicate No Smoking when oxygen is administered.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly. Findings: Review of the facility policy titled Quality Assurance and P...

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Based on record review and interview the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly. Findings: Review of the facility policy titled Quality Assurance and Performance Improvement revealed in part . 1. The QAA Committee shall be interdisciplinary and shall: b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program. Interview on 08/03/2022 at 1:59 p.m. with S1 DON revealed she was responsible for scheduling QAA meetings. Review of the facility's QAA meeting minutes revealed there was no documentation the committee had met for 2nd quarter of 2022. Interview on 08/03/2022 at 2:00 p.m. with S1 DON revealed she had not yet compiled her QAA data for June 2022. She stated a 2nd quarter QAA meeting had not been held as of today. She confirmed a 2nd quarter QAA meeting should have been held and had not been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure the resident's medical record included documentation the resident or resident representative was provided education regarding the be...

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Based on interview and record review, the facility failed to ensure the resident's medical record included documentation the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine and whether the resident did not receive the COVID-19 vaccine due to a medical contraindication or refusal for 1 (Resident #21) of 5 (Resident #7, Resident #12, Resident #21, Resident #24, and Resident #27) residents sampled for immunizations. Findings: Review of the Facility's policy titled COVID-19 Vaccination revealed in part . 22. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. d. Follow-up monitoring of the resident post vaccination. Review of Resident #21's medical record revealed an admit date of 09/09/2021 with diagnoses that included: Fracture Superior Rim of Right Pubis, Hypertension, Encounter for screening for other Viral Diseases, Encounter for Screening for Respiratory Tuberculosis, Displaced Intertrochanteric Fracture Right Femur, Alzheimer's Disease, Disorientation, and COVID-19. Review of Resident #21's Quarterly MDS with an ARD of 05/18/2022 revealed a BIMS score of 3 indicating severe cognitive impairment. Review of a progress note for Resident #21 dated 09/09/2021 at 3:54 p.m. revealed in part Resident #21 arrived at 2:00 p.m. and admitted under skilled services .Called physician's office for vaccination status and reports resident is not vaccinated for COVID-19. Review of the facility's Resident Vaccination Status Spreadsheet revealed Resident #21 was eligible for the COVD-19 vaccine but refused. Interview on 08/02/2022 at 11:40 a.m. with S1 DON revealed she could not find any documentation regarding the COVID-19 vaccine in Resident #21's medical record other than the note stating she was not vaccinated. Interview on 08/02/22 at 12:51 p.m. with S1 DON confirmed there was no documentation Resident #21 or her representative were educated on the COVID-19 vaccine and refused the vaccine in her medical record and there should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0888 (Tag F0888)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to follow infection control practices to mitigate the transmission and spread of COVID-19. The facility failed to develop and imp...

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Based on observation, interview, and record review the facility failed to follow infection control practices to mitigate the transmission and spread of COVID-19. The facility failed to develop and implement a policy that included additional measures for unvaccinated employees and failed to ensure unvaccinated employees wore N95 or higher level mask while in the facility for 2 (S5 CNA and S6 CNA) of 2 unvaccinated staff observations. Findings: Review of the facility's policy titled Employee COVID-19 Vaccinations revealed in part . 9. The facility will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19. (Specify the precautions to be taken, i.e. masking, social distancing, etc.). No additional precautions to mitigate the transmission and spread of COVID-19 were specified in the policy. Review of the Staff Vaccination Matrix revealed S5 CNA and S6 CNA had exemptions for the COVID-19 vaccine. Review of the exemption documentation revealed S5 CNA and S6 CNA were approved for a qualifying exemption. Observation on 08/01/2022 at 2:20 p.m. revealed S5 CNA entered a resident's room wearing a black surgical mask. Observation on 08/01/2022 at 2:23 p.m. revealed S5 CNA exited a resident's room wearing a black surgical mask. Interview on 08/01/2022 at 2:23 p.m. with S5 CNA revealed she did not receive the COVID-19 vaccine. S5 CNA reported she had a qualifying exemption. Observation on 08/02/2022 at 10:03 a.m. revealed S5 CNA entered a resident's room to provide care wearing a black surgical mask. Interview on 08/02/2022 at 10:08 a.m. with S5 CNA revealed she was wearing a surgical mask. S5 CNA reported she was told to wear a surgical mask in the facility and was never told to wear any other type of mask. S5 CNA stated she did not have any other mask underneath the black surgical mask. Interview on 08/02/2022 at 10:15 a.m. with S6 CNA revealed she did not receive the COVID-19 vaccine. S6 CNA reported she had a qualifying exemption. S6 CNA stated she was wearing a black surgical mask with no other mask underneath. S6 CNA further stated she was told to wear a surgical mask in the facility. Observation revealed she was wearing a black surgical mask. Interview on 08/02/2022 at 11:01 a.m. with S1 DON revealed exempted employees were to wear a surgical mask at all times just like vaccinated employees. When questioned about the facility's policy regarding additional precautions for staff who are not fully vaccinated, S1 DON stated the surgical mask was the only precaution taken. S1 DON reported the exempted employees were not pulled from resident care and were providing resident care. S1 DON further reported she was not aware exempted/unvaccinated employees needed to wear N95 masks.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that a resident who required dialysis received services consi...

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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 that a resident who required dialysis received services consistent with professional standards of practice for 1 (#71) of 1 (#71) resident reviewed for dialysis by failing to ensure there was ongoing communication and collaboration between the nursing home and the dialysis staff. Findings: Resident #71 Review of the facility's Care Planning-Dialysis revealed, in part, the following: Policy Explanation and Compliance Guidelines: 2. The care plan will reflect the coordination between the facility and the dialysis provider and will identify nursing home and dialysis responsibilities. 3. Interventions will include, but not limited to: a. Documentation and monitoring of complications b. Pre- and post- weights c. Assessing, observing, and documenting care of access sites, as applicable d. Nutrition and hydration, including the provision of meals and snacks on treatment days e. Lab tests f. Vital Signs g. Provision of medications on dialysis treatment days, such as which medications are: i. Administered during dialysis ii. Held prior to dialysis iii. Given prior to dialysis iv. Administered by dialysis staff h. Transportation arrangements i. Addressing any identified psychosocial needs . Review of Resident #71's medical record revealed an admit date of 03/04/2022 with diagnoses that included chronic kidney disease stage 4, dementia with behavioral disturbance, dependence on renal dialysis, and COVID-19. Review of Resident #71's MDS dated [DATE] revealed a BIMS score of 6 which indicated the resident's cognition was severely impaired. Further review of the MDS revealed Resident #71 required extensive assistance with bed mobility, transferring, eating, and toilet use. Review of Resident #71's medical record revealed no evidence of any communication sheets between the facility and the dialysis center. Further review of the medical record revealed no pre or post dialysis weights documented or documentation of the resident's vital signs before departing for dialysis. In an interview on 08/02/2022 at 3:40 p.m., S2 LPN acknowledged they do not have a dialysis communication book for Resident #71 nor do they send any communication form with the resident to dialysis. S2 LPN further reported dialysis does not send any type of communication back with the resident when she returns. S2 LPN reported dialysis never sends us anything. S2 LPN explained Resident #71 usually returns from dialysis around 12:30 p.m. but didn't get back today until about 2 p.m. S2 LPN explained dialysis staff didn't call or send any paperwork back with the resident. S2 LPN reported Resident #71's family member told her that the resident's port got clogged up at dialysis and caused the delay today. In an interview on 08/02/2022 at 3:44 p.m., S3 LPN confirmed they do not have a dialysis communication book for Resident #71. In an interview on 08/03/2022 at 11:47 a.m., S1 DON confirmed the facility does not utilize a dialysis communication book for Resident #1 nor do they use a dialysis communication sheet. S1 DON confirmed the facility does not send any information to dialysis with the resident and confirmed the resident does not return with any paperwork from the dialysis center.

COURTYARD OF NATCHITOCHES

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