Does Natchitoches Nursing and Rehabilitation Center, LL have any serious inspection findings?

Yes, Natchitoches Nursing and Rehabilitation Center, LL has 4 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 70 total deficiencies from recent inspections.

What are the staffing levels at Natchitoches Nursing and Rehabilitation Center, LL?

Natchitoches Nursing and Rehabilitation Center, LL has a two-star staffing rating from CMS with 0.27 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Natchitoches Nursing and Rehabilitation Center, LL

Name: Natchitoches Nursing and Rehabilitation Center, LL
Address: 750 KEYSER AVENUE, NATCHITOCHES, LA, 71457, US
Telephone: (318) 352-8779
Rating: 1.0

750 KEYSER AVENUE, NATCHITOCHES, LA 71457 · (318) 352-8779

For profit - Limited Liability company 98 Beds NORBERT BENNETT & DONALD DENZ Data: November 2025 4 Immediate Jeopardy citations

Trust Grade

0/100

#230 of 264 in LA

Share this report:

Natchitoches Nursing and Rehabilitation Center, LL nursing home in NATCHITOCHES, LA - Photo 1 of 2

Natchitoches Nursing and Rehabilitation Center, LL nursing home in NATCHITOCHES, LA - Photo 2 of 2

Photo by Google Street View

View 360° on Google Maps

Last Inspection: March 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Natchitoches Nursing and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the facility's care and operations. Ranked #230 out of 264 nursing homes in Louisiana, it is situated in the bottom half of facilities statewide, and it is the least favorable option in Natchitoches County. Although the facility is showing signs of improvement, with issues decreasing from 23 in 2024 to 9 in 2025, it still faces critical deficiencies, including a failure to monitor residents' health needs effectively and not following care plans, which put residents at risk. Staffing is a concern with a 69% turnover rate, suggesting instability in personnel, and while RN coverage is average, the facility has incurred $731,236 in fines, the highest in Louisiana, indicating ongoing compliance issues. Specific incidents include a resident not receiving critical lab monitoring and another resident who was able to leave the facility unnoticed, raising serious safety alarms. Overall, while there are some signs of improvement, families should be cautious given the facility's past performance and current challenges.

Trust Score: F
In Louisiana: #230/264
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $731,236 in fines. Lower than most Louisiana facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 70 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 23 issues

2025: 9 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Louisiana average (2.4)

Significant quality concerns identified by CMS

Staff Turnover: 69%

23pts above Louisiana avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $731,236

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: NORBERT BENNETT & DONALD DENZ

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (69%)

21 points above Louisiana average of 48%

The Ugly 70 deficiencies on record

4 life-threatening 2 actual harm

Jun 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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure x-ray results were followed up on in a timely manner for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: Review of Resident #1's clinical record revealed an admit date of 09/08/2020, with diagnoses which included Alzheimer's Disease with Late Onset; Vitamin Deficiency, Pain in Left Hip; Unspecified Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Unspecified Abnormalities of Gait and Mobility; Lack of Coordination, Muscle Weakness, Fracture of Unspecified Part of Neck of Left Femur, Presence of Left Artificial Hip Joint, and Dementia. Review of Resident #1's Care Plan dated 01/12/2025 revealed in part At risk for falls/injuries. 2/28/24; 3/16/24; 5/30/25: Unwitnessed fall with interventions to include . Contact MD with abnormal findings. Review of Resident #1's Progress notes revealed in part . Nursing note dated 05/30/2025 at 5:18 p.m. by S2 LPN: around 3:45pm Aid notified this nurse that Resident #1 was in pain during brief change, aid states that resident was holding L hip and screaming during change, when this nurse went to assess resident, resident appeared to be in pain, resident was asked where did she hurt, resident began to hold left thigh, NP was notified around 4:00 pm and she ordered STAT X-ray of the L hip This nurse called . to order STAT X-ray of L hip, this nurse reported everything to the oncoming nurse. Nursing note dated 05/30/2025 at 8:30 p.m. by S3 LPN: Late Entry: Resident C/O left hip pain. Nurse administered PRN medications and was effective. Bed in low position. Will continue to monitor. Nursing note dated 05/31/2025 at 10:45 a.m. by S2 LPN: NP was notified of X-ray results NP ordered for resident to be sent out to ER for CT scan . Resident #1 left facility by ambulance around 10:30 am. Review of Client #1's x-ray results revealed . Date of Service: 05/30/2025. Findings: There is a nondisplaced intertrochanteric fracture noted; Electronically Signed: 05/30/2025 at 7:20 p.m. received on 05/31/2025 at 9:20 a.m. Interview with S2 LPN on 06/18/2025 at 2:19 p.m. revealed on 05/30/2025 around 4:00 p.m., she put in a STAT order for Resident #1's x-ray to her left hip and the x-ray tech came between 6:00 p.m. and 6:30 p.m. S2 LPN stated that STAT x-ray results normally came back within a few hours. S2 LPN revealed that she reported Resident #1's x-ray results were pending to S3 LPN during shift change. Interview with S3 LPN on 06/18/2025 at 4:25 p.m. revealed on 05/30/2025 at 6:00 p.m., she received report from S2 LPN and was made aware that Resident #1 was awaiting x-ray results. S3 LPN stated that she observed the x-ray technician and S2 LPN assisting Client #1 during the x-ray. S3 LPN revealed that she expected the x-ray results in 2-3hrs max and that she would normally call if results were taking a long time. S3 LPN revealed that the x-ray results still had not come in by 05/31/2025 at 6:00 a.m. S3 LPN confirmed that she did not call to check on the x-ray results and she should have. S3 LPN stated that had she known the results were a fracture, she would have sent Resident #1 out that night to the Emergency Room. Interview with S1 DNS on 06/18/2025 at 3:00 p.m. revealed that STAT orders are normally received within 1-2 hours and if the nurse was aware of a pending x-ray result, she should know to look for the results. S1 DNS revealed that nursing staff would normally call the Imaging Center if the results were not sent within 2 hours. S1 DNS confirmed Resident #1's x-ray results should have been followed up on by the nurse assigned to care for Resident #1 that night and had not been.

Mar 2025 6 deficiencies 1 Harm

SERIOUS (H)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected multiple residents

Read full inspector narrative →

Resident #36 Review of an undated facility policy on 03/12/2025 at 11:15 a.m. titled, Meal Time Observation for Food Acceptance and Food Replacement revealed the following in part .Guideline: Residents will be observed during meal times to monitor acceptance and intake of food and beverage items, and offered food replacements of similar nutritive value or other food selections the resident might enjoy. Review of Resident #36's medical record revealed an admission date of 04/24/2024 and diagnoses included in part .Type 2 Diabetes Mellitus with Diabetic Mononeuropathy, Morbid Severe Obesity due to Excess Calories, Major Depressive Disorder, Single Episode, Anxiety Disorder, Neuromuscular Dysfunction of Bladder, and Essential Primary Hypertension. Review of Resident #36's Quarterly and State Optional MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/23/2025 revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. The resident was independent with eating. Review of Resident #36's care plan with an initial date of 11/12/2024 revealed the following in part .Focus: the resident has an ADL self-care performance deficit related to activity intolerance. Interventions: Eating-the resident is able to feed self with tray set up. Diet is pureed texture with nectar thickened consistency. Focus: the resident has a nutritional problem or potential for a nutritional problem related to dietary restriction, Diabetes Type II, swallowing issues, and dysphagia. Interventions: provide and serve diet as ordered. On 03/10/2025 at 12:13 p.m., Resident #36 was observed sitting in his wheelchair in the day area at a table alone. Resident #36 stated he had not received his lunch tray and he was hungry. Observation on 03/10/2025 at 12:18 p.m., revealed lunch carts being pushed out the kitchen for meal service and staff members serving lunch in the day area. Observed other residents eating in the day area and Resident #36 seated at a table alone in the day area with no lunch tray. Observation on 03/10/2025 at 12:21 p.m., revealed S5 CNA perform meal services which included handing out lunch trays and assisting residents with opening their beverages. Observed S5 CNA push her lunch cart out of the day area. Observed Resident #36 still seated at the table in the day area with no lunch tray. In an interview on 03/10/2025 at 12:28 p.m., S5 CNA revealed she had completed meal services in the day area. S5 CNA stated her lunch cart did not have Resident #36's lunch tray that his lunch tray was on the other lunch cart. In an interview on 03/10/2025 at 12:37 p.m., S4 CNA stated she was assigned to Resident #36 today and responsible for his meal services. S4 CNA stated she had asked Resident #36 if he was eating lunch and he refused and she did not offer an alternate meal. S4 CNA stated she put his original lunch tray in his room. S4 CNA confirmed she had thrown Resident #36's lunch tray in the garbage. In an interview on 03/10/2025 at 12:38 p.m., Resident #36 stated he did not refuse his lunch meal and he was hungry. Surveyor observed Resident #36 still seated in the day area at a table alone with no lunch tray. In an interview on 03/10/2025 at 12:44 p.m., Resident #36 stated that he normally eats in the day area with the other residents. Resident #36 confirmed he was not offered his lunch tray earlier and he did not refuse his lunch tray. In an interview on 03/10/2025 at 1:40 p.m., S10 LPN revealed she was assigned Resident #36 today and often cared for him. S10 LPN stated Resident #36 does not refuse his meals and has a good appetite. S10 LPN confirmed that Resident #36 should have been served his lunch tray in the day area with the other residents and S4 CNA should not have put his lunch tray in his room. S10 LPN confirmed that if Resident #36 did refuse his lunch tray, S4 CNA should have been offered his meal again or offered an alternate meal. In an interview on 03/10/2025 at 2:06 p.m., S2 DON confirmed that S4 CNA should have offered Resident #36 his lunch tray in the day area with the other residents and should not have left his lunch tray in the room. Based on observations, interviews, and record reviews, the facility failed to implement, monitor, and modify interventions, consistent with the resident's assessed needs and current professional standards of practice, to maintain acceptable parameters of nutritional status for 2 (Resident #3, and Resident #36) of 3 (Resident #3, Resident #14, and Resident #36) residents sampled for nutrition. The facility failed to ensure: 1. Meal intake was recorded for every meal for Resident #3 as care planned; 2. Resident #3 was assisted with all meals as care planned; 3. The MD/NP was notified when Resident #3 refused to eat, as care planned; 4. The MD/NP was notified of a severe weight loss for Resident #3; and 5. Failing to ensure a resident was provided a meal tray during lunchtime. This deficient practice resulted in an actual harm for Resident #3 on 03/05/2025 at 11:35 a.m., when S12 RD identified that Resident #3 had experienced a 7.7% severe weight loss that occurred from 12/04/2025 through 03/03/2025. Review of Resident #3's medical record revealed from 01/21/2025 through 03/03/2025, Resident #3 was not assisted with all meals, meal intake had not been recorded for every meal, and the MD/NP had not been notified when Resident #3 refused to eat and had exhibited severe weight loss. Findings: Review of an undated facility policy on 03/12/2025 at 11:15 a.m. titled, Meal Time Observation for Food Acceptance and Food Replacement revealed the following in part .Guideline: Residents will be observed during meal times to monitor acceptance and intake of food and beverage items, and offered food replacements of similar nutritive value or other food selections the resident might enjoy. Resident #3 Review of Resident #3's medical record revealed an admission date of 12/08/2016, with diagnoses that included, in part .Dementia and Alzheimer's disease. Review of Resident #3's Quarterly MDS with ARD of 12/19/2024 revealed a BIMS score of 99, indicating Resident #3 was unable to complete the interview. Resident #3 required partial to moderate assistance with eating. Review of an untitled form for Resident #3 dated 03/12/2025 revealed, in part: Eating/Nutrition: Assist resident with feeding at all meals Assist x1 staff for eating Provide and serve diet as ordered Set up assist and feed assist with all meals Review of Resident #3's weight records revealed on 12/04/2024, the resident weighed 141.0 lbs. On 03/03/2025, the resident weighed 130.2 pounds, a 7.7 % weight loss over the previous 3 months. Review of Resident #3's Care Plan revealed the resident had a nutritional problem or a potential nutritional problem related to Anorexia and Alzheimer's disease, with a problem onset date of 01/21/2025. The goal revealed the resident will maintain weight and consume at least 75% of most meals daily through review date. Interventions included, in part .monitor, document, and report if resident refuses to eat; feed resident all meals; and record intake every meal. Review of Resident #3's EHR revealed the CNA Plan of Care Response History for the following tasks from 12/04/2025 through 03/12/2025: ADL - Eating: 1. Resident #3's meal intake was not recorded on 12/18/2024, 12/20/2024, 12/23/20254, 12/25/2024, 12/27/2024, 12/28/2024, 01/01/2025, 01/06/2025, 01/12/205, 01/13/2025, 01/21/2025 - 01/30/2025, 02/03/2025 - 02/09/2025, 02/12/2025 - 02/15/2025, 02/17/2025, 02/19/2025, 02/20/2025, 02/23/2025, 02/26/2025, 02/27/2025, 03/01/2025, 03/03/2025, 03/04/2025, 03/07/2025, 03/08/2025, 03/09/2025 and 03/12/2025, as indicated on the plan of care. 2. Resident #3 refused 1 of 3 meals on 01/14/2025, and 1 of 3 meals on 01/17/2025. There was no documentation that Resident #3's meal refusals were reported as indicated on the care plan. 3. Resident #3 was documented as independent - no help or staff oversight at any time for 80 meals. Nutrition - Amount Eaten dated 12/04/2024 through 03/12/2025 revealed intake had not been recorded for 58% of meals served. She refused to eat 1 meal on 01/14/2025 and 1 meal on 01/17/2025. Review of Resident #3's RD Nutrition Assessment noted by S12 RD on 03/05/2025 revealed, in part . resident has had a decline. Gradual weight loss over the last 180 days with significant weight loss of 7.7% over the past 90 days. No new recommendations. Review of Resident #3's medical record revealed no documentation of MD or NP notification of meal refusal on 01/14/2025 or 01/17/2025. Review of Resident #3's medical record revealed no documentation of MD or NP notification of the 7.7% severe weight loss. Interview with S7 LPN on 03/11/2025 at 2:58 p.m. revealed she did not check Resident #3's medical record to monitor daily meal intake. She stated the CNA would notify her verbally if the resident had not eaten well, but had not received any such notification. Interview with S14 CNA on 03/12/2025 at 12:38 p.m. revealed she did not document Resident #3's meal intake in the medical record or report it to the nurse. She stated if Resident #3 consumed 5-25% of the meal, she wrote that information on the resident's meal ticket, placed the ticket on the tray, and returned the tray to the dietary department for review. S14 CNA stated she had worked in the facility for 16 years and this had always been the process for documenting meal intake. Interview with S15 Dietary Staff member on 03/12/2025 at 12:44 p.m., revealed she discarded meal tickets that were returned with resident meal trays. She stated dietary staff were not responsible for documenting or recording meal intake for residents. She stated she did not collect any information from the ticket, or monitor/record intake of the meal. Interview with S2 DON on 03/12/25 at 2:44 p.m. revealed the CNA was to notify the nurse if a resident consumed 50% or less of any meal. She stated the amount consumed was to be documented in the EHR after each meal, but that is something we are working on. S2 DON stated she was aware the CNAs had not been documenting meal intake. S2 DON stated the Registered Dietician (RD) reviewed the resident's weights, entered them into the electronic medical record, and gave the facility a list of her recommendations at each visit. S2 DON stated nursing staff, typically S2 DON or S6 Unit Manager, would notify the MD/NP of the RD's recommendations and of any weight loss identified. Interview with S12 RD on 03/12/2025 at 3:40 p.m. revealed the resident's weights and her recommendations were given to the nursing staff at each visit. The information was stored in a binder in S2 DON's office. S12 RD stated the resident's meal intake was not always documented in the electronic medical records, and the information was not reliable. Interview with S2 DON on 03/12/2025 at 4:23 p.m. confirmed Resident #3's meal intake had not been documented as ordered, but should have been. S2 DON confirmed the MD/NP were not notified of Resident #3's severe weight loss on 03/05/2025, but should have been. S2 DON could not explain why MD/NP had not been notified of Resident #3's severe weight loss. On 03/12/2025 at 4:34 p.m. S2 DON stated she had notified S13 NP of Resident #3's severe weight loss, and S13 NP would be entering orders. Telephone interview with S13 NP on 03/14/2025 at 11:25 a.m. confirmed she had not been notified of Resident #3's severe weight loss until 03/12/2025. She stated she ordered an appetite stimulant, and would have ordered the appetite stimulant on 03/05/2025 had she been notified of the severe weight loss. S13 NP confirmed there had been a delay in treatment for Resident #3's significant weight loss. S13 NP confirmed the appetite stimulant would have decreased, or even stopped, Resident #3's weight loss.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #23 Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, and mental and psychosocial needs for 1 (#23) of 24 sampled residents. The facility failed to ensure Resident #23 was care planned for discharge planning. Findings: Review on 03/12/2025 of the facility's policy titled Comprehensive Person Centered Care Plans last revised on 01/2025 revealed in part .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .The Comprehensive Person-Centered Care Plan contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines. Review of Resident #23's medical record revealed an admit date of 02/19/2024 with diagnoses that included in part .Schizophrenia, Diabetes Mellitus, and Chronic Pain Syndrome. Review of Resident #23's Quarterly MDS with an ARD of 12/05/2024 revealed a BIMS score of 15, which indicated intact cognition. Review of the MDS revealed Resident #23 required set up or clean up assistance with eating and was independent with rolling left and right, sitting to lying, lying to sitting, sit to stand, and chair/bed to chair transferring. The MDS review revealed the following: Is active discharge planning already occurring for the resident to return to the community? Yes. Has a referral been made to the Local Contact Agency (LCA)? Yes On 03/11/2025 at 1:30 p.m., a review of Resident #23's current care plan initiated on 01/02/2025 with a review date of 04/02/2025 revealed no evidence of discharge planning for the resident. In an interview on 03/11/2025 at 12:00 p.m., Resident #23 stated he had asked S2 DON about being moved to a facility in [NAME] but hadn't heard anything back. Resident #23 stated he asked S1 Administrator about it last week and hasn't heard anything back yet, but said he still wants to move. In an interview on 03/12/2025 at 11:51 a.m., S8 MDS confirmed Resident #23 was not care planned for remaining in the facility long term or for discharge planning. S8 MDS stated his care plan was completed by someone else prior to her being employed at this facility. S8 MDS stated all residents should be care planned for remaining in the facility or discharge planning. In an interview on 03/12/2025 at 2:52 p.m., S1 Administrator confirmed Resident #23 should have been care planned for discharge plannning and was not.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interviews, and record review, the facility failed to ensure all services provided met professional standards of quality. The facility failed to notify the physician of 3+ edema for 1 (#26) of 58 sampled residents. Findings: Review of Resident #26's medical record revealed an admission date of 03/17/2020, with a diagnosis of Edema. Review of Resident #26's current Physician Orders dated 10/31/2024 revealed . Monitor edema every shift. Indicate any edema with 0, 1+, 2+, 3+, or 4+. Notify physician if 3+ or 4+. Review of Resident #26's 01/2025 Progress Notes revealed Resident #26 had 3+ edema on 01/03/2025. Review of Resident #26's 01/2025 MAR revealed 3+ edema was documented on 01/09/2025. Review of Resident #26's 02/2025 MAR revealed 3+ edema was documented on 02/02/2025, 02/03/2025, 02/05/2025, 02/06/2025, 02/15/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, and 02/28/2025. Review of Resident #26's 03/2025 MAR revealed 3+ edema was documented on 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/10/2025, and 03/11/2025. Review of Resident #26's Encounter Note by S13 NP dated 02/10/2025 revealed, in part . History of Present Illness: edema to bilateral lower extremities Examination: Lymphatics: lymphedema to bilateral lower extremities, Musculoskeletal: Bilateral lower extremity edema Plan: Continue Lasix 40mg by mouth every morning, discontinue Lasix 20mg by mouth each night, monitor and report for increased edema Review of Resident #26's 01/2025, 02/2025, and 03/2025 Progress Notes revealed there was no documentation the physician was notified of 3+ edema on 01/03/2025, 01/09/2025, 02/02/2025, 02/03/2025, 02/05/2025, 02/06/2025, 02/15/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, 02/28/2025, 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/10/2025, and 03/11/2025. Observation of Resident #26 on 03/11/2025 at 9:25 a.m. revealed 3+ edema to bilateral lower extremity. Observation of Resident #26 on 03/11/2025 at 2:48 p.m. revealed 3+ edema to bilateral lower extremity. Interview with S7 LPN on 03/11/2025 at 2:48 p.m. revealed she had documented 3+ edema for Resident #26 on 03/10/2025 and 03/11/2025. S7 LPN stated she did not notify the physician of 3+ edema on 03/10/2025 or 03/11/2025. S7 LPN confirmed Resident #26's MAR indicated the physician was to be notified of 3+ or 4+ edema. Interview with S2 DON on 03/12/2025 at 2:44 p.m. confirmed the physician was not notified of Resident #26's 3+ edema on 03/10/2025 and 03/11/2025, but should have been.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Resident #59 Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 (#59) of 1 resident reviewed for ADLs (Activities of Daily Living). Findings: Review of Resident #59's medical record revealed an admit date of 01/13/2025 with diagnoses that included in part .Polyosteoarthritis, Type 2 Diabetes Mellitus, and Hypertension. Review of Resident #59's admission MDS with an ARD of 01/20/2025 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #59 was independent with eating and required partial to moderate assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed to chair transferring. Review of Resident #59's care plan revealed a focus area initiated on 01/17/2025 of The resident has an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance and stroke. Interventions included in part .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Observation of Resident #59 on 03/10/2025 at 9:38 a.m. revealed long, dirty fingernails on both hands. In an interview at this time, Resident #59 stated he would like his nails to be cut. Observation of Resident #59 on 03/11/2025 at 9:39 a.m. revealed the resident's nails were still long and needed to be cut. In an interview at this time, Resident #59 stated no one had offered to cut his nails, he had never refused to have them cut, and would like them to be cut. Observation of Resident #59's nails with S2 DON on 03/11/2025 at 9:41 a.m. revealed long nails to both hands. S2 DON confirmed the nails were long and needed to be cut. S2 DON stated the Treatment Nurse should have cut them.

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 F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Resident #23 Review of Resident #23's medical record revealed an admit date of 02/19/2024 with diagnoses that included in part .Schizophrenia, Diabetes Mellitus, Major Depressive Disorder, and Chronic Pain Syndrome. Review of Resident #23's Quarterly MDS with an ARD of 12/05/2024 revealed a BIMS score of 15, which indicated intact cognition. Review of Resident #23's current care plan revealed a focus area initiated on 01/02/2025 of The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, physical limitations. Interventions included in part .Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. Resident enjoys socials, bingo, arts and other group activities, likes to attend resident council meetings. Just needs reminders. Invite the resident to scheduled activities. In an interview on 03/10/2025 at 10:15 a.m., Resident #23 stated the facility doesn't have activities on the weekends and not enough during the week. Resident #23 stated during the week, the facility sometimes just has one activity per day, in the afternoon. In an interview on 03/11/2025 at 12:00 p.m., Resident #23 said there were no activities on Sunday, 03/09/2025. Resident #25 Review of Resident #25's clinical record revealed an admission date of 09/16/2024 with diagnoses that included Paraplegia, Unspecified; Drug-Induced Polyneuropathy; Generalized Anxiety Disorder; Acquired Absence of Right Leg Above Knee; Acquired Absence of Left Leg Above Knee; Colostomy Status; and Major Depressive Disorder. Review of Resident #25's Quarterly MDS with an ARD of 03/21/2025 revealed a BIMS score of 15 indicating intact cognition. Interview on 03/11/2025 at 11:25 a.m. with Resident #25 stated the facility has never offered activities on weekends since he's been admitted . Resident #25 stated no activities were offered this past weekend (03/8/2025-03/09/2025). Based on interview and record review the facility failed to provide an ongoing activities program to support residents in their choice of activities based on comprehensive assessments, care plans and preferences for 3 (Resident #23, Resident #25, and Resident #41) of 24 sampled residents. The facility failed to ensure an activities program occurred on the weekend. This deficient practice has the potential to effect all 58 residents currently residing in the facility. Findings: Review of a facility policy on 03/11/2025 at 2:00 p.m. titled, Activities and Social Events with a reviewed date of 10/2009, revealed the following in part .Procedure: 4. Daily activities, including those on the weekends and holidays, are provided, as well as scheduled religious and social activities .9. Individualized and group activities are provided that: B. are offered at hour of convenient to the residents, including evenings, holidays, and weekends. Review of the facility's March 2025 activities calendar revealed the following scheduled activities in part . 03/08/2025: 11:00 a.m. Ring Toss and 2:00 p.m. Blackjack 03/09/2025: 11:00 a.m. Online Church and 2:00 p.m. Board Games Resident #41 Review of Resident #41's medical record revealed an admission date of 09/12/2023 with diagnoses that included in part . Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Type 2 Diabetes Mellitus Without Complications. Review of Resident #41's Quarterly and State Optional MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/06/2025 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. Resident #41 was independent with bed mobility, transfers, and toileting. Review of Resident #41's Annual MDS with an ARD of 07/08/2024 revealed that it was very important to participate in group activities and perform his favorite activities. Review of Resident #41's care plan with an initial date of 11/29/2024 revealed the following in part .Focus: the resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to disease processes. Interventions: invite the resident to scheduled activities, provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, the resident prefers the following radio stations-old school rhythm and blues (R&B), and the resident needs assistance with activities of daily living (ADLs) as required during the activity. In an interview on 03/11/2025 at 8:46 a.m., Resident #41 revealed the facility activities are very poor and do not occur often. Resident #41 stated that S3 Activity Director only plays bingo on Mondays, Tuesdays, and Wednesdays and bingo is really the only organized activity that is done with the residents. Resident #41 revealed that S3 Activity Director is at the facility on the weekends but does not provide activities for the residents. Resident #41 stated this past weekend (03/08/2025 and 03/09/2025) there were no activities provided for the residents. Resident #41 stated he would like to have more activities on the weekend. In an interview on 03/11/2025 at 10:44 a.m., S5 CNA stated that on the weekends there are not many activities for the residents. S5 CNA confirmed she worked Sunday, 03/09/2025, from 7:00 a.m. -7:00 p.m. S5 CNA revealed part of her job duties are to get residents dressed and brought to the day area for activities. S5 CNA stated on Sunday, she did not bring any residents to the day room or assist with any activities because there were no activities provided. In an interview on 03/11/2025 at 12:01 p.m., S3 Activity Director revealed she is currently working seven days a week due to the activity assistant quitting. S3 Activity Director stated she works on the weekends and performs two scheduled activities on Saturday and Sunday. S3 Activity Director stated she does not delegate any of the schedule activities to the CNAs or other staff members and conducts the activities herself. In an interview on 03/11/2025 at 12:48 p.m., Resident #41 referenced his March 2025 activity calendar and stated that on Sunday, 03/09/2025, the scheduled activities were 11:00 a.m. Online Church and 2:00 p.m. Board Games. Resident #41 confirmed he never saw S3 Activity Director on Sunday, 03/09/2025, and the scheduled activities did not occur. In an interview on 03/12/2025 at 8:45 a.m., S11 CNA revealed on weekends there are very few resident activities. S11 CNA stated that S3 Activity Director does not come into work every weekend to perform activities. S11 CNA stated he worked day shift on 03/01/2025 and 03/02/2025 and did not bring any residents to the day room or assist with any activities because there were no activities provided. Review of S3 Activity Director's employee Time and Attendance Time Card for the last three weekends revealed in part Clock In/Out time: 02/22/2025, Saturday: no time 03/09/2025, Sunday: no time During an interview on 03/12/2025 at 09:26 a.m., S1 Administrator confirmed that S3 Activity Director had no time logged on the time clock for 02/22/2025 and 03/09/2025, which indicated she did not come into the facility on Saturday, 02/22/2025 and Sunday, 03/09/2025, to perform her duties as Activity Director.

CONCERN (E)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meetings included the required staff members for the facility's quarterly committee meetings. The facility failed to ensure the Infection Preventionist (IP) was in attendance at each quarterly committee meetings. This deficient practice had the potential to affect all 58 residents residing in the facility. Findings: Review of the facility's policy on 03/12/2025 at 2:40 p.m. titled Quality Improvement Program, with a revision date of 10/2022, revealed the following in part .Procedure 2. Committee team members shall consist of the DNS, Medical Director or designee, and three other staff; at least one of who must be the Administrator, Owner, a Board Member, or other individual in a leadership role; and the Infection Preventionist. Review of the facility's QAA Committee list revealed the following in part .The QAA Committee meets once monthly and as needed. The committee is comprised of: Executive Director, Director of Nursing, Medical Director, Social Services, Infection Control, Medical Records, MDS, Activities, Maintenance, Dietary, and Therapy. Review of the facility's Quarterly QAA Committee Meeting sign in sheets revealed the following staff were in attendance: 1. April 12, 2024-Executive Director, Director of Rehab, Activities Director, Dietary Manager, Housekeeping, Unit Manager-LPN, LPN-MDS, Medical Records, and Medical Director 2. July 12, 2024-Director of Rehab, Activities Director, Dietary Manager, Housekeeping, Unit Manager-LPN, LPN-MDS, Medical Records, and Medical Director 3. August 2024-Medical Director, Business Office Manager (BOM), Director of Maintenance (DON), Housekeeping, Social Services Director (SSD), Medical Records, Unit Manager, Activities Director, Dietary Manager, Administrator 4. September 2024-Medical Director, BOM, Director of Maintenance, Housekeeping, SSD, Medical Records, Unit Manager, Human Resources, Activities Director, Dietary Manager, and Administrator 5. January 17th, 2025-Administrator, Human Resources Representative, Director of Food and Nutrition, Therapy, Director of Maintenance, Medical Records, LPN-MDS, Activities Director, and SDC. Interview on 03/12/2025 at 4:10 p.m. with S1 Administrator confirmed the IP wasn't in attendance at any of the QAA Committee meetings and should have been.

Jan 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and interview, the facility failed to ensure the Medical Director was notified when a hospice resident had an accident resulting in injury and pain that could not be relieved for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility waited 14 hours for hospice to come assess Resident #1 before sending the resident to the emergency room. Findings: Review of facility's policy on 01/07/2025 titled Notification of Change in a Resident's Status dated 11/2017 revealed in part . 1. Guideline for notification of physician/responsible party: j. Abnormal complaints of pain, ineffective relief of pain from current regimen. Review of Resident #1's medical record revealed an admit date of 05/15/2020 with diagnoses that included in part .Alzheimer's Disease, Major Depressive Disorder, Pressure Ulcer of Sacral Region, and Edema. Review of Resident #1's Quarterly MDS with an ARD of 12/12/2024 revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Review of the MDS revealed Resident #1 was dependent with eating, rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transferring. Review of Resident #1's Care Plan revealed a problem onset on 09/05/2024 of Palliative Care, Resident is on Hospice. Interventions included: Provide tube feeding as ordered; provide pressure reducing devices to bed and chair; monitor for signs and symptoms of dehydration every shift; provide pain medication as ordered by MD and monitor effectiveness of medication; provide pain assessment every shift; hospice nurse to visit weekly and prn; hospice CNA to visit 2 times weekly; and monitor for signs and symptoms of altered respiratory status such as SOB, labored respirations, congestion, and abnormal breathing. Review of a facility Incident Report dated 12/13/2024 at 11:03 p.m. prepared by S3LPN revealed the following: Nurse went into room after hearing resident calling out for help. Upon entering room Resident was sitting on the floor with her back propped up against bed and her legs were folded underneath her. Aides were present in room. Resident skin was inspected. No breaks in skin or bruising noted. Resident does have raised area to left knee laterally and medially. Range of Motion not performed due to contractures. Resident is currently under the care of Hospice. Hospice and DON notified. Hospice Nurse on call gave order to schedule x-ray and to administer prn Lorazepam and Hydromorphone. Resident's daughter is present in room and is Responsible Party. Review of Resident #1's progress notes revealed the following: 12/14/2024 at 12:21 a.m. (late entry) by S3LPN - Nurse went into room after hearing resident calling out for help. Upon entering room resident was sitting on the floor with her back propped up against bed and her legs folded underneath her. Aides were present in the room. No breaks in skin or bruising noted. Resident does have raised area to left knee laterally and medially. Range of motion not performed due to contractures. Resident is currently under the care of hospice. Hospice and (facility) DON notified. Hospice nurse gave order to schedule x-ray and to administer prn Lorazepam and Hydromorphone. Resident's daughter is present in room and is RP 12/14/2024 at 12:25 by S7Unit Manager - Hospice on call RN returned call made by this nurse at 11:30a.m. Hospice nurse voiced resident's advanced age, and stated that if anything is broken it is very unlikely surgery will be able to be performed on her to correct bone d/t comorbidities. Hospice nurse gave order to give Hydromorphone q 4 hours and Lorazepam q 4 hours around the clock to manage pain .She is 30 miles away, for an admit, and will be here to assess her in person as soon as she can, to just keep her comfortable at this point . 12/14/2024 at 12:54 p.m. by S7Unit Manager - This nurse spoke with resident's daughter about x-rays and hospice orders. RP/daughter wants her to go to ER for better, more in depth x-rays and better pain control ER called and Report given to RN. EMS notified of pickup needed . Review of Resident #1's December 2024 MAR and Narcotic count record revealed Resident #1 received Lorazepam 1mg on 12/13/2024 at 11:00 p.m. and 12/14/2024 at 10:50 a.m. Review of Resident #1's December 2024 MAR and Narcotic count record revealed Resident #1 received Hydromorphone 2mg on 12/13/2024 at 11:00 p.m. and 12/14/2024 at 10:50 a.m. Review of triage notes for Resident #1 from hospice agency revealed in part . 12/13/2024 at 11:16 p.m. - (S3LPN) from facility calling, fell out of bed, complaining of left knee pain. Appears to be out of place. Skin not broken, found on floor sitting beside her bed. She is contracted to lower extremities, fall was unwitnessed, she was found with her legs under her, and she has a raised hard area to outside of her left knee. Requesting an order to send her out to ER to be evaluated. Mobile X-ray can be ordered but would likely be in am before taken. 12/13/2024 at 11:28 p.m. - accept, I will follow up and address this patient's needs. Signed by Hospice RN. 12/14/2024 Triage note-11:24 a.m. - (S7Unit Manager) from facility calling to state patient had a fall last night and stated the x-ray results show a broken femur. S7Unit Manager is requesting a return call and visit for info on possible medication orders, since the patient only has Tylenol available for pain. 12/14/2024 at 11:32 a.m. - Accept - I will follow up and address this patient's needs, signed electronically by Hospice RN. In an interview on 01/06/2025 at 2:38 p.m., S3LPN stated she went in Resident #1's room on 12/13/2024 (no time given), and found her on the floor with her legs under her and her back against the bed. S3LPN stated she called hospice, spoke with their on call nurse, told her what happened, that her left leg looked out of place and she thought it was broken. S3LPN stated the hospice nurse told her she didn't need to send her to the ER because if it didn't bruise instantly then it wasn't broken. S3LPN stated the hospice nurse told her to give Resident #1 the Dilaudid and Lorazepam she had ordered and get an x-ray in the morning of her femur. S3LPN stated the hospice nurse said she would come see her in the morning. In an interview on 01/06/2025 at 2:45 p.m., S6 CNA stated she was working with S5CNA and they heard yelling. S6CNA stated they realized it was Resident #1, went in her room, and found her on the floor with her back against bed and her left leg behind her. S6CNA said S3LPN came in and checked the resident before they put her up in bed. S6CNA stated you could see a lump or swelling on her left leg above her knee. S6CNA stated S3LPN gave her something for pain but said Resident #1 was in pain the rest of the night. S6CNA stated Resident #1 cried out when you touched her left leg. In a telephone interview on 01/07/2025 at 7:05 a.m., S5CNA stated she heard hollering and went down the hall and found Resident #1 sitting on the floor with her back against the bed. S5CNA stated the resident was in severe pain. S5CNA stated she and another aide put her back in bed and the nurse was in the room to assess her. S5CNA stated the resident was in severe pain and never went back to sleep. S5CNA stated Resident #1 was hollering in pain saying God take me and I hurt. S5CNA stated the nurse called hospice and gave her Dilaudid, but it didn't help. In a telephone interview on 01/07/2025 at 8:51 a.m., S4LPN stated she came to work at 6:00 a.m. on Saturday morning, 12/14/2024, and received report. S4LPN stated she and the night nurse went to see Resident #1 that morning after report. S4LPN stated Resident #1 was in bed and was in pain. S4LPN stated she would have rated Resident #1's pain as a 6 or 7 based on her facial expressions. S4LPN stated she didn't give Resident #1 any pain medicine until 10:51 a.m. because the night nurse said she had given her pain medicine already. S4LPN stated she asked the resident's daughter if she wanted her to give her mother something else for pain, and she said no. S4LPN said she called hospice that morning and they told her to get an x-ray. S4LPN stated S7Unit Manager sent the resident to the emergency room that day. In an interview on 01/07/2025 at 12:48 p.m., Resident #1's RP stated after Resident #1 fell, S3LPN gave Resident #1 her pain medicine, but it didn't help with her pain. She said Resident #1 hollered all night. She said no one could hardly touch her. Resident #1's RP stated the next morning, S4LPN came in and Resident #1 still had not gotten any pain relief. Resident #1's RP stated S4LPN called hospice to try to get some stronger pain medication. She said x-ray came to do the portable x-ray and she hollered while it was being done. Resident #1's RP stated they were waiting for hospice to come see her. She said about 1:30 pm they sent Resident #1 out to the ER. Resident #1's RP stated the ER had to put her hip back in place and put an immobilizer on her broken leg. In an interview on 01/07/2025 at 3:05 p.m., S7Unit Manager stated she came to the facility to work on care plans on Saturday 12/14/2024 about 8:45 a.m. or 9:00 a.m. S7Unit Manager said she called hospice after the x-ray results were received to tell them no one had come to see Resident #1. S7Unit Manager stated she called hospice and the nurse called her back at 12:25 p.m., and the nurse told her she it would be later in the day before she could come because she was 30 minutes away with another patient. S7Unit Manager stated they did not call their Medical Director or his nurse practitioner because, They won't do anything for hospice residents except tell them to follow up with hospice. In an interview on 01/07/2025 at 3:09 p.m., S2DON stated S3LPN called her during the night after the fall. S2DON stated she called back in morning and hospice had not shown up yet. S2DON stated S3LPN told her they were going to get an x-ray done. S2DON confirmed when hospice didn't come, staff should have done something else. S2DON stated, Yes, I would have called the doctor or sent her out. I probably would have just sent her out. S2DON confirmed the Medical Director and his NP don't usually treat hospice patients, but staff could have called him because something should have been done.

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, and the comprehensive care plan for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure Resident #1, who reported pain after a fall, and displayed nonverbal indicators of pain, received pain medication as ordered to alleviate pain. Findings: Review of facility policy on 01/07/2025, dated 01/2025, and titled Pain Evaluation/Management, revealed the policy did not address the administration of pain medication, as ordered. Review of Resident #1's medical record revealed an admit date of 05/15/2020, with diagnoses that included in part .Alzheimer's Disease, Major Depressive Disorder, Pressure Ulcer of Sacral Region, and Edema. Review of Resident #1's Quarterly MDS with an ARD of 12/12/2024, revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Review of the MDS revealed Resident #1 was dependent with eating, rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transferring. Review of Resident #1's Care Plan revealed a problem of Palliative Care, Resident is on Hospice, with a problem onset date of 09/05/2024. Interventions included in part . provide pain medication as ordered by MD, and monitor effectiveness of medication; provide pain assessment every shift. Review of Resident #1's physician's orders, and Medication Administration Record revealed the following orders: 12/01/2024: Hydromorphone HCL (Narcotic Pain Medication) 2mg Give 1 tablet via G-tube every 4 hours as needed for pain, shortness of breath. (Discontinued 12/14/2024 at 12:25 p.m.). 11/04/2024: Lorazepam Tab (Anti-anxiety Medication) 2mg Give 1 tablet via G-tube every 4 hours as needed for restlessness and agitation. (Discontinued 12/14/2024 at 12:25 p.m.). 12/14/2024 at 12:25 p.m.: Hydromorphone HCL 2mg per peg tube every 4 hours for pain management around the clock. 12/14/2024 at 12:25 p.m.: Lorazepam 2mg per peg tube every 4 hours for pain management around the clock. Review of a facility Incident Report dated 12/13/2024 at 11:03 p.m. prepared by S3LPN, revealed the following regarding Resident #1: Nurse went into room after hearing resident calling out for help. Upon entering room, Resident was sitting on the floor with her back propped up against bed, and her legs were folded underneath her. Aides were present in room. Resident skin was inspected. No breaks in skin or bruising noted. Resident does have raised area to left knee laterally and medially. Range of Motion not performed due to contractures. Resident is currently under the care of Hospice. Hospice and facility DON notified. Hospice Nurse on call gave order to schedule x-ray, and to administer prn Lorazepam and Hydromorphone. Resident's daughter is present in room and is Responsible Party. Review of Resident #1's Progress Notes revealed the following: 12/14/2024 at 12:21 a.m. (late entry) by S3LPN - Nurse went into room after hearing resident calling out for help. Upon entering room resident was sitting on the floor with her back propped up against bed, and her legs folded underneath her. Aides were present in the room. No breaks in skin or bruising noted. Resident does have raised area to left knee laterally and medially. Range of motion not performed due to contractures. Resident is currently under the care of hospice. Hospice and (facility) DON notified. Hospice nurse gave order to schedule x-ray and to administer prn Lorazepam and Hydromorphone. Resident's daughter is present in room and is RP . 12/14/2024 at 12:54 p.m. by S7Unit Manage - this nurse spoke with resident's daughter about x-rays and hospice orders. RP/daughter wants her to go to ER for better, more in depth x-rays, and better pain control .ER called and Report given to RN. EMS notified of pickup needed . Review of Resident #1's December 2024 MAR and Narcotic count record, revealed Resident #1 received Lorazepam 1mg on 12/13/2024 at 11:00 p.m., and 12/14/2024 at 10:50 a.m. Review of Resident #1's December 2024 MAR and Narcotic count record revealed Resident #1 received Hydromorphone 2mg on 12/13/2024 at 11:00 p.m., and 12/14/2024 at 10:50 a.m. In an interview on 01/06/2025 at 2:38 p.m., S3LPN stated on the night of 12/13/2024, she heard the resident hollering and went in her room, and found her on the floor sitting with her legs under her, and her back against the bed. S3LPN stated she called hospice, spoke with their on call nurse, and told her what happened, and that Resident #1's left looked displaced right above her knee, and was swollen, and she (S3 LPN) thought it was broken. S3LPN stated the hospice nurse told her if it didn't bruise instantly then it wasn't broken. S3LPN said the hospice nurse told her to give Resident #1 the Dilaudid (Hydromorphone) and Lorazepam she already had ordered, and get an x-ray of her femur in the morning. S3LPN stated she told the hospice nurse Resident #1 screamed when they lifted her; however, the hospice nurse said we could wait until morning to get an x-ray. S3LPN stated the hospice nurse didn't want Resident #1 sent to the ER and said she would come see her in the morning. S3LPN stated she gave Resident #1 the medications about 20-30 minutes after the fall. S3LPN said the medications were effective and the resident went on to sleep. S3LPN stated she had to go in Resident #1's room multiple times to do her peg tube (she didn't specify how many times or at what time), and she was resting quietly. In a telephone interview on 01/07/2025 at 8:51 a.m., S4LPN stated she came to work at 6:00 a.m. on 12/14/2024, and received report about the fall from the night nurse (S3 LPN). S4LPN stated she and the night nurse went to see Resident #1 that morning after report. S4LPN stated Resident #1 was in bed, and was in pain. S4LPN stated she would have rated Resident #1's pain as a 6 or 7 based on her facial expressions. S4LPN stated she didn't give Resident #1 any pain medicine until 10:51 a.m., because the night nurse said she had given her pain medicine already. S4LPN stated she asked the resident's daughter if she wanted her to give her mother something else for pain, and she said no. S4LPN stated she called hospice that morning because no one had come to see Resident #1 yet. S4LPN stated S7Unit Manager arrived to work on 12/14/2024, around 9:00 a.m., and they sent Resident #1 to the ER at 1:00 p.m. S4LPN stated when she returned to work on the morning of 12/15/2024, the resident wasn't in pain, because the nurse had gotten new orders for pain medication. In an interview on 01/07/2025 at 2:08 p.m., S2DON acknowledged Resident #1 did not receive any pain medication for almost 12 hours, although it was ordered every four hours as needed.

Nov 2024 4 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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, record review, 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 2 (#R1 and #R4) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) sampled residents. The facility failed to maintain privacy for residents by allowing the shower door to remain open during resident care. Findings: Review of the facility's policy dated (01/2023) titled Resident [NAME] of Rights revealed in part .Each resident has a right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the United States without interference, coercion including those rights specified herein. Review of the facility's policy dated (08/2011) titled Bath/Shower- Dependent revealed in part . Responsibility: Nursing Assistants or Licensed Nurses monitored by Charge Nurse. Procedure: Move resident to shower/tub room, close door for warmth and privacy. Observation of X Hall shower room on 11/21/2024 at 8:45 a.m. revealed the shower room was located near the beginning of X Hall. Observation revealed the shower door was propped open with the curtain pulled. Water was heard running, as a resident received care. Staff, residents, and visitors passed the opened shower room door as residents received care. Observation of X Hall shower room on 11/25/2024 at 9:25 a.m. revealed the shower door was propped open with the curtain pulled and water was heard running as Resident #R4 received care by S5 CNA. Resident #R1 was observed near the door of the shower room as he waited to receive a bath. Interview with Resident #R1 on 11/25/2024 at 09:28 a.m. revealed the shower door is usually open with the curtain pulled while he showered. Resident #R1 stated that he would prefer for the door to be closed when he was in the shower room. Record Review of Resident #R1's admission MDS with an ARD of 10/11/2024 revealed a BIMS of 13 (cognition intact). Record Review of Resident #R4's Quarterly MDS with ARD of 09/05/2024 revealed a BIMS of 09 (moderately impaired cognition). Interview on 11/25/2024 at 9:36 a.m. with S5 CNA on X Hall revealed that the door to the shower room should be closed during resident care, but was not. Interview with S1 DON and S2 Corporate RN on 11/25/2024 at 9:45 a.m. confirmed that it was procedure for staff to close the shower room door when care was provided.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure physician's orders were implemented as ordered. The facility failed to administer a medication (antibiotic) when ordered for 1 (#3) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) sampled residents. Findings: Review of the Facility's Policy titled Medication Administration General Guidelines dated (8/2016) revealed in part . Responsibility: All Licensed Nursing Personnel. Procedure: Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. Review of Resident #3's clinical record revealed an admit date of 09/28/2024 with diagnoses that included in part . Urinary Tract Infection, Vitamin Deficiency, Dementia and Osteoarthritis. Review of Resident #3's State Optional MDS with an ARD of 11/09/2024 revealed a BIMS of 6, which indicated severe cognitive impairment. Resident #3 required extensive assistance with one person physical assist for Bed Mobility, Transfers, and Toilet Use. Resident #3 required Supervision with set up help only for eating. Resident #3 had no behaviors for refusing care. Review of Resident #3's Care Plan revealed in part . At risk for cognitive loss and decline in communication as evidenced by BIMS. Interventions included: Administer medications as ordered. Review of Resident #3's Physician's Orders revealed in part . Augmentin (Antibiotic) 875-125mg tab, give 1 tab PO BID to begin 10/18/2024. Review of Resident #3's Progress notes revealed a note by S6 NP dated 10/22/2024 revealed in part . Resident was discharged back to nursing home on [DATE]. Discharge medication of Augmentin 875-125mg twice daily for 10 days. Review of Resident #3's 10/2024 Medication Administration Record (MAR) revealed no documented administration of Augmentin on 10/18/2024; 10/19/2024; 10/20/2024; 10/21/2024; 10/22/2024; or 10/23/2024. No refusals were documented. Interview with S1 DON and S2 Corporate RN on 11/21/2024 at 4:42 p.m. confirmed that Resident #3's Physician's order dated 10/18/2024 for Augmentin should have been administered starting 10/18/2024, but had 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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and interview the facility failed to dispose of garbage and refuse properly. The total facility census was 63 residents. Findings: Review of the facility's undated policy titled, Garbage and Rubbish Disposal on 11/21/2024 at 12:20 p.m. read in part . Guideline: All outside dumpsters will be maintained in a clean and sanitary condition. Procedure: 5. Storage areas will be kept clean to discourage pests. Storage areas should be routinely inspected by the facility pest control operator. 6. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. Observation on 11/21/2024 at 8:51 a.m. of the area outside of the facility's kitchen revealed one blue dumpster located inside a wooden fenced area. The dumpster receptacle was observed with the sliding door left open, and a cat jumped out of the dumpster. Observation revealed there was trash on the ground, in front of dumpster. A torn mattress and two walkers was outside of the dumpster area. Signage observed on the sliding door read in part .dumpster door to be closed at all times. Observation on 11/21/2024 at 1:40 p.m. revealed the dumpster sliding door remained open with trash on the ground. Interview with S4 Housekeeping Supervisor at time of observation revealed housekeeping was responsible for keeping the area around the dumpster clean. S4 Housekeeping Supervisor confirmed the sliding door should be closed at all times and area free of litter, but 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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and interview the facility failed to ensure a safe, functional and comfortable environment for residents. The facility failed to: 1. Repair a toilet base in Room A; and 2. Repair the shower room door on X hall. Findings: Observation of Room A's restroom on 11/21/2024 at 8:58 a.m. revealed broken pieces of a solid material underneath the toilet. Observation of Room A's restroom on 11/25/2024 at 3:28 p.m. revealed broken pieces of a solid material under the toilet. Interview with Resident #R2 on 11/25/2024 at 3:28 p.m. revealed the toilet in his room (Room A) had been in disrepair since he moved into the room last year. Review of Resident #R2's Quarterly MDS with an ARD of 11/07/2024 revealed a BIMS of 15. Observation of the shower door on X Hall on 11/25/2024 at 09:28 a.m. revealed a hole near the bottom of the door that was approximately 6 inches in width. Observation and Interview with S3 Maintenance on 11/25/2024 at 3:32 p.m. confirmed there was a hole and cracked area at the bottom of the shower door on X Hall, and there should not be. S3 Maintenance revealed the base rebroke under the toilet in Room A. S3 Maintenance confirmed the toilet in Room A needed to be repaired.

Oct 2024 3 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Quality of Care (Tag F0684)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and residents' person centered care plans for 6 (#3, #4, #5, #9, #10 and #12) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) sampled Residents. The facility failed to have a system in place to: 1. Notify the physician of a low critical Hemoglobin level for Resident #5 and failed to document bleeding monitoring for Resident #5 and Resident #12; 2. Obtain ordered weekly PT/INR levels for 2 (Resident #5 and Resident #12) of 2 residents receiving Coumadin, (an anticoagulant) therapy; 3. Ensure medications that included anticoagulant, analgesics, and antidiuretics were administered for Residents #5 and #9; 4. Obtain and/or monitor blood glucose levels as ordered for Resident #9; 5. Obtain and/or monitor blood pressure and pulses with medication administration for Resident #9; 6. Obtain routine laboratory draws as ordered for Residents #3 and #10; and 7. Ensure physician orders were followed regarding changing Resident #4's suprapubic catheter. This deficient practice resulted in an Immediate Jeopardy situation for Resident #5, who had a history of Coumadin toxicity and GI bleed, on 05/20/2024 when the facility failed to obtain an ordered PT/INR level and then failed to notify Resident #5's PCP of a critically low Hemoglobin of 7.5 g/dL and continued to administer Coumadin 7.5mg, an anticoagulant/ blood thinner, to Resident #5 on 05/22/2024, 05/24/2024, and 05/28/2024. Resident #5's PCP discovered the low critical laboratory results during a routine visit on 05/29/2024 and ordered STAT CBC and PT/INR. Resident #5 was subsequently transferred to the hospital on [DATE] diagnosed with Coumadin Toxicity, received a blood transfusion and an injection of Vitamin K, and remained hospitalized through 06/01/2024. The deficient practice continued at a potential for more than minimal harm for any resident in the facility who required lab monitoring and notification of changes to their PCP. S1 Administrator was notified of the Immediate Jeopardy situation on 10/24/2024 at 3:36 p.m. Findings: Review of Facility's policy, dated 11/2017, reviewed on 10/08/2024, titled Laboratory Tests read in part . Lab tests are completed as ordered by the physician or physician extender. PT/INR: Initially completed weekly for residents receiving warfarin. If stable and long term may complete monthly. Review of the facility's policy titled Notification of a Change in a Resident's Status, dated 11/2017, revealed in part . The attending physician/physician extender and the resident's representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Guideline for notification of physician/responsible party . f. Abnormal lab findings. Resident #5 Resident #5 admitted to the facility on [DATE] with diagnoses that included: Presence of Prostatic Heart Valve, Chronic Atrial Fibrillation, Cerebrovascular Disease, Persistent Mood Disorder, Liver Disease, Chronic Kidney Disease, COPD, Heart Failure, End Stage Renal Disease, and Dependence of Renal Dialysis. Review of Resident #5's 05/2024 Physician orders revealed an order to obtain PT/INR every Monday dated Friday, 05/17/2024. Review also revealed an order, dated 05/20/2024, to administer Coumadin 7.5mg every other day. There was no order for bleeding monitoring or bleeding monitoring completed for 05/2024 and 06/2024. Review of Resident #5's clinical record revealed there was no evidence a PT/INR had been drawn on Monday, 05/20/2024. Review revealed Resident #5 had a CBC drawn on 05/22/2024 with resulted low critical Hemoglobin of 7.5 which was reported by the laboratory to S6LPN at 2:22 p.m. on 05/22/2024. Review of Resident #5's medical record revealed no documentation Resident #5's PCP had been notified of the low critical Hemoglobin on 05/22/2024 or that Resident #5's PT/INR had not been drawn on 05/20/2024. Review of Resident #5's 05/2024 EMAR revealed Resident #5 received doses of Coumadin 7.5mg on 05/22/2024, 05/24/2024, and 05/28/2024. Review of a progress note for Resident #5, dated 05/29/2024, by S3NP read in part During this evaluation resident told S3NP that she felt like she was bleeding and that she had blood in her stool and has had to have multiple transfusions in the past. She had a critical Hemoglobin on 5/22/2024 of 7.5. S3NP nor MD was notified. S3NP gave orders to obtain PT/INR weekly, however PT/INR has been cancelled in the computer. Stat orders for CBC, PT/INR and fecal occult blood. Results are as follows 05/29/2024 HGB 4.8, HCT 16.6, PT 84.5, and INR 11.02. Orders were given to send patient to ER stat. A review off Resident #5's hospital record revealed Resident #5 was hospitalized [DATE] through 06/01/2024 with a diagnosis of Coumadin toxicity, received Vitamin K, and required 1 unit of packed red blood cells to be transfused. In an interview on 10/08/2024 at 9:30 a.m., S6 LPN revealed that when she received a critical lab, she would notify the NP by call or fax. S6 LPN stated with a critical lab like Resident #5's hemoglobin of 7.5, she probably would have texted S3 NP to notify her of the critical lab, and put it in the folder for the NP to sign off on. S6 LPN stated she could not recall the critical lab from 05/22/24, but it was not uncommon for her (Resident #5) to have a critical lab, because Resident #5 had some issues with bleeding but denied observing blood in her stool. S6 LPN stated she couldn't remember receiving the critical lab value from the lab on 05/22/2024. In a telephone interview on 10/08/2024 at 9:41 a.m., S3 NP stated her standard practice was for all PT/INRs to be drawn weekly on Monday, and Resident #5's PT/INR should have been drawn on Monday, no matter what was going on. S3 NP stated she was not notified of the critical lab on the day the labs were drawn (05/22/2024), and discovered the lab on 05/29/2024. During an interview on 10/09/2024 at 11:45 a.m., S2 DON and S4 Unit Manager revealed they were unsure why Resident #5's PT/INR wasn't drawn on 05/20/2024 but believed the requisition was not put in place after Resident #5 returned from the hospital on [DATE]. Review of Resident #5's 02/2024 EMAR revealed Coumadin 5mg dose was not documented as given on 02/03/2024. Review of Resident #5's EMAR/ETAR revealed monitoring for bleeding was not being done for 05/2024 and 06/2024 Review of Resident #5's 05/2024 EMAR revealed Coumadin 7.5mg dose was not documented as given on 05/26/2024. In an interview on 10/09/2024 at 10:14 a.m., S2 DON revealed the facility received Resident #5's critical H&H lab results on 05/22/2024, and failed to notify the MD or NP of the results, but should have. S2 DON stated the facility failed to ensure Resident #5's ordered PT/INR lab work was completed on 05/20/2024, 05/27/2024 and 06/03/2024, should have been followed up on and ensured that they were completed. S2 DON acknowledged Resident #5 was not being monitored for bleeding/bruising while on Coumadin therapy, but should have been. During an interview on 10/24/2024 at 9:15 a.m., S1 Administrator revealed the issue with the labs not being done and the PCP not being notified of critical labs for Resident #5 was not discovered until it was brought to her attention by the surveyors on 10/08/2024 as she, S2 DON and S4 Unit manager were not working at the facility in 05/2024. In an interview on 10/24/2024 at 11:48 a.m. with S8 Clinical Operations Nurse revealed after reviewing the Resident #5's 02/2024 and 05/2024 EMAR the 02/03/2024 and 05/26/2024 dose of prescribed Coumadin was missed and she believe agency staff worked the shifts and there is no documentation in nurses notes as to why the Coumadin wasn't given. Resident #12 Review of Resident #12's medical record revealed an admit date of 09/04/2021, with diagnoses that included in part .Aortic Valve Replacement, Cerebral Infarction due to Thrombosis, and Schizoaffective Disorder - Bipolar type. Review of Resident #12's current physician orders revealed the following, in part . 01/18/2024: Warfarin Sodium (Coumadin) 4mg, Give 2 tabs (8mg) by mouth every evening; and 11/03/2021: PT/INR every Monday. Review of Resident #12's Annual MDS with an ARD of 08/08/2024, revealed a BIMS score of 14, which indicated intact cognition. Review of the MDS revealed the resident required set up or clean up assistance with eating, and resident was independent with rolling left and right, lying to sitting on bed side, sitting to standing, and chair/bed to chair transferring. Review of Resident #12's Care Plan with a target date of 11/08/2024 revealed a problem of At risk for abnormal bleeding related to use of anticoagulant medications - related to presence of artificial heart valve, with a target date of 11/08/2024. Interventions included: administer medications as ordered, obtain lab work as ordered, and notify physician of results when available, nurse to monitor for active bleeding and bruising .if noted, notify MD, monitor for signs and symptoms of bleeding IE: bruising, black tarry stools, bright red vomit, coffee ground brown vomit, and red/pink/tea colored urine. Coumadin 8mg by mouth every evening. Review of Resident #12's 09/2024 EMAR revealed Resident #12 received 8mg of Coumadin every evening at 4:00 p.m. Review of the 09/2024 MAR revealed nurses were to monitor for active bleeding and bruising every shift, and notify MD if noted, due to Resident #12 on daily Coumadin therapy. The 09/2024 MAR revealed monitoring for active bleeding, was not documented on the 6:00 a.m. - 6:00 p.m. shift on 09/15/2024 and 09/19/2024 or on the 6:00 p.m. - 6:00 a.m. shift on 09/24/2024 and 09/25/2024. Review of Resident #12's 10/2024 EMAR revealed Resident #12 received Coumadin daily, and monitoring for bleeding and bruising was not documented on the 6:00 a.m. - 6:00 p.m. shift on 10/03/2024. Interview with S1 Administrator on 10/08/2024 at 10:00 a.m., and review of Resident #12's medical record revealed Resident #12's PT/INR was last obtained on Tuesday, 09/03/2024, although it was ordered to be checked every Monday. Review of a Progress Note for Resident #12 dated 09/23/2024, by S3 NP, revealed in part . History of present illness: He continues to refuse PT/INR due to him not liking the phlebotomist. Education provided on the importance of this lab .contacted unit managers for further assistance. In a telephone interview on 10/08/2024 at 10:30 a.m., S3 NP stated a PT/INR was supposed to be drawn every week for Resident #12. S3 NP stated after about two weeks of refusals, she went to talk to the resident, who told her he didn't like the phlebotomist, and refused to let her (the phlebotomist) draw it. S3 NP stated the resident agreed to let staff draw it. S3 NP reported she then talked to staff and asked them to draw it, and they agreed, but stated she hasn't received any results yet. In a telephone interview on 10/08/2024 at 11:05 a.m., S4 Unit Manager stated she couldn't recall if, or when she and S3 NP discussed staff drawing Resident #12's lab. S4 Unit Manager said she did recall having a conversation with S3 NP about Resident #12 refusing lab draws, but couldn't remember when it was. S4 Unit Manager stated she called the lab and asked them if they could send a different phlebotomist, and was told they could try. S4 Unit Manager stated she couldn't remember if she had followed up to see if Resident #12's blood was drawn, and didn't know if it had been. In a telephone interview on 10/08/2024 at 12:20 p.m., the Supervisor at the lab confirmed Resident #12 had refused to have his lab work drawn on 10/07/2024, 09/30/2024, 09/24/2024, 09/23/2024, 09/18/2024, and 09/17/2024 and said it was reported to S5 LPN. The lab Supervisor stated she did not see any documentation of anyone from the facility calling to request a different phlebotomist for Resident #12, but said they could change the time for his lab draw, and it would be a different phlebotomist. In a telephone interview on 10/08/2024 at 12:24 p.m., S5 LPN revealed she worked from 6:00 p.m. to 6:00 a.m. shift, and confirmed Resident #12 refused to let the lab draw his blood. S5 LPN stated Resident #12 doesn't want to be woken up in the middle of the night. S5 LPN stated she knew S4 Unit Manager was aware; however, no one had ever asked her to draw it. In an interview on 10/09/2024 at 1:00 p.m., S2 DON confirmed Resident #12 had not had a PT/INR level drawn since 09/03/2024, and stated no staff had attempted to draw it because they weren't aware they needed to draw it until yesterday. S2 DON stated she was unaware S3 NP had asked anyone in the facility to draw the resident's blood. S2 DON confirmed Resident #12 had orders to receive Coumadin 8 mg daily, and an order to have his PT/INR drawn weekly. S2 DON acknowledged the facility had continued to give Resident #12 Coumadin every day, although they were aware his lab had not been drawn in over a month. S2 DON acknowledged there was no documentation of Resident #12 being monitored consistently on each shift for bleeding or bruising. Resident #9 Review of Resident #9's medical record revealed an admit date of 09/12/2023 with diagnoses that included: Hemiplegia, Cerebral Infarction, Type 2 DM, Bladder Disorder, and Nocturia. Review of Resident #9's current physicians' orders revealed the following: 09/12/2023: Novolog 100 unit/ml vial bid- 60-199=0 units 200-250=2 units 251-300=4 units 301-350=6 units 351-400=9 units 401-give 12 units, recheck in 15 minutes, if still greater than 400, call me. 08/28/2024: Lidocaine 4% patch-apply one patch at HS and note remove in am 09/18/2024: Desmopressin Acetate 0.2mg PO at bedtime Review of Resident #9's 09/2024 EMAR revealed the following: Resident #9 did not receive his Lidocaine 4% patch on 09/05/2024. Resident #9 did not receive his Desmopressin Acetate 0.2mg by mouth on 09/25/2024 and 09/26/2024. Resident #9's accucheck/blood glucose levels were not documented 13 times in 09/2024, as ordered. Resident #9's blood pressure and pulse were not documented bid with blood pressure medication administration on 34 occasions during the month. In an interview on 10/09/2024 at 10:25 a.m., S2 DON acknowledged Resident #9's 09/2024 EMAR had missed documentation of vital signs, blood glucose levels, a Lidocaine patch application, and two doses of Desmopressin, as ordered, and shouldn't have. Resident #10 Review of Resident #10's medical record revealed an admit date of 03/19/2024 with diagnoses that included in part .Type 2 DM, Chronic Kidney Disease, and End Stage Renal Disease. Review of the current physician's orders revealed the following orders: 05/20/2024: Vitamin D3 1000 unit tablet every day 09/19/2024: Vitamin D level on 9/20/2024. Review of Resident #10's medical record revealed no documented evidence of a Vitamin D level being drawn on 09/20/2024. In an interview on 10/09/2024 at 1:14 p.m., S2 DON and S3 Unit Manager confirmed the Vitamin D level for Resident #10 was not drawn on 09/20/2024, as ordered, but should have been. S2 DON and S3 Unit Manager both stated they didn't know why it was not drawn, as ordered. Resident #3 Review of Resident #3's medical record revealed an admit date of 01/25/2022 with diagnoses that included: Anoxic brain damage, Cerebral Infarction, Type 2 DM, Neuromuscular dysfunction of bladder, Persistent Atrial fibrillation, and Schizoaffective disorder. Review of Resident #3's Physician's orders revealed the following: 06/07/2024: CBC, CMP, TSH, Mag (Magnesium) level every 6 months (Jan/July) Review of Resident #3's medical record revealed no magnesium level was completed as ordered. In an interview on 10/09/2024 at 11:19 a.m., S2 DON revealed the magnesium level for Resident #3 was not drawn in July 2024 as ordered by the physician, but should have been. In an interview on 10/09/2024 at 1:16 p.m., S2 DON and S4 Unit Manager revealed that they did not know why the magnesium lab was cancelled for 07/2024. Resident #4 Review of Resident #4's medical record revealed an admit date of 07/18/2017 with diagnoses that included Multiple Sclerosis, Neuromuscular Dysfunction, Schizophrenia, Major Depressive Disorder, Specified Anxiety Disorder, Type 2 DM, and Pressure ulcer to left heel. Review of Resident #4's Physician Orders revealed the following: 06/28/2024 Irrigate suprapubic catheter with 60 ml sterile water as needed 06/26/2024 May change Suprapubic catheter if needed 05/20/2024 Suprapubic catheter care with soap and water every shift Review of Resident #4's Care plan, with a review date of 11/20/2024, revealed Alteration in Elimination related to resident has suprapubic catheter. An intervention included on 08/12/2024 to change Suprapubic catheter every 2 weeks and PRN. Urology to follow up. Review of Resident #4's medical records revealed a physician order dated 08/12/2024 to change resident's suprapubic catheter every two weeks and prn. Review of Resident #4's medical records revealed documentation that Resident #4's suprapubic catheter had not been changed on 08/12/2024, 09/09/2024 or 09/23/2024, as scheduled. S2 DON confirmed the suprapubic catheter had not been changed as ordered, but should have been. The Immediate Jeopardy was removed on 10/25/2024 at 10:47 a.m., when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews, and observations that the Plan of Removal had been initiated and/or implemented. Corrective action 1. On 10/09/2024 at 5:00 p.m., an in-service was initiated for licensed nurses on ensuring critical labs are immediately communicated to the MD/NP for proper treatment and that ordered labs are obtained; in-servicing completed 10/12/2024. 2. On 10/17/2024 Clinical Operation Consultants initiated 100% audit of all labs from 09/2024 and 10/17/2024 to ensure compliance with lab orders. Any concerns were immediately addressed. Continue to monitor daily x4 weeks. 3. On 10/21/2024, Clinical Operations Consultant completed 100% lab verification with Nurse Practitioner to ensure facility had correct lab ordered. 4. On 10/08/2024, Clinical Operations Consultant started lab audit to ensure any critical labs were communicated to MD/NP as warranted as well to ensure ordered labs obtained. This continues as an ongoing audit with lab orders/routine labs follow up with Nurse Practitioner. 5. Executive Director, Director of Nurses and Clinical Operations Nurse's employment was separated 05/24/2024 prior to facility gaining knowledge of alleged deficient practice. 6. On 10/09/2024, Charge Nurse received corrective counseling by Executive Director regarding not communicating critical labs to the physician/nurse practitioner. 7. On 10/24/2024, Staff Development Coordinator initiated educational in-servicing of all nurses regarding following physician orders. All agency nurses to be trained prior to next shift 8. Daily morning meetings with interim Director of Nurses and Unit Manager initiated 10/24/2024 where all physician orders from the day before are reviewed to ensure all properly followed up on. 9. On 10/24/2024 reviewed general medication administration policy and initiated in-servicing of all nurses regarding administering ordered medication. All agency nurses and staff nurses to be trainer prior to next shift. 10. On 10/24/2024 reviewed insulin administration policy and initiated in-servicing of all nurses regarding properly documenting all blood sugar results. All agency nurses and staff nurses to be trained prior to next shift. 11. On 10/24/2024 reviewed lab policy and initiated in-servicing of all nurses regarding obtaining all ordered lab and notifying MD/NP of critical labs. All agency nurses and staff nurses to be trained prior to next shift. 12. Clinical Operations Nurse or designee will monitor morning meeting with Director of Nurses and Unit Manager to ensure all orders are properly completed and followed up on five days a week x 4 weeks. 13. The facility asserts that their will be no further likelihood for any serious harm to any residents. The likelihood for serious harm to residents no longer exists. Facility Completion date: 10/25/2024.

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected 1 resident

Read full inspector narrative →

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 6 (#3, #5, #4, #9, #10 and #12) of 13 sampled residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13). The Facility failed to: 1. Ensure there was a system in place to monitor the completion of laboratory draws and timely communication of abnormal lab results to the provider; and 2. Follow and implement physician's orders for residents who required bleeding and glucose monitoring, routine labs, medication administration and catheterization. This deficient practice resulted in an Immediate Jeopardy situation for Resident #5, who had a history of Coumadin toxicity and GI (gastrointestinal) bleed, on 05/20/2024 when the facility failed to obtain an ordered PT/INR level, failed to notify #5's PCP (primary care physician) of a critically low Hemoglobin of 7.5 g/dL and continued to administer Coumadin 7.5mg, an anticoagulant/ blood thinner, to Resident #5 on 05/22/2024, 05/24/2024, and 05/28/2024. Resident #5's PCP noticed the low critical laboratory results during a routine visit on 05/29/2024 and ordered STAT CBC and PT/INR. Resident #5 was subsequently transferred to the hospital where she received a blood transfusion and injection of Vitamin K. The deficient practice continued at a potential for more than minimal harm for any resident in the facility who required lab monitoring and notification of changes to their PCP. S1 Administrator was notified of the Immediate Jeopardy on 10/24/2024 at 3:36 p.m. Findings: Cross Reference F684 Review of the facility's policy revised 11/2017 titled Laboratory Tests revealed in part . Lab tests are completed as ordered by the physician or physician extender . Responsibility: All Licensed Nursing Personnel monitored by Director of Nursing or Designee. 7. Any labs not obtained as indicated will be rescheduled by the Licensed Nurse. 9. The Licensed Nurse, or designee, will forward the lab results to the appropriate IDT nursing and dietary staff for review. The physician/physician extender will be promptly notified of abnormal results according to facility policy. Resident #5 In an interview on 10/09/2024 at 10:14 a.m., S2 DON revealed the facility received Resident #5's critically low Hemoglobin lab results on 05/22/2024 at 2:22 p.m., and failed to notify the MD or NP of the results, but should have. S2 DON confirmed the facility failed to ensure Resident #5's ordered PT/INR lab work was completed on 05/20/2024, 05/27/2024 and 06/03/2024, and should have been followed up on but was not. S2 DON acknowledged Resident #5 was not being monitored for bleeding/bruising while on Coumadin therapy, but should have been. In an interview on 10/24/2024 at 9:15 a.m., S1 Administrator acknowledged the facility's multiple quality of care issues being cited. S1 Administrator reported the facility has had a high turnover rate in administrative leadership positions, such as the Administrator, DON, and Clinical Operations Nurse positions, which may have attributed to many of these care issues. An interview on 10/24/2024 at 11:48 a.m. with S8 Clinical Operations Nurse revealed after reviewing Resident #5's 02/2024 and 05/2024 EMAR, the 02/03/2024 and 05/26/2024 dose of prescribed Coumadin was missed. S8 Clinical Operations Nurse believed agency staff worked the shifts and there was no documentation in nurses' notes as to why the Coumadin wasn't given. Resident #12 In an interview on 10/09/2024 at 1:00 p.m., S2 DON confirmed Resident #12 had not had a PT/INR level drawn since 09/03/2024, and stated no staff had attempted to draw it because they weren't aware they needed to draw it until yesterday. S2 DON stated she was unaware S3 NP had asked anyone in the facility to draw the resident's blood. S2 DON confirmed Resident #12 had orders to receive Coumadin 8 mg daily, and an order to have his PT/INR drawn weekly. S2 DON acknowledged the facility had continued to give Resident #12 Coumadin every day, although they were aware his lab had not been drawn in over a month. S2 DON acknowledged there was no documentation of Resident #12 being monitored consistently on each shift for bleeding or bruising. Resident #9 In an interview on 10/09/2024 at 10:25 a.m., S2 DON acknowledged Resident #9's 09/2024 EMAR had missed documentation of vital signs, blood glucose levels, a Lidocaine patch application, and two doses of Desmopressin, as ordered, and shouldn't have. Resident #10 In an interview on 10/09/2024 at 1:14 p.m., S2 DON and S3 Unit Manager confirmed the Vitamin D level for Resident #10 was not drawn on 09/20/2024, as ordered, but should have been. S2 DON and S3 Unit Manager both stated they didn't know why it was not drawn, as ordered. Resident #3 In an interview on 10/09/2024 at 11:19 a.m., S2 DON revealed the magnesium level for Resident #3 was not drawn in 07/2024 as ordered by the physician, but should have been. In an interview on 10/09/2024 1:16 p.m., S2 DON and S4 Unit Manager revealed that they did not know why the magnesium lab was cancelled for 07/2024. Resident #4 Review of Resident #4's medical records revealed a physician order dated 08/12/2024 to change resident's suprapubic catheter every two weeks and prn. Review of Resident #4's medical records revealed documentation that Resident #4's suprapubic catheter had not been changed on 08/12/2024, 09/09/2024 or 09/23/2024, as scheduled. S2 DON confirmed the suprapubic catheter had not been changed as ordered, but should have been. The Immediate Jeopardy was removed on 10/25/2024 at 10:47 a.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews, and observations that the Plan of Removal had been initiated and/or implemented. Corrective action l. On 10/09/2024 at 5:00 p.m., an in-service was initiated for licensed nurses on ensuring critical labs are immediately communicated to the MD/NP for proper treatment and that ordered labs are obtained: in-servicing completed 10/12/2024. 2. On 10/17/2024 Clinical Operation Consultants initiated 100% audit of all labs from 09/2024 and 10/17/2024 to ensure compliance with lab orders. Any concerns were immediately addressed. Continue to monitor daily x4 weeks. 3. On 10/21/2024, Clinical Operations Consultant completed 100% lab verification with Nurse Practitioner to ensure facility had correct lab ordered. 4. On 10/08/2024, Clinical Operations Consultant started lab audit to ensure any critical labs were communicated to MD/NP as warranted as well to ensure ordered labs obtained. This continues as an ongoing audit with lab orders/routine labs follow up with Nurse Practitioner. 5. Executive Director, Director of Nurses and Clinical Operations Nurse's employment was separated 05/24/2024 prior to facility gaining knowledge of alleged deficient practice. 6. On 10/09/2024, Charge Nurse received corrective counseling by Executive Director regarding not communicating critical labs to the physician/nurse practitioner. 7. On 10/24/2024, Staff Development Coordinator initiated educational in-servicing of all nurses regarding following physician orders. All agency nurses and staff nurses to be trained prior to next shift. 8. Daily morning meetings with interim Director of Nurses and Unit Manager initiated 10/24/2024 where all physician orders from the day before are reviewed to ensure all properly followed up. 9. On 10/24/2024 reviewed general medication administration policy and initiated in-servicing of all nurses regarding administering ordered medication. All agency nurses and staff nurses to be trained prior to next shift. 10. On 10/24/2024 reviewed insulin administration policy and initiated in-servicing of all nurses regarding properly documenting all blood sugar results. All agency nurses and staff nurses to be trained prior to next shift. 11. On 10/24/2024 reviewed lab policy and initiated in-servicing of all nurses regarding obtaining all ordered lab and notifying MD/NP of critical labs. All agency nurses and staff nurses to be trained prior to next shift. 12. Clinical Operations Nurse or designee will monitor morning meeting with Director of Nurses and Unit Manager to ensure all orders are properly five days a week x 4 weeks. 13. Executive Director and Director of Nurses in-serviced on 10/24/2024 by [NAME] President regarding ensuring the facility is administered in a manner that uses resources to effectively and efficiently meets the needs of the residents by ensuring there is a system in place to monitor the completion of laboratory draws and timely communication of abnormal lab results to the provider. 14. Vice President of Operations to monitor Executive Director and Director of Nursing weekly x 4 weeks to ensure compliance of corrective action. 15. The facility asserts that there will be no further likelihood for any serious harm to any resident. The likelihood for serious harm to residents no longer exists. Facility Completion date: 10/25/2024.

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 F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review, observation, and interview, the facility failed to provide a private space for the Resident Council Meeting held 10/07/2024 and failed to act promptly upon the grievances voiced by the residents during monthly resident council meetings. The deficient practice had the potential to affect a total of 66 residents residing in the facility. Findings: Review of the facility's policy titled Resident Council dated 02/2017 revealed in part . 1. The Resident Council structure and process will be established by the residents with the Social Services staff. 2. Monthly meetings will be scheduled in an area that promotes privacy or per Resident request. Review of the facility's policy titled Complaint/Grievance/Missing Property dated 01/2015 revealed in part . A.1. Resident Council meetings are to allow time for residents to address concerns or complaints. Minutes are to reflect the issues and the direction taken. Respective Department Heads and/or Executive Director will follow up on issues noted. In an observation of the Resident Council meeting on 10/07/2024 at 1:30 p.m., it was noted the meeting was held in the day room near the front entrance of the facility, and near the nurses' station. The area was open to anyone who entered the front door, in view of the nurses' station, open to a resident hallway, and connected to the dining room. During the meeting, a staff member walked through and held a conversation with the social services staff who was assisting with the meeting, and two staff members were seated at the nurses' station. During the meeting, a visitor entered the facility and stood in the day room area, and listened to a portion of the meeting. During the 10/07/2024 Resident Council meeting, residents complained about staff not rounding every two hours, call lights not being answered timely, beds not being made, and CNAs waking them up at night being too loud. The residents reported these issues had been an ongoing problem that had not been addressed by the facility. Review of the Resident Council meeting held 09/11/2024 revealed in part . Old business-was this issue resolved to your satisfaction? No, related to call lights. New business-11 in attendance complained beds were not being made, rounds not being done by staff, and call lights were not being answered in a timely manner. Review of the Resident Council meeting held 08/14/2024 revealed in part . Old business-Was this issue resolved to your satisfaction? 5 residents stated no, related to beds not being made in timely manner, and 6 residents responded no, related to loud CNAs at night. Review of the Resident Council meeting held 07/10/2024 revealed in part . New business-8 residents complained CNAs of loud at night, 7 residents complained that more room rounds were needed, and 7 residents complained beds were not being made in a timely manner. Review of the Resident Council binder revealed the facility responded to the above complaints by in-servicing staff monthly. No other interventions were documented. In an interview on 10/09/2024 at 1:30 p.m., S1 Administrator and S2 DON acknowledged the Resident Council meeting was not held in a private space, and the concerns voiced by the members continued for multiple months, and had not been resolved.

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure residents were provided with a diet specific for his special dietary needs and preferences. The facility failed to ensure that an artificial sugar sweetener was available for use for Resident #1 who required a diabetic precautions diet. The total facility census was 62 residents. Findings: Review of Resident #1's Medical Record revealed an admission date of 02/19/2024 with diagnoses that included Diabetes due to underlying condition with Diabetic Neuropathy, Unspecified, Hyperlipidemia, Essential Primary Hypertension, Schizophrenia and Mood Disorder due to known Physiological condition and other Intellectual Disabilities. Review of Resident #1's Physician Orders for September 2024 revealed an order dated 02/19/2024 for Regular diet with DM Precautions Diagnosis: Diabetes due to underlying condition with Diabetic Neuropathy, Unspecified. Review of Resident #1's Quarterly MDS with an ARD of 09/05/2024 revealed a BIMS score of 15, indicating intact cognition. Review of Resident #1's Care Plan with a Target date of 09/29/2024 revealed an altered health maintenance related to Diabetes, Hyperglycemia and Hypoglycemia with interventions that included in part . provide diet as ordered by MD. Further review of Care Plan revealed Resident #1 with potential for weight loss with goal for resident will eat 75% of meals served and approaches that included in part . on a Regular with DM precautions diet, determine food preferences and promptly offer resident food alternatives when appropriate for any meal served. Interview on 09/17/2024 at 3:40 p.m. with resident in his room revealed he is a diabetic and had not had any Sweet'n Low packets for the past couple of days. Resident #1 reported that he had asked the kitchen aide for some and was told they had run out of Sweet'n Low since Saturday, 09/14/2024. Observation on 09/18/2024 at 8:20 a.m. in resident's room revealed Resident #1 sitting up on the edge of his bed with his breakfast tray on over-bed table. Interview with Resident #1 at this time reported that he ate his biscuit and drank his orange juice but didn't eat his grits because he didn't have any sweet n low to put it his grits. Resident #1 stated he also likes to put some artificial sweetener in his water and ice cubes. Interview on 09/18/2024 at 10:55 a.m. with S3 Dietary aide revealed she did not have any alternative artificial sweetener available at this time until the supply truck comes. S3 Dietary Aide reported that we should have some today because the truck was to deliver with supplies this morning. Interview on 09/18/2024 at 12:05 p.m. with S2 DM revealed we offer regular sugar and then Sweet'n Low, sugar-free jelly and sugar-free syrup for the diabetic residents. S2 DM revealed she was made aware that the kitchen had run out of the Sweet'n Low since Saturday 09/14/2024 and the truck arrived this morning. S2 DM revealed that she overlooked it when she placed her last order. S2 DM revealed that normally she would have bought what is needed and would be reimbursed by the facility but just overlooked it. S2 DM confirmed that she should have let someone know in the office about running out of Sweet'n Low sugar substitute to purchase some for the residents on diabetic precaution diets and did not. Interview on 09/19/2024 at 12:30 p.m. with S1 Admin revealed the DM should have asked someone in the office to purchase some Sweet'n Low sugar packs as soon as she was aware of running low so we could have purchased locally until the truck delivered items. S1 Admin confirmed that the DM should have ensured an alternative sugar substitute was available for residents who required diabetic precautions and did not.

May 2024 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident #1, who had been assessed to be at risk for elopement, received adequate supervision to prevent him from exiting the facility without staff knowledge, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 05/13/2024 at 11:30 a.m., when Resident #1, (a moderately cognitively impaired resident who was identified as an elopement risk), asked S5 Agency Nurse to unlock the facility's front door so he could go see his wife, while holding a clear trash bag containing clothing items. S5 Agency nurse did not notify any other staff of Resident #1's exit seeking behavior. Resident #1, who was last seen at the nurses' station by S3 LPN Unit Manager at 12:45 p.m., was found at 1:00 p.m., 0.4 miles away from the facility, down a busy four-lane roadway, by staff from Resident #1's IOP (Intensive Outpatient Program). The IOP staff notified S4 LPN SDC and S2 DON of Resident #1's whereabouts. S4 LPN SDC drove to Resident #1's location to assist the IOP staff with returning Resident #1 back to the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 05/23/2024 at 5:25 p.m. The Immediate Jeopardy was removed on 05/24/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility had implemented an acceptable Plan of Removal (POR) prior to the survey exit. The likelihood of elopement exists for all newly admitted residents with a history of wandering/elopement due to failure to retrain all facility staff. Findings: Review of a facility policy titled Missing Resident/Elopements, and dated 05/2022, revealed in part . Policy: The Unit Charge Nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc., the staff in these programs will be responsible for the location of their participants. Procedure: l. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Review of Resident #1's medical records from a local hospital revealed in part . admit date : [DATE] Has been admitted to behavioral unit for worsening confusion. Apparently, he and his spouse live out in woods and he wandered off and had to be located by police. She brought him to primary care clinic where he was evaluated and sent here for further treatment. Reason for admission: Neurocognitive Disorder with behavioral disturbances Review of Resident #1's clinical record revealed an admit date of 04/15/2024, with diagnoses that included: Major Depressive Disorder, Neurocognitive Disorder due to known physiological condition with Behavioral Disturbance, Unspecified Dementia, and Alzheimer's Disease. Review of Resident #1's Risk of Elopement Evaluation dated 04/15/2024, revealed he exhibited wandering behavior in the last 60 days, wandered aimlessly, ambulated independently, and was at risk for elopement with an intervention of door alarms. Review of Resident #1's admission MDS with an ARD of 04/24/2024 revealed a BIMS score of 9, indicating moderate cognitive impairment. Review of Resident #1's care plan revealed a problem of at risk for elopement related to diagnoses of Dementia and Alzheimer's disease, and a history of wandering, with an onset date of 04/15/2024. Interventions included in part . alert staff to resident wandering/elopement behavior, provide reality orientation during routine care daily, monitor resident's whereabouts every 1 hour, and redirect when exhibit behaviors of elopement/wandering, such as going to doors, following staff to exit doors. Review of Resident #1's Admission/readmission Evaluation dated 04/15/2024, revealed Resident #1 had a history of wandering, ambulated independently, and was at risk for elopement, with a care plan intervention of location monitoring. Review of Resident #1's Physician Progress note dated 04/29/2024 revealed in part . Seen today for admission visit . Recently hospitalized at a local Behavioral hospital from [DATE] through 04/15/2024. According to hospital paperwork, patient admitted due to worsening confusion. Patient was sent from walk-in clinic under PEC .He also wanders off at night and recently got lost in woods, law enforcement had to locate the patient .Attending IOP. Review of Resident #1's 05/2024 Flow Sheet revealed in part . -Start Date 04/18/2024 - Monitor resident location every hour. -05/13/2024 - S5 Agency Nurse initialed that Resident #1's location was monitored at 12:00 p.m. and 1:00 p.m. Interview on 05/21/2024 at 3:26 p.m. with S3 LPN Unit Manager, revealed she last saw Resident #1 on 05/13/2024 at 12:45 p.m. at the nurses' station. S3 LPN Unit Manager reported another resident was being discharged from the facility at that time, and the other resident's family was back and forth, and in and out the facility's front door moving her things out. S3 LPN Unit Manager reported the other resident's family might have thought Resident #1 was a visitor because he was very ambulatory. Interview on 05/21/2024 at 3:42 p.m. with S4 LPN SDC, revealed on 05/13/2024, an employee (did not remember the name of the employee) from Resident #1's IOP program called the facility around 1:00 p.m. to report that one of their drivers saw Resident #1 walking down a busy four-lane roadway. S4 LPN SDC stated she found Resident #1 on the busy four-lane roadway approximately 0.4 miles away, sitting on the side of a business with 3 employees (could not remember their names) from the IOP Program. S4 LPN SDC stated when she asked Resident #1 why he left the facility, Resident #1 told her he wanted to go home. S4 LPN SDC stated Resident #1 got on the IOP Program van to go back to the facility, and she followed them. S4 LPN/SDC stated they arrived at the facility together around 1:05 p.m. Interview on 05/22/2024 at 12:19 p.m. with S2 DON revealed she received a telephone call at approximately 1:00 p.m., from an IOP Program employee, informing her Resident #1 was at a business down the busy four-lane roadway. Interview on 05/22/2024 at 3:19 p.m. with S6 Transportation, revealed she last saw Resident #1 walking towards his room around 12:00 p.m. on 05/13/2024. S6 Transportation stated she told Resident #1 it was time for lunch, and to go up front. S6 Transportation reported Resident #1 had been confused lately, and she told S5 Agency Nurse to keep an eye on him because he could not leave the facility. S6 Transportation reported around 12:00 p.m., Resident #1 was observed walking around the front near the nurses' station, and S5 Agency Nurse redirected him towards the dining room. Interview on 05/22/2024 at 3:58 p.m. with S1 ADM revealed a resident's family was moving belongings out of the facility on 05/13/2024, around the time that Resident #1 eloped from the facility. S1 ADM reported she assumed staff opened the door to let family members in and out. S1 ADM stated staff were at the nurses' station and corridor, and the staff must have left the open door unattended in order for Resident #1 to have been able to leave the facility without being seen by staff. S1 ADM stated it would have only taken a split second, and with a lot going on in a little space, no one noticed Resident #1 leave. Interview on 05/23/2024 at 11:21 a.m. with S3 LPN Unit Manager, revealed she did not think to monitor Resident #1 when another resident's family was moving belongings and holding the door open, because she did not think Resident #1 was at risk for elopement at that time. S3 LPN Unit Manager stated he was not at risk for elopement until he came back. Telephone interview on 05/23/2024 at 11:52 a.m. with two IOP Program LPNs revealed they received a telephone call from their PRN van driver around 12:30 p.m., to report he had observed Resident #1 walking alone on a busy four-lane roadway. One LPN stated the van driver came to the office and she, along with a Senior Care Therapist, got into the van with the driver to go check on Resident #1, while the second LPN reported she called the facility to notify them. The first LPN stated it took them approximately 5 minutes from the van driver's telephone call to get to Resident #1, who was found standing by a business located on the busy four-lane roadway. The LPN stated Resident #1 was irritated, and said he did not want to go back to the nursing home because he wanted to go see his wife. The LPN stated Resident #1 was wearing a cowboy hat, jeans, and boots, and he was carrying an office sized trash bag with a few pieces of clothing in it. She stated S4 LPN SDC arrived about 5 minutes later and tried to get him to go with her in her vehicle; however, he refused. She stated Resident #1 finally agreed to go back, and got in their van and went back to the facility. Telephone interview on 05/23/2024 at 2:11 p.m. with S5 Agency Nurse revealed she was Resident #1's nurse on 05/13/2024 when he eloped from the facility. S5 Agency Nurse stated Resident #1 came to her at the nurses' station at around 11:30 a.m. asking her to unlock the front door so he could leave to see wife. S5 Agency Nurse stated Resident #1 was carrying a clear trash bag with clothes. S5 Agency Nurse reported S6 Transportation told her Resident #1 did that frequently, so she redirected him to the dining room. S5 Agency Nurse reported Resident #1 sat down at the table and when she asked if she could put his clothes up, he got agitated and said no to leave them with him. S5 Agency Nurse stated she left the bag with him and went back to the nurses' station. S5 Agency Nurse reported she was asked to go the dining room at 12:15 p.m. to go monitor a resident at risk for choking. S5 Agency Nurse stated she could not recall if Resident #1 was in the dining room at that time. S5 Agency Nurse reported that was the second shift she had worked at the facility, and she did not receive an official orientation to the facility. S5 Agency Nurse stated she was only oriented on where and what to chart. S5 Agency Nurse stated she was not told who was risk for elopement, and she was not aware Resident #1 was at risk for elopement, and he did not have a wander guard on. S5 Agency Nurse stated people are in and out of the front door and residents have the code. S5 Agency Nurse reported she was unsure of the last time she saw Resident #1 before he eloped from the facility. S5 Agency Nurse stated she did not feel Resident #1 needed increased supervision when he asked to leave while carrying a bag of clothes. She reported she did not notify the S3 Unit Manager, S2 DON or S1 ADM of Resident #1's behavior. S5 Agency Nurse reported she signed off on Resident #1's every hour location monitoring at 12:00 p.m. and 1:00 p.m., because she saw him at 11:30 a.m. and after 1:00 p.m. Interview on 05/23/2024 at 2:31 p.m. with S1 ADM confirmed supervision should have been increased at 11:30 a.m. on 05/13/2024, when Resident #1 asked S5 Agency Nurse to unlock the front door to leave to go see his wife. S1 ADM reported staff know what residents are at risk for elopement by an elopement binder that is maintained at the nurses' station. S1 ADM confirmed Resident #1 was at risk for elopement at the time of the incident on 05/13/2024, but he was not placed in the elopement binder until after he eloped from the facility. S1 SDM stated the off going nurse should in-service oncoming agency nurses on who is at risk for elopement. Interview on 05/23/2024 at 4:48 p.m. with S1 ADM revealed the facility did not have a policy on training all staff including agency staff on risk for elopement. Telephone interview on 05/24/2024 at 1:32 p.m. with another resident's grandson, revealed he and his fiancée went to the facility around lunchtime on 05/13/2024, to help his grandmother move out. He stated when they first arrived, a couple that looked like visitors entered the code to the front door, to let them into the facility, and they gave him the code. He reported when he went to go out, the code did not work, so he got staff to let him out. He stated when he was coming back in the front door of the facility from moving his truck, he saw a man wearing a cowboy hat, a button up shirt, a vest, jeans, and boots, go out the door as he was coming in. He reported there were no staff by the front door at that time. He stated he could not recall who opened the door for him to come in after moving his truck. He reported when they were wheeling his grandmother out of the facility, the man was back inside. He stated he did not know the timeframe between the man leaving the facility, and seeing him back inside.

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected 1 resident

Read full inspector narrative →

Based on interview on record review, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The Administration failed to have an effective system in place to ensure Resident #1, who was assessed as being at risk for elopement, was adequately supervised to prevent him from exiting the front door of the facility unattended. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 05/13/2024 at 11:30 a.m., when Resident #1, (a moderately cognitively impaired resident who was identified as an elopement risk), asked S5 Agency Nurse to unlock the facility's front door so he could go see his wife, while holding a clear trash bag containing clothing items. S5 Agency Nurse did not notify any other staff of Resident #1's exit seeking behavior. Resident #1, who was last seen at the nurses' station by S3 LPN Unit Manager at 12:45 p.m., and was found at 1:00 p.m., 0.4 miles away, down a busy four-lane roadway, by staff from Resident #1's IOP (Intensive Outpatient Program). The IOP staff notified S4 LPN SDC and S2 DON of Resident #1's whereabouts, and S4 LPN SDC drove to Resident #1's location to assist the IOP staff with returning Resident #1 back to the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 05/23/2024 at 5:25 p.m. The Immediate Jeopardy was removed on 05/24/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The likelihood of elopement exists for all newly admitted residents with a history of wandering/elopement due to failure to retrain all facility staff. Findings: Cross Refer to F689 Review of a facility policy titled Missing Resident/Elopements, and dated 05/2022, revealed in part . Policy: The Unit Charge Nurse is responsible for knowing the location of their residents. When residents are participating in various programs, such as physical therapy, recreational activities, dining, etc., the staff in these programs will be responsible for the location of their participants. Procedure: l. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as practical. Interview on 05/22/2024 at 12:19 p.m. with S2 DON revealed she received a telephone call at approximately 1:00 p.m., from an IOP Program employee, informing her Resident #1 was at a business down the busy four-lane roadway. Interview on 05/22/2024 at 3:58 p.m. with S1 ADM revealed a resident's family was moving her belongings out of the facility on 05/13/2024, around the time that Resident #1 eloped from the facility. S1 ADM reported she assumed staff opened the door to let the family members in and out. S1 ADM stated the staff must have left the open door unattended in order for Resident #1 to have been able to leave the facility without being seen by staff. S1 ADM stated staff were at the nurses' station and corridor, it would have only taken a split second, and with a lot going on in a little space, no one noticed Resident #1 leave. S1 ADM stated they determined Resident #1 only required every one hour monitoring for elopement, and did not require a higher level of supervision, through nursing staff assessment, speaking with his wife, and watching him get acclimated to the facility. Interview on 05/23/2024 at 2:31 p.m. with S1 ADM confirmed supervision should have been increased at 11:30 a.m. on 05/13/2024, when Resident #1 asked S5 Agency Nurse to unlock the front door to leave to go see his wife. S1 ADM reported staff know what residents are at risk for elopement by an elopement binder that is maintained at the nurses' station. S1 ADM confirmed Resident #1 was at risk for elopement at the time of the incident on 05/13/2024 when he eloped, but he was not placed in the elopement binder until after he eloped from the facility. S1 SDM stated the off going nurse should in-service oncoming agency nurses on who is at risk for elopement. Interview on 05/23/2024 at 4:48 p.m. with S1 ADM revealed the facility did not have a policy on training all staff including agency staff on risk for elopement.

Jan 2024 13 deficiencies 1 Harm

SERIOUS (H) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans. The facility failed to ensure physician orders to obtain lab work was followed (#11, #16, #17, #43 and #59), failed to ensure medication was administered in a timely manner (#59), and failed to ensure medication was administered as ordered by the physician (#11), for 5 (#11, #16, #17, #43, and #59) of 24 sampled residents. This deficient practice resulted in an Actual Harm for Resident #17. On 12/27/2023, S10 NP ordered to obtain a CBC, BMP, ESR, CRP, and UA with C-Reflex on 12/28/2023. According to interview with S2 DON, S10 NP, and review of Resident #17's medical record, the orders were never carried out. On 01/02/2024 at approximately 12:50 p.m., Resident #17 was transferred to the emergency department of a local hospital for a temperature of 103.1, and audible wheezing. Resident #17 was diagnosed with UTI (Urinary Tract Infection), and was admitted to the hospital for treatment of the UTI on 01/02/2024 through 01/04/2024. Findings: Review of the facility's policy titled Laboratory Tests read in part . Lab tests are completed as ordered by the physician or physician extender. Licensed Nurse, or designee shall obtain the labs ordered by the physician or physician extender. The licensed nurse will complete all lab requisitions for all routine lab work needing to be done on the day they are due. This will be done using the information on the Lab Scheduling/Tracking form. The licensed nurse, or designee, will complete the appropriate Lab Requisition Form. This will be completed prior to each lab day, using the information on the Scheduling/Lab Tracking form. Any newly ordered labs needing immediate attention will be added to the Lab Scheduling/Tracking form on each unit. The lab will be obtained as ordered. Review of the facility's policy titled Medication Administration-General Guidelines revealed in part . 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 5. All current medications and dosage schedules are listed on the resident's medication administration record eMAR/eTAR and administered timely according to facility policy. Resident #17 Review of Resident #17's medical record revealed an admit date of 07/21/2023, with diagnoses that included in part . Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, Atherosclerotic Heart Disease, Diverticulitis, Osteoarthritis, Urinary Tract Infection, Epilepsy, and Chronic Obstructive Pulmonary Disorder. Review of Resident #17's Quarterly MDS with an ARD of 11/30/2023, revealed a BIMS score of 10 (Moderate Cognitive Impairment). Resident #17 had functional limitations due to impairment on one side. Resident #17 required Substantial/Maximal assistance with eating, oral hygiene, toileting, showering/bathing, dressing, and transfers. Resident #17 was always incontinent of bowel and bladder. Review of Resident #17's Care Plan with a target date of 02/22/2024, revealed she was at risk for infection related to history of UTI, and was incontinent of bowel and bladder. Interventions included in part . Provide peri-care after each incontinent episode, monitor for signs and symptoms of UTI and contact MD if noted, and toilet every 2 hours, and as needed. Review of Resident #17's Physicians Orders dated 12/27/2023, revealed an order was written to obtain a CBC, BMP, ESR, CRP, and UA with C-Reflex on 12/28/2023. Review of Resident #17's medical record including completed lab results revealed there was no documentation that the above order was implemented. Review of Resident #17's Departmental Note dated 01/02/2024 at 1:45 p.m. by S35 LPN revealed the following in part .During routine med pass, this nurse and S5 LPN noticed resident was hot to the touch, temp 103.1. Resident also had audible wheezing. Resident sent to the ER, and left the facility to ED at 12:50 p.m. Review of Resident #17's medical record revealed Resident #17 was sent out to the ER on [DATE], and admitted with diagnoses of UTI, Dehydration, and Sepsis. Interview on 01/11/2024 at 9:32 a.m. with S10 NP revealed she did not receive lab or UA results from her 12/27/2023 order. S10 NP stated she had trouble with the facility carrying out orders. S10 NP stated she would have treated Resident #17 in-house with antibiotics if the labs and UA had been collected at the time she ordered. S10 NP stated this would have prevented Resident #17 from being admitted to the hospital on [DATE] with a diagnosis of UTI. Interview on 01/11/2024 at 10:38 a.m. with S2 DON revealed the orders to obtain a CBC, BMP, ESR, CRP, and UA with C-Reflex on 12/28/2023 were not carried out. S2 DON confirmed the lab work and UA had not been collected. Interview on 01/11/2024 at 11:08 a.m. with S2 DON revealed she and S8 Unit Manager were responsible for reviewing new written orders when NP makes rounds. S2 DON stated the order should be placed in the computer, a call should be made to notify the lab of the order, and staff should carry out the orders. S2 DON stated when labs are ordered, the labs are expected to be collected the following day, and when an UA is ordered, it is expected to be collected on the day it was ordered. S2 DON stated lab came to the facility to collect labs Monday- Friday, and as needed for stat orders. S2 DON stated she was ultimately responsible for ensuring the orders were carried out, and had failed to do so. Resident #16 Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE], and had diagnoses that included in part . Dementia, Primary Generalized Osteoarthritis, Type 2 DM, Major Depressive Disorder, Abnormal weight loss, and Alzheimer's Disease. Review of Resident #16's Quarterly MDS with an ARD of 11/09/2023, revealed Resident #16 had a BIMS of 99 (Unable to assess cognition). Resident #16 required supervision/setup assistance for eating; moderate assistance for oral hygiene, and dressing; and maximal assistance for toileting, showering/bathing, and personal hygiene. Resident #16 was always incontinent of Bowel and Bladder. Review of Resident #16's physician's orders revealed the following: 12/21/2023: UA (Urinalysis) with Reflex. Review of Resident #16's medical record revealed lab results for the Urinalysis with an order date of 12/21/2023 was not carried out, and there were no results within the medical record. Interview on 01/11/2024 at 4:30 p.m. with S2 DON revealed she could not find results for the UA ordered on 12/21/2023, and confirmed the lab had not been completed for Resident #16. Interview on 01/11/2024 at 9:32 a.m. with S10 NP revealed she ordered a UA on 12/21/2023, because Resident #16 had a decline, and she needed to rule out a UTI. S10 NP confirmed there was a delay in care, and the UA should have been collected. Interview on 01/11/2024 at 11:08 a.m. with S2 DON, revealed she and S8 Unit Manager were responsible for reviewing new written orders when a provider made rounds. S2 DON stated the order should have been placed in the computer, a call should have been made to notify lab of the order, and staff should have collected the UA on the day of order. S2 DON stated she was ultimately responsible for ensuring the orders were carried out, and had failed to do so. Resident #59 Review of Resident #59's medical record revealed an admit date of 11/01/2023. Resident #59 had the following diagnoses that included in part . Schizoaffective Disorder, Bipolar Type; and Unspecified Dementia, unspecified severity with other behavioral disturbances. Review of Resident #59's Annual MDS with an ARD of 11/10/2023 revealed Resident #59 had a BIMS of 8 (Moderate Cognitive Impairment). Resident #59 had wandering behaviors which occurred 1-3 days. Resident required Partial/Moderate assistance for toileting, showering/bathing, and dressing. Resident #59 had occasional incontinence of urine and was always incontinent of bowel. Review of Resident #59's physician's orders revealed the following: 01/06/2024: CBC, CMP, and UA. 01/08/2024: Macrobid 100mg twice daily for 10 days, diagnosis- UTI. Review of Resident #59's medical record revealed a UA was ordered on 01/06/2024. The medical record revealed the UA was not collected until 01/09/2024, and revealed the presence of bacteria in the urine. Interview on 01/11/2024 at 9:32 a.m. with S10 NP revealed she ordered UA on 01/06/2024, as Resident #59 had presented with UTI symptoms. S10 NP confirmed she ordered Macrobid 100mg twice daily for 10 days on 01/08/2024. Review of Resident #59's 01/2024 MAR revealed the resident had not received Macrobid 100mg twice daily starting 01/08/2024. Interview on 01/11/2024 at 12:25 p.m. with S7 LPN revealed she was unaware Resident #59 had recently been diagnosed with UTI, and was unaware Resident #59 had an order for Macrobid 100mg BID X10 days. S7 LPN confirmed she had not administered Macrobid to Resident #59, and confirmed this medication was not listed on Resident #59's MAR, and was not available on her medication cart. S7 LPN stated the nurse who received the order for Macrobid on 01/08/2024 was responsible for entering the medication on the MAR, and obtaining the medication from pharmacy. Interview on 01/11/2024 at 12:39 p.m. with S2 DON revealed S8 Unit Manager received the order to begin Macrobid 100mg BID X 10 days for Resident #59 on 01/08/2024. S2 DON confirmed there was a delay in care. S2 DON confirmed S8 Unit Manager should have entered the order into the computer, called pharmacy to get the medication, and had the medication added to Resident #59's MAR, but failed to do so. Resident #11 Review of the medical record for Resident #11 revealed an admit date of 05/23/2012, with diagnoses that included: Dementia, Respiratory Syncytial Virus, Pruritus and Dermatitis, and Encounter for Attention to Gastrostomy Tube. Review of Resident #11's Quarterly MDS with an ARD of 11/17/2023 revealed a BIMS score of 14, indicating intact cognition. Review of the MDS revealed Resident #11 required substantial or maximal assistance with personal hygiene, and extensive assistance by two persons with bed mobility and toilet use. Review of Resident #11's physician's orders revealed the following orders: 12/14/2023: Ivermectin per pharmacy dosing x 1 dose, and repeat in one week. 12/28/2023: Medrol 4 mg dose pack (Methylprednisolone-a steroid). Review of Resident #11's December 2023 MAR revealed the resident received the first dose of Ivermectin on 12/14/2023, but never received the second dose, as scheduled one week later. Review of Resident #11's January 2024 MAR revealed the resident never received the final dose of Methylprednisolone 4mg on the sixth day (01/03/2024), as scheduled. Interview at 01/10/2024 at 10:05 a.m. with S11 Corporate RN, confirmed Resident #11 did not receive the second dose of Ivermectin, and did not receive the last dose of the Methylprednisolone dose pack on 01/03/2024. Review of Resident #11's nurses' notes revealed the following: 01/04/2024 at 2:16 p.m. - The Nurse Practitioner made rounds and ordered a chest x-ray, CBC, BMP, and a Urinalysis with reflex. Documented by S8 Unit Manager. 01/07/2024 at 10:26 p.m. - UA collected in and out cath. Awaiting lab tech in a.m. Documented by S9 LPN. Review of Resident #11's medical record revealed lab results for the CBC, BMP, and Urinalysis, with a collection date of 01/08/2024. In an interview on 01/11/2024 at 9:40 a.m., S10 NP stated she ordered the two doses of Ivermectin because Resident #11 had a constant itch. S10 NP stated she was not notified the resident didn't receive the second Ivermectin dose, or the final dose of Methylprednisolone. S10 NP confirmed she ordered the chest x-ray, CBC, BMP, and Urinalysis on 01/04/2024 because she didn't think the resident had improved enough since her recent hospital stay. S10 NP confirmed there was a delay in obtaining the blood work and urinalysis. In an interview on 01/11/24 at 10:27 a.m., S8 Unit Manager stated the NP or MD puts orders on a certain rack and she makes copies and gives them to the floor nurse to transcribe and carry out the orders. S8 Unit Manager said the floor nurse should fill out a form for lab work and place it in the binder behind the day it is to be done. S8 Unit Manager stated if a UA was ordered, the floor nurses are supposed to collect the urine and put it in the fridge to be picked up. S8 Unit Manager said the floor nurses should collect the urine as soon as possible, but said it should be done in less than 24 hours. S8 Unit Manager stated the lab comes to the facility every day except Saturday and Sunday, unless the lab was ordered stat. In an interview on 01/11/2024 at 11:21 a.m., S2 DON reviewed Resident #11's medical record and confirmed Resident #11's blood work and urinalysis were ordered on 01/04/2024, the urinalysis was not collected until 01/07/2024, and the blood work was not collected until 01/08/2024. S2 DON confirmed there was a delay in care because the lab work should have been drawn the next morning, and the urinalysis the same day it was ordered. In an interview on 01/11/24 at 10:27 a.m., S8 Unit Manager stated the NP or MD puts orders on a certain rack and she makes copies and gives them to the floor nurse to transcribe and carry out the orders. S8 Unit Manager said the floor nurse should fill out a form for lab work and place it in the binder behind the day it is to be done. S8 Unit Manager stated if a UA was ordered, the floor nurses are supposed to collect the urine and put it in the fridge to be picked up. S8 Unit Manager said the floor nurses should collect the urine as soon as possible, but said it should be done in less than 24 hours. S8 Unit Manager stated the lab comes to the facility every day except Saturday and Sunday, unless the lab was ordered stat. In an interview on 01/11/2024 at 11:21 a.m., S2 DON reviewed Resident #11's medical record and confirmed Resident #11's blood work and urinalysis were ordered on 01/04/2024, the urinalysis was not collected until 01/07/2024, and the blood work was not collected until 01/08/2024. S2 DON confirmed there was a delay in care because the lab work should have been drawn the next morning, and the urinalysis the same day it was ordered. Resident #43 Review of Resident #43's medical record revealed an admit date of 09/12/2023, with diagnoses that included: Hemiplegia, Type 2 Diabetes Mellitus, Dementia, and Adjustment Disorder. Review of Resident #43's Quarterly MDS with an ARD of 11/21/2023 revealed a BIMS score of 9, which indicated moderately impaired cognition. Review of the MDS revealed the resident required substantial/maximal assistance with toilet hygiene, and set up or clean up assistance with eating; Review of Resident #43's nurses' notes revealed the following: 01/04/2024 at 2:12 p.m.: 8:00 a.m. S10 NP made rounds with new orders noted: Obtain UA (urinalysis) with reflex. Documented by S8 Unit Manager. Review of Resident #43's lab results revealed the urine was collected on 01/08/2024 at 4:11 a.m., and revealed the resident had a urinary tract infection. In an interview on 01/11/2024 at 9:36 a.m., S10 NP confirmed she ordered a UA on Resident #43 on 01/04/2024, because the resident had increased behaviors and was angry with staff. S10 NP stated the UA was not done until 01/08/2024, and was positive for a UTI. S10 NP confirmed there was a delay in care, and the UA should have been done sooner. In an interview on 01/11/2024 at 11:21 a.m., S2 DON confirmed there was a delay in care, and staff took too long to collect his urine. S2 DON stated a urinalysis should be done the same day it was ordered.

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure cognitively impaired residents were treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 2 (#17, #59) of 4 (#17, #22, #53, and #59) Residents reviewed for dignity in a total sample of 24. The facility failed to: 1. Ensure Resident #17's hair was maintained in a manner of her preference. 2. Ensure Resident #59 was dressed appropriately. Findings: Resident #17 Review of Resident #17's medical record revealed an admit date [DATE] of with diagnoses that included in part . Hemiplegia, Dysphasia, Schizoaffective Disorder-Bipolar Type, Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, Major Depressive Disorder, Generalized Anxiety Disorder, Atherosclerotic Heart Disease, Diverticulitis, Osteoarthritis, Urinary Tract Infection, Epilepsy, and Chronic Obstructive Pulmonary Disorder. Review of Resident #17's Quarterly MDS with an ARD of 11/30/2023 revealed a BIMS score of 10 (Moderate Cognitive Impairment). Resident #17 had functional limitations due to impairment on one side. Resident #17 required Substantial/Maximal assistance with eating, oral hygiene, toileting, showering/bathing, dressing, and transfers. Review of Resident #17's Care Plan with target date of 02/22/2024 revealed she required routine care related to her impaired mobility. Approaches included; Provide bath of Resident's choice 3 times a week. Interview on 01/08/2024 at 10:15 a.m. with Resident #17 revealed staff had not been bathing her, or washing her hair and her hair became matted. Resident #17 stated her daughter had to cut her hair short, and this made her sad. Telephone interview on 01/08/2024 at 11:11 a.m. with Resident#17's daughter revealed on 12/23/2023 she visited the facility and her mother's hair was so matted from lack of care, and bathing that she had to cut her mother's hair off. Interview on 01/10/2024 at 4:30 p.m. with S2 DON revealed she was aware of the concerns of Residents not receiving scheduled baths, and had educated staff to always document a reason as to why a resident did not receive a bath on their scheduled days. S2 DON confirmed with a review of Resident #17's 12/2023 bathing report, Resident #17 was scheduled to receive baths on Tuesday, Thursday, and Saturday's but had not received scheduled baths. Resident #17 had 2 documented baths, and 2 documented refusals. S2 DON confirmed Resident #17 did not receive baths as scheduled, but should have. Interview on 01/11/2024 at 9:18 a.m. with S19 Admissions Coordinator revealed on 12/19/2023 Resident #17 voiced a complaint to him about staff not bathing her and washing her hair, and her hair had become matted. S19 Admissions Coordinator stated he was aware Resident #17's daughter visited on 12/23/2023, and had to cut Resident #17's hair which made Resident sad because of her religion, she preferred longer hair. Resident #59 Review of Resident #59's medical record revealed an admit date of 11/01/2023. Resident #59 had the following diagnoses that included in part . Schizoaffective Disorder, Bipolar Type; and Unspecified Dementia, unspecified severity with other behavioral disturbances.\ Review of Resident #59's Annual MDS with an ARD of 11/10/2023 revealed Resident #59 had a BIMS of 8 (Moderate Cognitive Impairment). Resident #59 had wandering behaviors which occurred 1-3 days. Resident required Partial/Moderate assistance for toileting, showering/bathing, and dressing. Resident #59 had occasional incontinence of urine and was always incontinent of bowel. Observation on 01/08/2024 at 10:11 a.m. of Resident #59 in her room revealed her door remained open to hall, and no privacy curtain drawn. Resident #59 was observed from hall undressed from waist down, and had a soiled pull up saturated with urine that she placed on the floor next to her roommate's bed when surveyor presented into room. Resident #59 stated she was looking for clothes, and was left wet too long, so she changed herself. Interview on 01/08/2024 at 10:15 a.m. with S26 LPN confirmed Resident #59 needed assistance with dressing/toileting, and the Resident should not have been without clothing.

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 F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (Resident #28) of 1 resident reviewed for environment. The facility failed to ensure Resident #28 had an adaptive call light in reach in order to call for assistance. The total facility census was 58 residents. Findings: Review of Resident #28's Medical Record revealed an admission date of 10/12/2022 with diagnoses that included Quadriplegia, C5-C7 Complete, Chronic Kidney Disease, Neuromuscular dysfunction of bladder, Anxiety disorder, Pressure Ulcer of Left Hip, Unstageable, Pressure Ulcer of Sacral Region, Unstageable, Chronic Pain, Depression and Essential Primary Hypertension. Review of Resident #28's Physician's Orders revealed: 10/12/2022 - Admit to (facility) under the care of _____ Hospice 10/12/2022 - O2 Nasal Cannula at 2 liters prn SOB 10/12/2022 - Morphine Sulfate 100mg/5 ml concentrate give 0.25ml po every 2 hours prn pain 10/12/2022 - Ondansetron HCl 4mg give 1 tablet po every 6 hours prn nausea 10/12/2022 - Hydrocodone-acetaminophen 7.5/325mg give 1 tablet po every 6 hours prn chronic pain. Review of Resident #28's Annual Minimum Data Set (MDS) with an ARD of 10/23/2023 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident had intact cognition. Resident #28 had bilateral impairment to extremities and was totally dependent on staff with bed mobility, dressing, bathing, toileting, oral and personal hygiene. Review of Resident #28's Care Plan with a target date of 01/11/2024 revealed in part . Routine care needs Diagnoses: Quadriplegia, Contractures, Colostomy and Catheter. Approaches included in part . Respond to call light promptly. Observation of Resident #28 on 01/08/2024 at 10:51 a.m. revealed resident was paralyzed with bilateral upper and lower extremity contractures noted. Resident was observed lying on his back with his lower extremities turned towards his right side. Resident had call light button located on his right side. Interview at this time with Resident #28 stated he could not reach the call light to call for help if needed because he could not move or straighten his arm to reach call light. Resident #28 stated the aide usually puts call light button in his left hand but it must have fallen out. He stated the call light button does not stay in his hand because he is a quadriplegic. Interview on 01/09/2024 at 08:50 a.m. with S3 SSD revealed Resident #28 had a grievance in reference to his call light a couple of months ago. S3 SSD revealed the grievance was resolved by the previous ED. Observation of Resident #28 on 01/09/2024 at 9:00 a.m. revealed resident awake lying in bed with head of bed elevated. Observation of call light button in bed on his right side. Interview at this time with Resident #28 stated he is unable to reach the call light button and demonstrated to this surveyor that he was unable to use or reach the call light button. Resident stated the aide offered to put the call light in his hand but it doesn't stay in his hand and he stated he would just holler if he needed anything. Observation of Resident #28 on 01/09/2024 at 11:00 a.m. with call light button remained unreachable on his right side. Resident #28 stated the call light plate switch on the wall was broken and changed out last month and that was when he noticed that he didn't have his tap touch call light pad anymore and had a call light button instead. Resident #28 stated he is supposed to have a touch tap call light pad because he is not able to push the button on a call light button due to being paralyzed. Observation of Resident #28 on 01/09/2024 at 01:40 p.m. revealed resident lying in bed on back side with call light button remained unreachable at the foot of his bed. Interview at this time with Resident stated he is not able to reach call light as he is unable to move or extend his arms to use it. He stated he used to have a tap type touch call light pad but they had taken it out about a month ago. Observation of a touch type tap call light pad lying on top of the empty bed in resident's room. He stated the aide who worked yesterday evening passed by his room with his light on and she just passed by his door. Observation and interview in Resident #28's room on 01/09/2024 at 01:49 p.m. accompanied by S13 COTA revealed Resident #28 lying in bed with a call light button remained unreachable on his right side. S13 COTA revealed Resident #28 needed and used to have a tap touch type call pad to be placed close to his reach. Observation revealed a tap touch call light pad lying on the other empty bed in resident's room. S13 COTA confirmed that Resident #28 should have this type of tap touch call pad close within his reach instead of a call light button and did not. Observation of Resident #28 on 01/09/2024 at 1:57 p.m. lying in bed with call light button remained unreachable by resident. This surveyor summoned S22 CNA to resident's room. S22 CNA stated she had asked him if he wanted the call light in his hand earlier this morning and stated he would just holler if he needed something. Interview on 01/09/2024 at 02:11 p.m. with S16 Maintenance Supervisor stated the previous ED informed him 2 weeks ago that he was to be the interim Housekeeping Supervisor due to the previous Housekeeping Supervisor not showing up to work. S16 Maintenance Supervisor stated he was not aware that resident call light box was changed out or replaced and that his Maintenance Assistant must have replaced it. Interview on 01/09/2024 at 3:04 p.m. with S17 MDS LPN revealed she was responsible for resident care plans. S17 MDS LPN revealed that Resident #28 was dependent on staff for his needs and required an adaptive call light to call for assistance when needed. S17 MDS LPN confirmed that Resident #28 did not have a care plan in place for an adaptive tap touch call light pad to be within his reach at all times and should have. Interview on 01/11/2024 at 1:30 p.m. with S2 DON confirmed that Resident #28 was dependent on staff and was required to have an adaptive tap touch call light pad within his reach at all times for assistance and did 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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility failed to ensure their grievance policy and procedure was followed. The facility failed to inform the resident/resident's RP (responsible party) of investigation findings and actions taken to correct the identified problems for 1 (#17) of 24 sampled residents. Findings: Review of the facility policy titled Grievance/Missing Property revealed in part . Grievances may be presented to any staff member; the staff member may resolve the issue immediately. If unable to resolve immediately, follow the Grievance Procedure. 1. Respective Department Head, Executive Director and/or Grievance Official will follow-up on issues noted. 2. Supervisory personnel or department heads are responsible for reviewing the Grievance form within 10 working days. Department heads are responsible for reviewing, signing and forwarding the completed complaint form to the Executive Director and/or Grievance Official. 3. Social Service is responsible for notifying resident representative, family/next of kin and Ombudsman, as appropriate, of resolution. Supervisory personnel shall be responsible for notifying the resident of resolution and so indicate on grievance form. Review of the facility's grievance log for the month of December 2023 revealed Resident #17 had 2 grievances on file. On 12/19/2023 Resident #17 voiced a grievance to S19 Admissions Coordinator regarding her hair not being washed. Immediate response/steps taken to investigate grievance: S3 SSD and S2 DON upgraded bathing schedule to include hair washing. Conclusion: Resolved. There was no documented corrective action taken, and no documented information concerning a follow up given to the Resident/Resident's RP. On 12/25/2023 Resident #17's RP filed a grievance with S3 SSD. S3 SSD documented Resident #17's RP had concerns about overall care from nursing, hair not being kept up, wounds not being supervised, staff not encouraging Resident to eat when she refuses, not being turned, and CNA sitting in room on phone. Action taken: CNA and Treatment education from S2 DON, verbally. There was no documented corrective action taken, and no documented information concerning a follow up given to the Resident/Resident's RP. Interview on 01/08/2024 at 10:15 a.m. with Resident #17 revealed she relied on staff for bathing her. Resident #17 stated staff had not been washing her hair, so she had to cut it short recently, and that made her sad. Resident #17 stated she often was left with a soiled diaper and had to wait for 1 hour or more, before being changed. Interview on 01/08/2024 at 11:15 a.m. with Resident #17's RP revealed she had filed a grievance with S2 DON on 12/23/2023 regarding the lack of care she felt Resident# 17 was receiving, but she had not received a follow up. Resident #17's RP stated she called to get a follow up, and to check on the lab work that was ordered late December 2023, but was informed they did not have lab results, and was told if something was wrong with the labs, the lab would have called. Interview on 01/10/2024 at 4:40 p.m. with S1 Administrator revealed all grievances are documented on a grievance log, investigated by the appropriate staff member, and a follow up was provided to whomever made the grievance. S1 Administrator stated she was aware of 1 complaint made by Resident #17's RP. S1 Administrator stated S2 DON placed Resident #17 on a daily bathing schedule, and addressed the other concerns. S1 Administrator stated she had not received any complaints directly from Resident#17/Resident's RP, and S2 DON had informed her all concerns had been addressed. Interview on 01/11/2024 at 8:29 a.m. with S2 DON revealed she had received a complaint from Resident #17's RP on 12/25/2023. S2 DON stated Resident #17's RP had concerns related to the Resident's hair not being washed, pressure ulcer concerns, and staff not encouraging Resident when she refused care. S2 DON stated she had Resident #17 moved to daily showers, and educated nursing staff and CNA's on rounding, and performing ADL care. S2 DON stated she did this verbally and had no documentation of actions taken, or a documented follow up to Resident #17's RP, but should have. S2 DON confirmed she had no documentation of investigation summaries for either of the above mentioned complaints for Resident #17. Interview on 01/11/2024 at 9:18 a.m. with S19 Admissions Coordinator revealed on 12/19/2023 Resident #17 voiced a complaint to him about staff not bathing her and washing her hair, and her hair had become matted. S19 Admissions Coordinator revealed he immediately informed S2 DON of the concerns, and followed up with Resident #17 and Resident's RP, but was not sure if S3 SSD, or someone in Administration documented a follow up given to Resident/Resident's RP. S19 Admissions Coordinator stated he was aware Resident #17's RP visited on 12/23/2023, but was unaware another complaint had been made.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 (Resident #10) of 1 sampled resident reviewed for foot care. Findings: Review of the Facility's Preventive Skin Care Policy revealed the following including: 4. Provide Preventive skin care to all residents .a. Keep skin clean, dry, and cleansed at the time of soiling and at routine intervals. Observation on 01/09/2024 at 4:22 p.m. revealed Resident #10 sitting in his wheelchair in his room asleep. He had a dressing intact to his right foot. Observation on 01/11/2024 at 8:45 a.m. revealed Resident #10 sitting in his wheelchair in the front lobby. He had a dressing intact to his right foot. He confirmed that he had asked one of the nurses to change his dressing to his right foot because it was dirty from drainage. Resident #10 stated the nurse refused to do the treatment because it was not her job. Review of Resident #10's EHR revealed an admit date of 12/02/2022. Resident #10 had the following diagnoses including Diabetes due to underlying condition with Diabetic Neuropathy. Review of Resident #10's 01/2024 Physician Orders revealed the following including: 11/21/2023 - Right Heel Diabetic Ulcer - Apply Vashe soaked gauze to wound bed for 5-10 minutes, remove and apply Medi-Honey and Calcium Alginate. Apply dry dressing, wrap with Kerlix, secure with tape, change Tuesday, Thursday, Saturday & prn. Review of Resident #10's Care Plan with target date of 02/02/2024 for Potential for Skin Breakdown r/t Diabetic Ulcer to Right Heel - Approaches included: Treatment as ordered. Review of Resident #10's 01/2024 Departmental Notes revealed on 01/06/2024 at 12:20 a.m. Resident #10 called a nurse into his room asking for the dressing to be change to his right foot. S18 LPN refused to perform the wound care and informed Resident #10 the dressing change was for the treatment nurse to do, not her. Resident #10 ask for scissors to perform the wound care himself and S18 LPN informed him she could not give him scissors. Interview on 01/10/2024 at 12:43 p.m. with S11 Corporate Nurse revealed she was unable to explain the above documentation by S18 LPN but stated this was not a correct response when a resident asked for a dressing change. Interview on 01/10/2024 at 12:48 p.m. with S2 DON confirmed the above documentation and stated it should not have happened.

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 F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #10) of 1 sampled resident receiving dialysis. Findings: Review of the facility's Dialysis Information Update Transfer Policy revealed the following: Policy: A Dialysis Information Update Transfer Form is completed each time a resident receives outpatient dialysis. This ensures enhanced communication between the two facilities. Procedure: 1. The top section of the Dialysis Information Update Transfer Form is completed by the nurse responsible for sending the resident to the dialysis unit/facility.3. The bottom section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident. 4. Once the form is completed in its entirety, the most recent form should be filed under Consultant Reports in the medical record. 5. As applicable, any instructions related to the resident care received from the dialysis unit should be relayed to the appropriate facility staff and followed up as indicated. Review of Resident #10's EHR revealed an admit date of 12/02/2022. Resident #10 had the following diagnoses including Dependence on Renal Dialysis, Type 1 Diabetic Mellitus with Diabetic Chronic Kidney Disease and End Stage Renal Disease. Review of Resident #10's 01/2024 Physician Orders revealed the following including: 11/10/2023 - Dialysis Tuesday, Thursday, and Saturday, Left Chest Wall ASH Cath Review of Resident #10's Care Plan with target date of 02/02/2024 for Resident has DX of ESRD/currently receiving Hemodialysis 3 x week - Approaches: Dialysis 3 x week on Tuesday, Thursday, and Saturday; and monitor vital signs as ordered by MD. Review of Resident #10's Yearly MDS with an ARD of 11/30/2023 revealed a BIMS score of 15 (cognitively intact) and Resident #10 was on Dialysis. Review of Resident #10's 11/2023 - 01/2024 Dialysis Information Update Transfer Forms revealed the following days that the forms were not done or not completed: There were no forms on 11/04/2023, 11/07/2023, 11/09/2023, 11/11/2023, 11/21/2023, 11/23/2023, 11/28/2023, 12/02/2023, 12/07/2023, 12/09/2023, 12/12/2023, 12/14/2023, 12/16/2023, 12/19/2023, 12/23/2023, 12/26/2023,12/28/2023, 12/30/2023, 01/04/2024 and 01/09/2024. There were incomplete forms on 11/02/2023, 11/19/2023, 11/20/2023, 11/25/2023, 11/30/2023, 12/05/2023, 12/21/2023 and 01/02/2024. Interview on 01/10/2024 at 4:27 p.m. with S2 DON confirmed the above findings. S2 DON stated that the nurse taking care of Resident #10 should complete the assessment before and after the resident's dialysis. She stated if the Dialysis Center's section was not complete, the nurse should call and get the missing information. S2 DON stated the Dialysis Information Update Transfer Form should be completed every time a resident goes to and returns from dialysis.

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 F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review the facility failed to act promptly upon grievances and recommendations of the resident council concerning issues of resident care and life in the facility; and failed to demonstrate their response and rationale for such response. The facility census was 58. Findings: Review of the facility's Resident Council Policy revealed the following including: The Social Services Director or designee will facilitate the organization and maintenance of a facility Resident Council. Responsibility: Social Service Director or designee. Review of the facility's Grievance Policy reveal the following in part, A. 1. Respective Department Head, Executive Director and/or Grievance Official will follow-up on issues noted. a. Grievances may be presented to any staff member who will then report the issue utilizing the Grievance Form to his/her supervisor and/or department head. b. The supervisor will discuss the concerns/grievances and appropriate solutions with the department direction. Review of the facility's Resident Rights Policy revealed the following in part, 18. The facility shall provide an approved designated staff person to provide assistance and who responds in writing to requests from the meetings. Grievances or recommendations by the group regarding resident care and life in the facility must be promptly acted on by the facility. Observation on 01/08/2024 at 1:00 p.m. during a Resident Council Meeting revealed S3 SSD and S4 Activity Director and 11 residents present at the meeting. There were 5 residents who complained about call light response time, ADL care, and low staff. One resident stated there was only 1 CNA on the night shift and the CNA was new. One resident stated there was never enough Aide staff to provide care she needed. There was one resident who ask for more fresh fruit. There were 4 residents who complained of the facility food. Review of the minutes from the above Resident Council Meeting revealed no documented concerns about staffing, call light response time, ADL care or request for fresh fruit. There were only 9 residents listed as attendees. Review of the minutes from the 12/28/2023 Resident Council Meeting revealed old business concerning more fruit and call lights. Both areas were marked as not resolved, with no explanation. New business included documentation that 7 residents had issues with call light and 2 residents with issues concerning night staff, taking hours to answer call light and staff handling residents roughly. There were no department responses noted. Review of the minutes from the 12/05/2023 Resident Council Meeting revealed new business concerning more fruit. There was no old business issues reviewed. There were no department responses noted. Review of the minutes from the 11/21/2023 Resident Council Meeting revealed unresolved old business concerning food served cold, CNAs not answering call lights, CNAs taking wipes and diapers from residents and using for other residents and not getting residents out of bed until after 12:00 p.m. New business included bingo for cash prizes and making sure residents receive correct dietary menu. There were no departmental responses noted. Interview on 01/10/2024 at 8:15 a.m. with S4 Activity Director revealed documentation of the minutes from the Resident Council Meeting held on 01/08/2024 and all previous meetings were complete. She stated the minutes should be reviewed by the Executive Director with corrective measures documented and the forms were not. Interview on 01/11/2024 at 10:00 a.m. with S3 SSD (Social Service Director) revealed that the Activity Director was responsible for submitting findings from Resident Council Meeting to Administration and obtaining follow up on issues discussed in the meetings.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26 Review of Resident #26's medical record revealed Resident #26 was admitted to the facility on [DATE]. Resident #26 had diagnoses that included in part . Dementia, Kidney Failure, Urinary Incontinence, Anxiety, Dizziness and Giddiness, and Unsteadiness on feet. Review of Resident #26's Quarterly MDS with ARD of 12/07/2023 revealed Resident #26 had a BIMS of 13 (intact cognition). Resident required Substantial/Maximal assistance for toileting, showering/bathing, and dressing. Resident was always incontinent of Bowel/Bladder. Observation on 01/10/2024 at 9:41 a.m. of Resident #26's room revealed a strong urine odor within room. There was a heavily soiled pull up that contained urine lying on the floor beside the right side of Resident's bed. Interview with Resident #26 at time of observation revealed she called for help, but had to wait too long for assistance. Resident #26 stated she had to go to the restroom on her own, and pointed to her bathroom. Observation of the bathroom revealed the toilet seat had smeared feces on the seat, and there was a strong smell of feces and urine. Interview on 01/10/2024 at 9:56 a.m. with S2 DON in Resident #26's room confirmed the Resident's room and restroom was unsanitary, and needed to be cleaned. Observation on 01/11/2024 at 8:41 a.m. of Resident #26's room revealed a strong urine odor within room. There was a heavily soiled pull up that contained urine lying on the floor beside the left side of Resident's bed. Interview on 01/11/2024 at 8:45 a.m. with S7 LPN in Resident #26's room revealed the soiled pull up needed to be discarded. S7 LPN stated on numerous occasions when she presented to work for 7 a.m. shift, Residents were in need of ADL care. S7 LPN confirmed Resident #26 needed assistance with toileting. Interview on 01/11/2024 at 8:49 a.m. with S1 Administrator in Resident #26's room confirmed the Resident's room had a strong urine odor, was unsanitary, and needed to be cleaned. Resident #59 Review of Resident #59's medical record revealed an admit date of 11/01/2023. Resident #59 had the following diagnoses that included in part . Schizoaffective Disorder, Bipolar Type; and Unspecified Dementia, unspecified severity with other behavioral disturbances. Review of Resident #59's Annual MDS with an ARD of 11/10/2023 revealed Resident #59 had a BIMS of 8, indicating moderately impaired cognition. Resident #59 had wandering behaviors which occurred 1-3 days. Resident required Partial/Moderate assistance for toileting, showering/bathing, and dressing. Resident #59 had occasional incontinence of urine and was always incontinent of bowel. Observation on 01/08/2024 at 10:11 a.m. of Resident #59's room revealed there was a strong urine odor. Resident #59 was undressed from waist down, and had a soiled pull up saturated with urine that she placed on the floor next to her roommate's bed. Resident #59 stated she was looking for clothes, and was left wet too long, so she changed herself. Observation of Resident #59's restroom revealed the floor was heavily soiled with pieces of trash on the floor. Interview on 01/08/2024 at 10:15 a.m. with S26 LPN confirmed the room smelled of urine, Resident #59 needed assistance with dressing/toileting, and the restroom needed cleaning. Observation on 01/11/2024 at 8:38 a.m. of Resident #59's room revealed she was sitting up on side of bed, and there was a moderate amount of feces smeared on her bed sheet. Observation of the bed side commode next to Resident #59's bed revealed feces smeared on the toilet seat. Interview on 01/11/2024 at 8:49 a.m. with S1 Administrator in Resident #59's room confirmed the Resident's room was unsanitary and bed sheets were unsanitary, and needed to be changed. Observation on 01/08/2024 at 08:50 a.m. of Hall Y residents' rooms with sand and dirt debris noted on the floors. Interview at this time with S14 Housekeeper revealed that she usually works at another facility and came with their Administrator this morning to help clean because their housekeepers had called in again. S14 Housekeeper revealed the residents' rooms and bathrooms on Hall Y were very dirty and needed cleaning. Observation on 01/08/2024 at 10:55 a.m. of Bathroom X revealed one electric wheelchair and one manual wheelchair folded and parked in front of and blocking the bathroom lavatory sink. Further observation revealed a spot of wet, sticky dark residue that surrounded the floor around bottom of the commode and several dark brown areas of caked debris on the floor. Observation on 01/09/2024 at 08:56 a.m. of Bathroom X revealed one electric wheelchair and one manual wheelchair remained folded and parked in the same position as above findings. Observation of wet, sticky dark residue remained on the floor surrounded around bottom of the commode. Observation of several dark brown areas of caked debris remained on the floor in Bathroom X. Observation of a bedpan with brown debris noted laying on top of the manual wheelchair in Bathroom X. Interview at this time in Bathroom X accompanied by S7 LPN confirmed the above findings and stated residents' rooms and bathrooms on Hall Y appeared as if they had not been cleaned in quite some time. Interview on 01/09/2024 at 09:00 a.m. in Bathroom X accompanied by S14 Housekeeper revealed she had passed the mop yesterday in Bathroom X around the wheelchairs because she could not move the electric wheelchair. S14 Housekeeper stated she was unable to remove the dark brown caked debris from the floor with the mop but it would not come off. S14 Housekeeper stated she brought a scraper today to try to scrape of the dirt off the floors. S14 Housekeeper stated the floors in residents' rooms on Hall Y were very dirty and look like they had not been cleaned in a while. Interview on 01/11/2024 at 11:56 a.m. with S20 Housekeeping Aide revealed she had worked here for about 3 months and revealed she was aware of the wheelchairs in Bathroom X. S20 Housekeeping Aide stated she had mopped Bathroom X floors but could not get the dark caked debris off of the floor. Interview on 01/11/2024 at 11:58 a.m. with S14 Housekeeper revealed she had sprayed cleaner on the floor of Bathroom X and let it sit for a little while before she used the scraper to scrape it off. She stated she mopped the floor after until the dark spots of debris were finally gone. S14 Housekeeper confirmed the floors in Bathroom X were bad and dirty and had to really scrub hard to remove the caked on debris. Based on observation and interview the facility failed to provide a safe, clean, comfortable and homelike environment including housekeeping and maintenance service necessary to maintain a sanitary environment for 58 residents residing in the facility. Findings: Observation on 01/09/2024 at 10:48 a.m. of the facility shower room on Hall X revealed a stained, hair filled towel in front of a chair and trash scattered all over the floor. Interview on 01/09/2024 at 10:51 a.m. with S5 LPN confirmed the above findings and stated the dirty towel should not be on the floor and the trash should be removed. Interview on 01/09/2024 at 10:55 a.m. with S6 CNA who was rolling a resident into the shower room revealed she left the towel on the floor to keep residents from slipping after they received their shower.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16 Review of Resident #16's medical record revealed Resident was admitted to facility on 09/20/2011 and had diagnoses that included in part . Dementia, Primary Generalized Osteoarthritis, Type 2 DM, Major Depressive Disorder, Abnormal weight loss, and Alzheimer's Disease. Review of Resident #16's Quarterly MDS with ARD of 11/09/2023 revealed Resident #16 had a BIMS of 99 (Unable to assess cognition). Resident #16 required Supervision/Setup assistance for eating. Moderate assistance for oral hygiene, and dressing. Maximal assistance for toileting, showering/bathing, and personal hygiene. Resident was always incontinent of Bowel and Bladder. Review of Resident #16's Care Plan with target date of 02/2024 revealed she was at risk for weight loss, required set up assist and supervision with meals, and ate meals in the dining room. Approaches included; provide set up assist and encouragement with all meals, serve diet as ordered, document food intake at each meal, and double dessert portions. Review of Resident #16's 12/2023-01/2024 Meal Intake Reports revealed intakes of each meal were not recorded. Observation on 01/08/2024 at 10:25 a.m. of Resident #16 revealed she was attempting to eat a snack. Resident #16's bedside table had a white Styrofoam cup of grape punch on it. Resident #16 had a snack cake, but had trouble removing item from wrapper. Resident nodded Yes when asked if she needed assistance with meals and snacks. Resident #16 nodded No when asked if staff helped her with meals. There was no staff member observed in Resident #16's room. Observation on 01/08/2024 at 10:40 a.m. of Resident #16 in her room revealed the cup of grape punch was observed spilt over onto floor. Observation on 01/09/2024 at 5:09 p.m. revealed Resident #16 was served supper meal in her room. Staff observed placing tray on bedside table and instructed Resident #16 to sit up and eat supper. Resident #16 was observed sitting up on side of bed, and began to eat meal. Observation of Resident #16's meal card on supper tray revealed under notes section Double Dessert Portions. Observation of the tray revealed one serving of dessert. Observation on 01/09/2024 at 5:38 p.m. revealed S28 CNA went into Resident #16's room, and removed supper tray. S28 CNA did not offer encouragement to Resident to eat meal. Interview with S28 CNA at time of observation revealed Resident #16 only took one bite of meat. Observation of Resident #16's supper tray revealed all of the food items remained on the tray. Observation on 01/10/2024 at 12:40 p.m. revealed Resident #16 was seated up in bed of her room with lunch tray on bedside table over bed. Resident #16 was drinking a cup juice and was observed with a large amount of juice on her gown. Interview with S24 CNA at time of observation revealed Resident #16 typically did not eat well, and only liked to eat sweets. Review of Resident #16's meal card with S24 revealed Resident was to receive double portions of dessert. Resident #16 tray observed with one serving of pears. Interview on 01/10/2024 at 12:45 p.m. with S7 LPN revealed Resident #16's meal card on tray stated Double Dessert Portions S7 LPN confirmed Resident #16 was not served double dessert portion, but should have been. S7 LPN was unsure if Resident #16 was ordered to be supervised with meals, but stated Resident had not been supervised and ate in her room. Interview on 01/10/2024 at 2:00 p.m. with S29 ST revealed he had evaluated Resident #16 as needed, and felt Resident #16 did not do well with feeding herself, and would benefit from staff assistance at a table. Interview on 01/10/2024 at 4:30 p.m. with S2 DON confirmed Resident #16 did not have all meal intakes recorded for 12/2023 and 01/2024, but should have. Resident #26 Review of Resident #26's medical record revealed Resident #26 was admitted to the facility on [DATE]. Resident #26 had diagnoses that included in part . Dementia, Kidney Failure, Urinary Incontinence, Anxiety, Dizziness and Giddiness, and Unsteadiness on feet. Review of Resident #26's Quarterly MDS with ARD of 12/07/2023 revealed Resident #26 had a BIMS of 13 (cognitively intact). Resident required Substantial/Maximal assistance for toileting, showering/bathing, and dressing. Resident was always incontinent of Bowel/Bladder. Review of Resident #26's Care Plan with target date of 02/13/2024 revealed Resident #26 required staff assistance with ADL's, and was at risk for infection. Approaches included administer medications as ordered. Observation on 01/08/2024 at 10:30 a.m. of Resident #26 revealed she was sitting up on side of bed visiting with a friend. Observation revealed 3 pills lying on bed near Resident. Resident #26 stated nurse had put medications here this morning and pointed to bed side table. There was an empty medication cup lying on the floor. Resident #26 stated she took all of her medications in the cup. Interview on 01/08/2024 at 10:51 a.m. with S2 DON in Resident #26's room revealed Resident had 3 pills loose in bed. Resident #26 stated she was unaware she had dropped the medications. S2 DON confirmed nurse administering medication should stay and observe Resident to ensure medication was taken, but had not. S2 DON identified the pills as; Namenda (dementia medication), Gemtesa (bladder medication), and Zoloft (antidepressant medication). Resident #28 Review of Resident #28's Medical Record revealed an admission date of 10/12/2022 with diagnoses that included Quadriplegia, C5-C7 Complete, Chronic Kidney Disease, Neuromuscular Dysfunction of Bladder, Anxiety Disorder, Pressure Ulcer of Left Hip, Unstageable, Pressure Ulcer of Sacral Region, Unstageable, Depression, Insomnia, Chronic Pain and Essential Primary Hypertension. Review of Resident #28's Physician's Orders revealed: 10/12/2022 - Admit to (facility) under the care of _____ Hospice 10/12/2022 - O2 Nasal Cannula at 2 liters prn SOB 10/12/2022 - Morphine Sulfate 100mg/5 ml concentrate give 0.25ml po every 2 hours prn pain 10/12/2022 - Ondansetron HCl 4mg give 1 tablet by mouth every 6 hours prn nausea 10/12/2022 - Hydrocodone-acetaminophen 7.5mg/325mg give 1 tablet by mouth every 6 hours prn chronic pain. Review of Resident #28's Annual Minimum Data Set (MDS) with an ARD of 10/23/2023 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident had intact cognition and required Hospice care. Resident #28 had bilateral impairment to extremities and was dependent on staff with bed mobility, dressing, bathing, toileting, oral and personal hygiene. Review of Resident #28's Care Plan with a target date of 01/11/2024 revealed in part . Routine care needs DX Quadriplegia, Contractures, Colostomy and Catheter. Approaches included in part . Respond to call light promptly. Interview on 01/09/2024 at 3:04 p.m. with S17 MDS LPN revealed she was responsible for resident care plans. S17 MDS LPN revealed that Resident #28 was dependent on staff for his needs and required an adaptive call light to call for assistance when needed. S17 MDS LPN confirmed that Resident #28 did not have a care plan in place for an adaptive tap touch call light pad to be within his reach at all times and should have. Interview on 01/11/2024 at 1:30 p.m. with S2 DON confirmed that Resident #28 was required to have an adaptive touch call light pad within his reach at all times and did not. S2 DON confirmed Resident #28 should have been care-planned for an adaptive touch call light pad within reach at all times and was not. Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 (Resident #10, Resident #12, Resident #16, Resident #26, and Resident #28) of 24 sampled residents. Findings: Review of the facility's policy titled, Care Plans read in part . Policy: Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care. Responsibility: Nurse will be monitored by ED. Procedure: 1. The Care Plan will be developed within 2 days. Subsequent meetings will take place yearly and as needed. 2. The team along with the resident and/or family members will identify services needed, preferences, and ability and care level guidelines. 3. The Care plan will be reviewed and/or revised yearly with the completion of the Admission/ Readmission/Yearly Evaluation and with changes in resident's condition as needed. 4. A meeting note will be entered. Resident #10 Review of Resident #10's EHR revealed an admit date of 12/02/2022. Resident #10 had the following diagnoses including: Long Term (current) use of opiate analgesic; Rhabdomyolysis, Diabetes due to underlying condition with Diabetic Nephropathy; Other Chronic Pain; Mood Disorder due to known Physiological condition with Depressive features; Dependence on Renal Dialysis, Schizoaffective Disorder, unspecified; Insomnia, Type 1 DM with Diabetic Chronic Kidney Disease; Hypertension and ESRD. Review of Resident #10's 01/2024 Physician Orders revealed the following including: 11/10/2023 - Amitriptyline HCL 50 mg po q HS 11/10/2023 - Abilify 15 mg po q HS 11/10/2023 - Norco 10-325 1 po q 6 hrs prn 11/10/2023 - Trazodone 50 mg po q HS 11/10/2023 - Duloxetine HCL DR 60 mg po BID 11/10/2023 - Lantus 100U/ml give 15U SQ BID 11/10/2023 - If BG >400 give 12U of insulin. Recheck q 1 hour until <400 - Notify MD with symptoms of Hyperglycemia or elevate BG over 400 for > 3hours 11/10/2023 - Accu-checks AC/HS - Humulin R 100U/ml vial per sliding scale - 200-250=2U, 251-300=4U, 301-350=6U, 351-400=9U 11/10/2023 - Shunt check q shift for thrill & bruit 11/10/2023 - Dialysis Tuesday, Thursday & Saturday, Left Chest Wall ASH Cath 11/10/2023 - Remeron 15 mg Sol Tab po q HS 11/12/2023 - Document pain scale before wound treatment 0=none, 1-3=mild pain, 4-5=moderate, 6-7=severe, 8-10=very severe pain 11/12/2023 - Document pain scale after wound treatment 0=none, 1-3=mild pain, 4-5=moderate, 6-7=severe; 8-10=very severe pain 11/13/2023 - Eliquis 2.5 mg 1 po qd 11/21/2023 - Right Heel [NAME] - Apply Vashe soaked gauze to wound bed for 5-10 minutes, remove, apply Medi-Honey and Ca++ Alginate. Apply dry dressing, wrap with Kerlix, secure with tape, change, Tuesday, Thursday, Saturday & prn 11/21/2023 - Xanax 0.25 mg po q HS 12/28/2023 - Seroquel 100 mg po q HS 12/29/2023 - Tramadol HCL 50 mg q 1 po q 12 hrs prn 12/29/2023 - Offer 1 Nepro Shake daily (include in fluid restriction) Review of Resident #10's Care Plan with target date of 2/2024 for Altered Health Maintenance R/T Diabetes - Approaches: Provide medication as ordered by MD & Monitor blood sugar levels as ordered by MD; Altered Mood State DX of Depression, Mood Disorder known physiological condition with depressive features - Approaches: Provide Medication as ordered by MD; Cardiac output altered R/T Hypertension - Approaches: Provide medication as ordered & Monitor BP as ordered by MD. There was no monitoring noted due to Resident #10 being on an anti-coagulant. Interview on 01/11/2024 at 4:27 p.m. with S2 DON confirmed Resident #10 was not given medications or monitored as ordered by the Physician. S2 DON stated this should not have happened. S2 DON further confirmed that Resident #10 was on an anti-coagulant and this should have been noted in his Care Plan and was not. Review of Resident #10's 12/2023 - 01/2024 E-Mars revealed the following days Resident #10 was not given his medications as ordered by the Physician or was not monitored as ordered by Physician: 12/01/2023, 12/02/2023 12/03/2023, 12/04/2023, 12/05/2023, 12/09/2023, 12/11/2023, 12/13/2023, 12/15/2023, 12/18/2023, 12/19/2023, 12/21/2023, 12/24/2023, 12/26/2023, 12/28/2023, 12/29/2023, 01/01/2024, and 01/08/2024. Resident #12 Review of Resident #12's EHR revealed an admit date of 10/04/2023 with the following diagnoses including Unspecified PVD; Chronic Kidney Disease, Stage 3, moderate; COPD; GERD; Type 2 DM with Foot Ulcer, Depression, unspecified, and Generalized Anxiety Disorder. Review of Resident #12's 01/2024 Physician Orders revealed the following including: 10/04/2023 - Levothyroxine 50 mcg 1 po q a.m. 10/04/2023 - Pantoprazole NA DR 40 mg 1 po q day 10/04/2023 - Gabapentin 300 mg 1 po BID 10/04/2023 - Metformin HCL 500 mg po BID 10/04/2023 - Cymbalta 60 mg po BID 10/04/2023 - Melatonin 5 mg po q HS 10/04/2023 - Ambien 5 mg po q HS 10/04/2023 - ASA EC 81 mg po q day 10/04/2023 - Atorvastatin 10 mg po 1 HS 10/04/2023 - Humulin R 100U/ml per sliding scale: 80-150=0U, 151-200=2U, 201-250=4U, 251-300=6U, 301-350=8U, 351-400=10U >400, Call MD 10/05/2023 - Document pain scale every shift 01/04/2024 - Trazadone 50 mg 2 tabs po q HS 01/04/2024 - Lantus 100U/ml give 22U SQ q day 01/06/2024 - Ozempic 0.25-0.5 mg/dose pen inject 0.5 mg DS q wk 01/07/2024 - Zyprexa 7.5 mg po q HS Review of Resident #12's Care Plan with a target date of 04/01/2024 for Altered Mood State R/T Depression and Side Effects of Anti-Depression Meds - Approaches: Provide medication as ordered by MD & Monitor for side effects/effectiveness of medications q shift -report s/s to MD if noted; Altered Health Maintenance R/T Diabetes - Approaches: Provide medications as ordered; Monitor for s/s of hypo/hyperglycemia - report to MD as noted; Potential for Abdominal Discomfort/Pain R/T Hx of GERD - Approaches: Monitor for c/o abdominal discomfort/pain daily and Provide medication as ordered by MD; Alteration in Comfort/Pain R/T Hx of OA - Approaches: Provide pain medications as ordered by MD and monitor for effectiveness; Airway Clearance, Impaired R/T COPD - Approaches: Provide medication as ordered by MD; Altered Health Maintenance R/T Dx of Chronic Kidney Disease (Stage 3) - Approaches: Provide medication as ordered by MD; Sleep pattern disturbance R/T Insomnia - Approaches: Provide medication as ordered by MD and monitor effectiveness; and Potential for Altered Tissue Perfusion R/T Hx of PVD - Approaches: Provide medication as ordered by MD. Review of Resident #12's 12/2023 MAR revealed the following days when medications were not given or monitoring was not conducted as ordered: 12/01/2023, 12/07/2023, 12/09/2023, 12/10/2023, 12/12/2023, 12/14/2023, 12/15/2023, 12/16/2023 12/17/2023, 12/18/2023, 12/20/2023, 12/21/2023, 12/22/2023, 12/23/2023, 12/24/2023, 12/25/2023, and 12/29/2023. Interview on 01/11/2024 at 4:27 p.m. with S2 DON confirmed Resident #12 was not given medications or monitored as ordered by the Physician. S2 DON stated this should not have happened.

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17 Review of Resident #17's medical record revealed an admit date [DATE] of with diagnoses that included in part . Hemiplegia, Dysphasia, Schizoaffective Disorder-Bipolar Type, Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, Major Depressive Disorder, Generalized Anxiety Disorder, Atherosclerotic Heart Disease, Diverticulitis, Osteoarthritis, Urinary Tract Infection, Epilepsy, and Chronic Obstructive Pulmonary Disorder. Review of Resident #17's Quarterly MDS with an ARD of 11/30/2023 revealed a BIMS score of 10 (Moderate Cognitive Impairment). Resident #17 had functional limitations due to impairment on one side. Resident #17 required Substantial/Maximal assistance with eating, oral hygiene, toileting, showering/bathing, dressing, and transfers. Resident #17 was always incontinent of bowel and bladder. Review of Resident #17's Care Plan with target date of 02/22/2024 revealed she required routine care related to her impaired mobility. Approaches included; Provide bath of Resident's choice 3 times a week. Interview on 01/08/2024 at 10:15 a.m. with Resident #17 revealed she relied on staff for bathing her. Resident #17 stated staff had not been washing her hair, so she had to cut it short recently, and that made her sad. Resident #17 stated she often was left with a soiled diaper and had to wait for 1 hour or more, before being changed. Telephone interview on 01/08/2024 at 11:11 a.m. with Resident#17's daughter revealed on 12/23/2023 she visited the facility and her mother's hair was so matted from lack of care, and bathing that she had to cut her mother's hair off. Interview on 01/10/2024 at 4:30 p.m. with S2 DON revealed she was aware of the concerns of Residents not receiving scheduled baths, and had educated staff to always document a reason as to why a resident did not receive a bath on their scheduled days. S2 DON confirmed with a review of Resident #17's 12/2023 bathing report, Resident #17 was scheduled to receive baths on Tuesday, Thursday, and Saturday's but had not received scheduled baths. Resident #17 had 2 documented baths, and 2 documented refusals. S2 DON confirmed Resident #17 did not receive baths as scheduled and outlined in her care plan, but should have. Resident #12 Observation on 01/08/2024 at 1:00 p.m. of Resident # 12 during the Resident Council meeting revealed she was sitting in her Geri-Chair covered with a blanket. Resident #12 stated she had not received a bath in a long time and that she had only received 2 baths since being admitted into the facility. Resident #12 also stated it took a long time for staff to answer her call light. Observation on 01/09/2024 at 1:30 p.m. revealed Resident #12 lying in bed. Resident #12 stated she had not had a bath. She was wearing the same clothes as yesterday. She stated she wanted to get out of her bed and had been waiting about an hour for assistance. Resident #12 stated Aides had to use a lift to move her. Review of Resident #12's EHR revealed an admit date of 10/04/2023 with the following diagnoses including unspecified PVD; moderate COPD; and Type 2 DM with foot ulcer. Review of Resident #12's Care Plan with target date of 04/01/2024 for Routine care needs r/t dx of DM Type 2, OA, PVD, Anxiety, Depression; - Goal included: Will have all ADLs met on a daily basis - Interventions included in part: Provide bath of choice 3 times a week and to respond to call light promptly. There was no mention of use of a lift for transfer Review of Resident #12's Annual MDS with an ARD of 10/12/2023 revealed a BIMS score of 15 indicating intact cognition. Resident #12 required substantial/maximal assistance with shower/bathing, personal hygiene, and tub/shower transfer. There was no information concerning refusal of care. Review of Resident #12's Nurse Notes revealed no mention of refusal of care. Review of Resident #12's 12/2023 - 01/2024 Bathing Report revealed the following days that Resident #12 received a bath/shower: 12/01/2023, 12/09/2023, 12/13/2023, 01/03/2024 and 01/08/2024. Interview on 01/10/2024 at 4:27 p.m. with S2 DON confirmed the findings on Resident #12's Bathing Report and that Resident #12 had not received baths/showers as she should. Based on record review, observation, and interview, the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 5 (#5, #11, #12, #17, & #53) of 7 (#5, #11, #12, #17, #22, #30, & #53) residents reviewed for ADLs. Findings: Resident #5 Review of the medical record for Resident #5 revealed an admit date of 11/06/2020 with diagnoses that included: Schizoaffective Disorder, Chronic Kidney Disease, Muscle Weakness, and Type 2 Diabetes Mellitus. Review of Resident #5's Quarterly MDS with an ARD of 11/23/2023 revealed a BIMS score of 13, indicating intact cognition. Review of the MDS revealed Resident #5 was dependent with showering/bathing, dependent with toileting hygiene, and dependent with tub/shower transferring. Review of Resident #5's care plan revealed a problem of incontinent of bowel and bladder and requires assistance with dressing, grooming and hygiene tasks, bed mobility and transfers per staff. The care plan interventions included to offer assistance for grooming and hygiene tasks. In an interview on 01/08/2024 at 10:00 a.m., Resident #5 stated the facility often did not have enough CNA's working to give her showers. Resident #5 reported a few weeks ago she went about two weeks without a shower because there was only one CNA working. Resident #5 stated she required two CNAs to use the lift to transfer her for a shower. Resident #5 stated when that occurs, she gets bed baths and did not feel that was good enough. Review of the bath schedule revealed Resident #5 was scheduled for a shower on Mondays, Wednesdays, and Fridays on the 11:00 p.m.-7:00 a.m. shift. Review of Resident #5's bathing report from 12/01/2023 through 01/09/2024 revealed she did not receive a bath/shower as scheduled on 12/01/2023, 12/08/2023, 12/18/2023, 12/20/2023, 12/25/2023, 12/27/2023, 01/01/2024, 01/03/2024, and 01/05/2024. Further review revealed Resident #5 was not bathed 12/16/2023 through 12/21/2023, 12/24/2023 through 12/28/2023, and 12/30/2023 through 01/07/2024. In an interview on 01/10/2024 at 4:31 p.m., S2 DON reviewed the bathing record for Resident #5 and confirmed the resident did not receive baths three times per week as scheduled and there were no refusals documented in the record or care plan. Resident #11 Review of the medical record for Resident #11 revealed an admit date of 05/23/2012 with diagnoses that included: Dementia, Respiratory Syncytial Virus, and Encounter for Attention to Gastrostomy Tube. Review of Resident #11's Quarterly MDS with an ARD of 11/17/2023 revealed a BIMS score of 14 indicating intact cognition. Review of the MDS revealed Resident #11 required substantial or maximal assistance with personal hygiene and extensive assistance by two person assist with bed mobility and toilet use. Review of Resident #11's care plan revealed a problem of physical mobility impaired related to generalized weakness. Interventions included to provide physical extensive assistance by one person with dressing and bathing task. In an interview on 01/08/2024 at 4:02 p.m., Resident #11 stated Cut my nails. Observation of her nails at that time revealed the resident's nails were long, some jagged, and all had a brown substance beneath them. In an interview and observation on 01/10/2024 at 8:05 a.m., Resident #11's fingernails were long with a brown substance under them and she said she had been trying to get someone to cut them. Observation of both hands revealed her nails were long and extended past the fingertip by a quarter to a third of an inch. In an interview on 01/10/2024 at 8:26 a.m., S7 LPN confirmed Resident #11's fingernails needed to be cut and stated she would get the treatment nurse to cut them today. Resident #53 Review of the medical record for Resident #53 revealed an admit date of 08/30/2023 with diagnoses that included: Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Major Depressive Disorder. Review of Resident #53's Quarterly MDS with an ARD of 12/05/2023 revealed a BIMS score of 15 which indicated intact cognition. The MDS revealed the resident required partial/moderate assistance with showering. Review of Resident #53's care plan revealed a problem of Routine Care Needs with interventions that included to provide bath of resident's choice three times per week and provide oral hygiene daily and as needed. In an interview on 01/08/2024 at 9:50 a.m., Resident #53 stated she was only getting bathed about every two weeks. Resident #53 stated when she asks why she can't be bathed, staff tell her they don't have enough staff. She confirmed she would like to bathe every other day. Resident #53 stated they were not following the bathing schedule. Review of the resident bath schedule revealed Resident #53 was scheduled for showers on Tuesdays, Thursdays, and Saturdays during the 7:00 a.m. to 3:00 p.m. shift. Review of Resident #53's bathing report for 12/01/2023-01/09/2024 revealed the resident received only 4 baths/showers in December 2023 out of the 12 scheduled dates. Further review revealed only one shower was provided from 01/01/2024 through 01/09/2024. In an interview on 01/10/2024 at 4:31 p.m., S2 DON reviewed Resident #53's bathing report and confirmed she did not receive baths three times per week as scheduled and outlined in her care plan.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to provide sufficient numbers of CNAs to perform services on a 24-hour basis to provide nursing care to all residents in accordance to the resident care plans for all 58 residents in the facility; Findings: Review of the Facility's Facility Assessment Tool Staffing Plan revealed the following including: Staffing Plan 3.2 - Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Nurse Aides - 20 per day (8 hour shift); Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any time - Nursing Assistants - 1:7 Residents on Days (6 CNAs/2 Restorative Aides); 1:12 Residents on evenings (3-4 CNAs); and 1:19 Residents on nights (3 CNAs). Review of the Facility's Staffing Pattern Report Form revealed the following days when there was not enough CNAs based on the Facility Assessment: 11/25/2023 - Facility Census: 62 - 4 CNAs worked on the evening shift and it should have been 5. 12/02/2023 & 12/03/2023 - Facility Census: 64 - 4 CNAs worked on the evening shift and it should have been 5. 12/16/2023 - Facility Census: 63 - 8 CNAs worked on the day shift and it should have been 9; and 4 CNAs worked on the evening shift and it should have been 5. 12/17/2023 - Facility Census: 62 - 7 CNAs worked on the day shift and it should have been 8. 12/23/2023 - Facility Census: 60 - 4 CNAs worked on the evening shift and it should have been 5. 12/24/2023 - Facility Census: 60 - 6 CNAs worked on the day shift and it should have been 9; 3 CNAs worked on the evening shift and it should have been 6. 12/25/2023 - Facility Census: 60 - 6 CNAs worked on the day shift and it should have been 9; and 1 CNA worked on the night shift and it should have been 3. 12/26/2023 - Facility Census: 60 - 6 CNAs worked on the day shift and it should have been 9; and 1 CNA worked on the evening shift and it should have been 5. 12/27/2023 - Facility Census: 58 - 4 CNAs worked on the day shift and it should have been 8; and 2 CNAs worked on the night shift and it should have been 3. 12/28/2023 - Facility Census: 58 - 6 CNAs worked on the day shift and it should have been 8; and 2 CNAs worked on the night shift and it should have been 3. 12/29/2023 - Facility Census: 57 - 6 CNAs worked on the day shift and it should have been 8; and 2 CNAs worked on the night shift and it should have been 3. 12/31/2023 - Facility Census: 57 - 6 CNAs worked on the day shift and it should have been 8; and 3 CNAs worked on the evening shift and it should have been 5. 01/01/2024 - Facility Census: 57 - 7 CNAs worked on the day shift and it should have been 8; and 4 CNAs worked on the evening shift and it should have been 5. 01/02/2024 - Facility Census: 57 - 7 CNAs worked on the day shift and it should have been 8; 4 CNAs worked on the evening shift and it should have been 5; and 1 CNA worked on the night shift and it should have been 3. 01/03/2024 - Facility Census: 56 - 4 CNAs worked on the evening shift and it should have been 5. 01/04/2024 - Facility Census: 57 - 7 CNAs worked on the day shift and it should have been 8; and 4 CNAs worked on the evening shift and it should have been 5. 01/05/2024 - Facility Census: 57 - 4 CNAs worked on the evening shift and it should have been 5. 01/06/2024 - Facility Census: 57 - 7 CNAs worked on the day shift and it should have been 8; and 4 CNAs worked on the evening shift and it should have been 5. Interview on 01/11/2024 at 10:23 a.m. with S2 DON revealed she was aware of the CNA staffing issue in the facility. S2 DON confirmed at times there was only 1 CNA available to work the night shift. Interview on 01/11/2023 at 3:00 p.m. with S13 COTA revealed there were 17 residents who required the use of a 2-person lift in the facility. S13 COTA stated she was aware that the facility had staffing issues.

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

FACILITY Based on observation and interview the facility failed to dispose of garbage and refuse properly. This could affect all 58 residents in the facility. The total facility census was 58 residents. Findings: Review of the facility's policy titled, Garbage and Rubbish Disposal read in part . Guideline: Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen does not encourage infest or rodents. All outside dumpsters will be maintained in a clean and sanitary condition. Procedure: 6. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. Observation on 01/08/2024 at 09:20 a.m. revealed the slide door of the facility dumpster open. Observation of several pieces of paper trash on the ground surrounding the facility's dumpster and one broken bed frame outside of the kitchen door on the ground. Interview at this time with S15 Dietary Manager confirmed the above findings. S15 Dietary Manager stated she was unaware of when the broken bed frame was put outside. S15 Dietary Manager confirmed that the facility's dumpster slide door should have been closed and was not. S15 Dietary Manager confirmed that the broken bed frame on the ground outside of the kitchen and the paper trash should have been picked up and the area surrounding the dumpster should have been cleaned and was not. Interview on 01/08/2024 at 09:50 a.m. with S16 Maintenance Supervisor revealed the broken bed frame was put outside of the kitchen on the ground since last week. S16 Maintenance Supervisor verified that he had not had a chance to call the landscaper to come pick it up to bring to the scrap-yard to be disposed of and should have. Observation on 01/09/2024 at 10:50 a.m. of the facility's dumpster revealed the trash truck was gone and the broken bed frame remained on the ground outside of the kitchen. Interview on 01/09/2024 at 10:51 a.m. with S27 Housekeeping Aide revealed the broken bedframe was still outside on the ground by the kitchen and not picked up yet when the city trash came and picked up the trash this morning. Interview on 01/09/2024 at 02:53 p.m. with S1 Administrator revealed she was aware of the broken bed frame removed from the building and placed outside on the ground by the kitchen. S1 Administrator stated she was unaware of a policy on garbage disposal and the procedure for proper disposal of broken equipment. S1 Administrator confirmed that the facility's dumpster slide door should have been closed and the area surrounding the facility's dumpster should have been cleaned and was not.

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following: 1. Proper hand hygiene during wound care for Resident # 17. 2. Proper staff training of chemicals used for cleaning and disinfection of environment. 3. Proper handling of medical equipment during wound care for Resident # 28. This failed practice had the potential to affect all staff and the residents residing at the facility. The facility census was 58. Findings: Review of the facility's policy titled, Standard Precautions read in part . Policy: Standard Precautions will be utilized to provide a primary strategy for the prevention of HAI agents among patients and healthcare personnel. Definitions in part . Standard Precautions applies to all persons regardless of their diagnosis or presumed infectious status. Procedure in part: 1. During delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surface. 2. Wash hands when visibly soiled, after contact with blood, body fluids, secretions, excretions, patient's intact skin or wound dressings and contaminated items immediately after removing gloves and between patient contacts. 5. Handle soiled patient care equipment in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene. 6. Environmental control - follow procedures for routine care, cleaning and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas. 1. Review of Resident #17's medical record revealed an admit date [DATE] of with diagnoses that included in part . Hemiplegia, Dysphasia, Schizoaffective Disorder-Bipolar Type, Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, Major Depressive Disorder, Generalized Anxiety Disorder, Atherosclerotic Heart Disease, Diverticulitis, Osteoarthritis, Urinary Tract Infection, Epilepsy, and Chronic Obstructive Pulmonary Disorder. Review of Resident #17's Quarterly MDS with an ARD of 11/30/2023 revealed a BIMS score of 10 (Moderate Cognitive Impairment). Resident #17 had functional limitations due to impairment on one side. Resident #17 required Substantial/Maximal assistance with eating, oral hygiene, toileting, showering/bathing, dressing, and transfers. Resident #17 was always incontinent of bowel and bladder. Review of Resident #17's Care Plan with target date of 02/22/2024 revealed she was at risk for infection and skin breakdown. Approaches included; turn and reposition every 2hrs and prn, and provide wound care as ordered. Review of Resident #17's 01/2024 Physician's Orders revealed in part . 12/07/2023-Right Medial Heel- Pressure Ulcer-Stage 4- Cleanse with wound cleanser, pat dry, apply gel fiber silver, cover with dry dressing. Change daily, and with soiling, and/or dislodgement. 12/14/2023-Sacrum-Pressure Ulcer- Stage 2- Cleanse with wound cleanser, pat dry, apply collagen, and apply dry dressing. Change every other day & PRN. Observation on 01/10/2024 at 3:58 p.m. of Resident #17's wound care performed by S12 TX (Treatment) LPN revealed S12 TX LPN donned gloves, sprayed wound cleanser to right heel, obtained dry gauze from bedside table, dried wound with gauze, removed gloves and donned a new pair of gloves without performing hand hygiene. S12 TX LPN then obtained gel fiber silver from bedside table and applied to wound. S12 TX LPN removed gloves, and donned a new pair of gloves without performing hand hygiene. S12 TX LPN then obtained dry dressing from bedside table, and covered wound with dressing. Interview on 01/10/2024 at 4:02 p.m. with S12 TX LPN confirmed she should have performed hand hygiene after removing gloves; prior to donning new gloves, but did not. 2. Review of Vindicator Disinfectant Manufacturer's Instructions for use revealed in part .Allow to remain visibly wet for 10 minutes. Review of [NAME] QT Plus Disinfectant Manufactures Instructions for use revealed in part .Electrostatic spray application is for efficacy claims with a 10 minute contact time and 1:128 dilution. Interview on 01/09/2024 at 10:55 a.m. with S30 HK (Housekeeping) revealed he worked full time for another facility within the same corporation and was here to help out today. S30 HK stated he had not been trained by anyone at this facility on the chemicals used for cleaning and disinfecting. S30 HK stated he used the same products at the other facility, but was unsure of the dwell time of the products used. S30 HK stated he came to help this facility with his supervisor, S14 Housekeeper. Interview on 01/09/2024 at 10:58 a.m. with S14 Housekeeper revealed she was the House Keeping Supervisor for another facility within the same corporation and was asked to come help this facility today. S14 Housekeeper stated she had not received training at this facility. Interview on 01/09/2024 at 11:00 a.m. with S27 Housekeeping Aide revealed he worked full time for this facility, and was hired approximately 2 months ago. S27 Housekeeping Aide stated he did not know who his immediate supervisor was, and had not received training on the products he used. Interview on 01/09/2024 at 11:04 a.m. with S1 Administrator revealed there was no current Housekeeping Supervisor for the facility. Interview on 01/09/2024 at 11:09 a.m. with S34 CNA within Hall Y Shower room revealed she was responsible for cleaning shower/whirlpool between each resident's use. S34 CNA stated she used Vindicator disinfectant for cleaning. S34 CNA stated she sprayed the Vindacator, let the product sit for 20 seconds, wiped with towel, and then rinsed product. 01/09/2024 at 2:30 p.m. Requested Housekeepers training for the following employed House Keepers: S27 Housekeeping Aide, S31 HK, S32 HK, and S33 HK. Review of Housekeeping training within the above staff personnel records revealed the section that contained products used within department which included appropriate use and storage of each product, was incomplete. Interview on 01/10/2024 at 9:29 a.m. with S31 HK revealed she had worked at the facility for approximately 4 months, but had not received training on how to use the products she used for cleaning. S31 HK stated she was unsure who her supervisor was. S31 HK stated she used Vindacator and [NAME] QT-TB for cleaning, and the dwell time for these products was 5 minutes. Interview on 01/10/2023 at 4:45 p.m. with S1 Administrator and S21 ED revealed a review of the requested trainings for the above Housekeepers. S21 ED stated the housekeepers had received training on their job duties, but confirmed the training requirements on the completed training forms within the personnel records for products used was blank. S21 ED confirmed the previous Housekeeping Supervisor did not document trainings for the products used, but should have. 3. Review of Resident #28's Medical Record revealed an admission date of 10/12/2022 with diagnoses that included: Quadriplegia, C5-C7 Complete, Pressure Ulcer of left hip, Unstageable, Pressure Ulcer of sacral region, Unstageable and Chronic Kidney Disease. Review of Resident #28's Quarterly MDS with an ARD of 07/13/2023 revealed a BIMS score of 14 and resident required Hospice services and Pressure Ulcer/Injury care. Review of Resident #28's Care Plan with a Target date of 01/11/2024 revealed altered skin integrity related to multiple Pressure Ulcers to Left Hip Ischial Tuberosity, Stage 4 and Sacrum, unstageable. Approaches included to turn & reposition q 2 hours, measure wound weekly and treatment as ordered per physician. Review of Resident #28's Physician's Orders for 01/2024 read in part . 04/03/2023 - Pressure Ulcer of Left Hip, Unstageable to left anterior/superior trochanter - Cleanse with wound cleanser, pat dry with dry gauze, apply small amount of Medi-Honey to wound bed, then apply small piece of Ca Alginate and cover with dry dressing 3x week on MWF and prn soiled or dislodgement. 05/22/2023 - Sacrum Pressure Ulcer, Unstageable - Cleanse with wound cleanser, pat dry, and apply skin prep cover with dry dressing change q MWF and prn soilage or dislodgement. Observation on 01/10/2024 at 09:35 a.m. of Resident #28's wound care performed by Hospice RN and S12 TX LPN, whom placed treatment cart in resident's room. Observation of wound care revealed Hospice RN did not change gloves or perform hand hygiene throughout wound care to left hip trochanter and sacral pressure ulcer wounds. Observation revealed Hospice RN and S12 TX LPN did not clean/disinfect the treatment cart prior to, and after removing treatment cart from Resident #28's room. Interview on 01/10/2024 at 09:54 a.m. with Hospice RN revealed Resident #28's wound care treatments are 2x weekly, and the facility nurses also do wound care prn soilage. Hospice RN stated she typically does not change her gloves during wound care treatment. Hospice RN stated Resident #28 did not have drainage or infection, so she did not change her gloves before, during, after, or between wound care treatments. Hospice RN confirmed S12 TX LPN accompanied her for assistance with Resident #28's wound care and brought the treatment cart into the resident's room without cleaning it. Interview on 01/10/2024 at 09:59 a.m. with S12 TX LPN revealed she performed Resident #28's wound care on the days that the Hospice RN did not come, and the floor nurse or weekend RN will change his wound if soiled as needed. S12 TX LPN stated she sometimes rolled the treatment cart into resident's room if the resident doesn't have an infection. S12 TX LPN confirmed that she rolled the facility's treatment cart into Resident #28's room to perform his wound care, and should not have.

Nov 2023 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide incontinent care to a dependent resident for 1(Resident #2) of 3 (Resident #1, Resident #2, & Resident #3) residents sampled for ADL's. Findings: Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 07/09/2020 with diagnoses which included Fibromyalgia; Pressure Ulcer of sacral region, unspecified stage; Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified; Iron Deficiency Anemia, unspecified; and Hyperlipidemia, unspecified. Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/28/2023 revealed a BIMS (Brief Interview for Mental Status) of 14 (cognitively intact). Resident #2 required 2 person physical assist with bed mobility, dressing, and toilet use and 1 person physical assist with eating and bathing. Resident #2 was always incontinent of bowel and had a Foley catheter in place. Review of Care Plan revealed Resident #2 needed total assistance with bathing/hygiene related, with a target date of 12/01/2023. Approaches included, staff to provide ADLs and bathe per schedule. Observation on 11/06/2023 at 2:40 p.m. revealed Resident #2 soiled with brown liquid feces on gown, pad, and fitted/flat sheet. Interview with Resident #2 on 11/06/2023 at 2:40 p.m. revealed she had called for assistance for more than an hour and a half. Resident #2 stated a white lady came in turned the light off and stated she would send a CNA in to change her. Resident #2 stated she has a stage 4 pressure wound on her sacral and she should be not be left soiled for a long time. Interview on 11/07/2023 at 10:25 a.m. with Resident #2 accompanied by S1 Clinical Operation Nurse. Resident #2 stated on 11/06/2023, it was approximately an hour and a half before S1 Clinical Operation Nurse came into her room after putting the call light on for assistance. When asked by the surveyor how could she be certain that it was an hour and a half. Resident #2 stated I have a clock on my microwave. Microwave sits on top of a 5 feet refrigerator/freezer with large green numbers. The time on the microwave was noted to be correct. Interview on 11/07/2023 at 10:30 a.m. with S1 Clinical Operation Nurse confirmed after speaking with Resident #2 that the CNA failed to answer the call light for Resident #2 in a timely manner to provide ADL care.

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, record review and interview, the facility to provide appropriate and sufficient services, treatment and care according to standards of professional practice for Resident #2 who was reviewed for urinary catheter or UTI (urinary tract infection) out of a total of 3 sampled residents. The facility failed to ensure Resident #2's Foley catheter care was performed as ordered by the physician. Findings: Review of the Facility's Policy titled Catheter Care read in part: Policy: Catheter care is performed to keep the catheter insertion site clean. Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 07/09/2020 with diagnoses which included Fibromyalgia; Pressure Ulcer of sacral region, unspecified stage; Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified; Iron Deficiency Anemia, unspecified; and Hyperlipidemia, unspecified. Review of the November 2023 Physician orders revealed: Foley catheter care with soap and water q (every) shift Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/28/2023 revealed a BIMS (Brief Interview for Mental Status) of 14 (cognitively intact). Resident #2 was always incontinent of bowel and had a Foley catheter in place. Interview on 11/08/2023 at 10:00 a.m., revealed Resident #2's room smelled of urine. Resident #2 stated the urine smell was coming from her female genitals where the catheter was located. Resident #2 stated the CNAs (Certified Nursing Assistant) don't clean her female genitals and around the catheter every day. Resident #2 stated the CNAs will only wash her female genitals and the catheter area on her bath days (Monday, Wednesday and Friday). Observation on 11/08/2023 at 11:45 a.m. of Resident #2's Foley catheter, accompanied by S3LPN, revealed a thick, white, creamy substance around the insertion site with smears of brownish substance on the incontinent brief. S3 LPN confirmed Resident #2's Foley catheter site should have been cleaned and wasn't. Observation of Resident #2's Foley on 11/08/2023 at 1:28 p.m., accompanied by S4Interim Director of Nursing, revealed a thick, white, creamy substance around the insertion site with smears of brownish substance on the incontinent brief. Resident #2 stated to S4Interim Director of Nursing she had not received her bath, and catheter had not been done. S4Interim Director of Nursing confirmed she had no documented evidence that Resident #'s catheter care was performed as ordered daily. S4Interim Director of Nursing confirmed that catheter care with soap and water should have been done and wasn't.

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 F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observations, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1(Resident #2) of 3 (Resident #1, Resident #2, & Resident #3) sampled residents. The facility failed to ensure Resident #2's call light was answered within a timely manner after calling for assistance. Findings: Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/28/2023 revealed she had a BIMS (Brief Interview for Mental Status) of 14 (cognitively intact). Observation on 11/06/2023 at approximately 1:10 p.m. while in Resident#1's room, this surveyor heard a beeping sound. After exiting Resident #1's room, the beeping sound became louder. The sound was noted to be coming from the call light panel located behind the nurses' station. Resident #2's room was illuminated in red on the call light panel. Observation by this surveyor revealed the light over Resident#2's room door was noted to be on, and the beeping sound was audible from 1:10 p.m. -2:30 p.m. without any staff responding to Resident #2's call light. Observation on 11/06/2023 at 2:30 p.m. of the call light panel at nurses station with S1 Clinical Operation Nurse, confirmed Resident #2's call light was activated. S1Clinical Operation Nurse proceed to Resident #2's room to answer the call light. Resident #2's call light over room door was noted to still be on, and went off once S1 Clinical Operation entered the room. Interview on 11/06/2023 at 2:35 p.m. with S2 CNA revealed the beeping sound was an indication that a resident's call light was on. S2 CNA stated the beeping sounds goes off and the light over the resident's door lights up when a Resident calls for assistance. Interview on 11/06/2023 at 2:40 p.m. with Resident #2 revealed she had called for assistance on 11/06/2023 at approximately 1:10 p.m. and it had been more than an hour and a half before staff responded. Interview on 11/07/2023 at 10:30 a.m. with S1 Clinical Operation Nurse confirmed after speaking with Resident #2, staff failed to answer the call light for Resident #2 in a timely manner and should have.

Oct 2023 10 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, record review and interview, the facility failed to ensure a resident's right to be treated with respect and dignity, for 1 (#R1) of 4 (#R1, #R2, #R3, and #R4) random sampled residents, in a total sample of 7 residents (#1, #2, #3, #R1, #R2, #R3, and #R4). Findings: Review of #R1's Quarterly MDS with an ARD of 09/14/2023 revealed a BIMS score of 11, indicating #R1 was cognitively intact. Observation on 10/24/2023 at 8:32 a.m. revealed #R1 informed S12 CNA that she was wet and needed to be changed. #R1 stated her bottom was burning. S12 CNA informed #R1 that they were passing breakfast trays, and she would have to wait until the trays were passed to be changed. Observation on 10/24/2023 at 8:39 a.m. revealed S12 CNA brought #R1's breakfast tray into her room and began feeding #R1. S12 CNA did not change #R1's incontinent brief prior to feeding #R1 breakfast. Observation on 10/24/2023 at 8:50 a.m. revealed S12 CNA exited #R1's room with breakfast tray in her hand. Interview with #R1 on 10/24/2023 at 8:52 a.m. revealed she still needed to be changed, and stated her bottom was burning. Observation on 10/24/2023 at 9:12 a.m. revealed S12 CNA entered #R1's room and began to change her, and give her a bath. S1 DON entered #R1's room and assisted S12 CNA with bathing #R1. Interview with S1 DON on 10/26/2023 at 3:00 p.m. confirmed S12 CNA should have changed #R1 prior to feeding her breakfast. S1 DON stated #R1 should not have been fed her breakfast while she was wet with urine.

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 F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences, by failing to ensure the resident had a call light within reach for 1 (Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Review of Resident #4's medical record revealed an admit date of 04/19/202, with diagnoses that included: Morbid Obesity, Type 2 Diabetes Mellitus, Bed Confinement Status, Chronic Pain, and Other Sequelae of Cerebral Infarction. Review of Resident #4's Quarterly MDS with an ARD of 09/28/2023 revealed a BIMS score of 13, indicating intact cognition. The MDS revealed Resident #4 required extensive 2+ person physical assistance with bed mobility, dressing, and toilet use. Review of Resident #4's care plan with a target date of 12/2023 revealed a problem of Routine Care Needs related to Morbid Obesity, Paraplegia, and CVA, with interventions that included: keep call light within easy reach, and respond to call light promptly. Observation on 10/20/2023 at 12:25 p.m. revealed Resident #4's call light was out of reach, and was hooked to the top of the privacy curtain near the ceiling. Interview on 10/20/2023 at 12:25 p.m. with Resident #4 revealed he had not seen his call light in about 10 hours. Observation on 10/20/2023 at 2:06 p.m. revealed a CNA in the room feeding Resident #4. Resident #4's call light was out of reach and was hooked to the top of the privacy curtain near the ceiling. Observation on 10/20/2023 at 2:32 p.m. revealed Resident #4's call light was out of reach, and was hooked to the top of the privacy curtain near the ceiling. Observation on 10/20/2023 at 2:39 p.m. accompanied by S2 RN revealed Resident #4's call light was out of reach, and was hooked to the top of the privacy curtain near the ceiling. Interview with S2 RN at that time confirmed Resident #4's call light was out of reach.

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (Resident #1 and Resident #5) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents' rooms. Findings: 1. Observation of Resident #1's room on 10/19/2023 at 12:54 p.m., and 10/20/2023 at 9:39 a.m. revealed a green wall that was in need of repair. The green wall had four areas of missing paint which exposed the white underneath. Three of the areas were approximately two to three inches in length, one was approximately eleven inches in length, and all were approximately two inches wide. Observation on 10/20/2023 at 9:56 a.m. of Resident #1's room accompanied by S2 RN, and interview of S2 RN at that time confirmed that the green wall that had four areas of missing paint which exposed the white underneath. Three of the areas were approximately two to three inches in length, one was approximately eleven inches in length, and all were approximately two inches wide. S2 RN confirmed there were four areas on the wall with paint missing, and reported the wall was in need of repair. 2. Observation of Resident #5's room on 10/20/2023 at 10:19 a.m., and 10/20/2023 at 2:11 p.m., revealed a privacy curtain with dried brown debris in multiple areas. There was a green wall that had a large white board nailed to the area behind the bed. The large white board was peeling in the corner leaving brown exposed. Approximately half of the baseboards were missing on the same wall. Observation on 10/20/2023 at 2:40 p.m. of Resident #5's room accompanied by S2 RN, and interview with S2 RN at that time revealed S2 RN confirmed that the green wall had a large white board nailed to the area behind the bed. The large white board was peeling in the corner leaving brown exposed. Approximately half of the baseboards were missing on the same wall. S2 RN confirmed the wall and baseboards were in need of repair, and that there were multiple areas of dried brown debris on the privacy curtain, but should not have been.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide services to meet professional standards of practice for 1 (Resident #2) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled residents. The facility failed to perform Neurological checks on Resident #2 after finding the resident on the floor with a laceration to his head. Findings: Review of a facility policy titled Neurological Checks after head injury revealed neurological checks should be performed every 15 minutes X 4, every 30 minutes X 2, every hour X 4 and every shift X 24 hours. The resident's condition should be documented in the nurses' notes every shift X 72 hours. Review of an investigation conducted by the facility revealed Resident #2 sustained a laceration/injury of unknown origin on 10/07/2023. The facility investigation revealed Resident #2 was found on the floor with a laceration to the middle of his head/scalp. Resident #2 was evaluated in ER and returned to the facility the same day. Documentation in the investigation revealed in part . Neuro checks were conducted on the resident. Review of Resident #2's Nurses' Notes dated 10/07/2023 (not timed) by S5 Agency LPN, revealed during evening med pass, nurse entered room and observed resident lying in fetal position on the right side holding head with blood on floor under head. Resident #2 was making a grunting noise, staff called medical transport, and sent the resident out to the ER at 5:23 p.m. via stretcher. Review of ER documentation revealed Resident #2 was evaluated on 10/07/2023 for a superficial laceration to his head, and discharged back to the facility on [DATE]. Review of Resident #2's Nurses' Notes revealed there was no evidence in the Nurse's Notes of what time Resident #2 returned from the hospital on [DATE], and no evidence that Neurological Checks were completed. Interview with S1 DON on 10/25/2023 at 3:00 p.m. revealed there was no evidence that staff performed Neurological checks on Resident #2 after he returned from the hospital on [DATE]. S1 DON confirmed the staff should have conducted and documented Neurological checks on Resident #2 according to the facility's policy titled Neurological Checks after head injury.

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice of 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Review of Resident #1's medical record revealed an admit date of 08/22/2023, with diagnoses that included: Acute and Chronic Respiratory Failure, Fracture of the Mandible, Unspecified Displaced Fracture of Fifth Cervical Vertebra, and Traumatic Subdural Hemorrhage. Review of Resident #1's admission MDS with an ARD of 09/05/2023 revealed a BIMS score of 99, indicating Resident #1 was unable to complete the interview, and had severely impaired cognitive skills for daily decision making. The MDS revealed Resident #1 required extensive 2+ person physical assistance with bed mobility. Review of Resident #1's 10/2023 Physician Orders revealed orders for full code, ipratropium bromide/albuterol sulfate (used to control asthma, chronic bronchitis, emphysema) 0.5-3(2.5) mg/3 mL neb q 4 hours, and acetylcysteine (used to relieve chest congestion in asthma, chronic bronchitis, emphysema) 20% vial neb 4 mL q 12 hours. Review of the facility's policy titled Small Volume Nebulizer Therapy revealed in part . Nebulizer Therapy will be utilized to administer medication per Physician's Order. 15. Store in a plastic bag. Observation on 10/19/2023 at 12:54 p.m., and 10/20/2023 at 9:39 a.m. revealed a nebulizer machine on Resident #1's nightstand with the nebulizer mask uncovered and open to air. An Ambu bag inside a plastic bag was on the floor to the left of Resident #1's nightstand. Observation on 10/20/2023 at 9:56 a.m. accompanied by S2 RN revealed a nebulizer machine on Resident #1's nightstand with the nebulizer mask uncovered and open to air. An Ambu bag inside a plastic bag was on the floor to the left of Resident #1's nightstand. Interview with S2 RN at that time confirmed the nebulizer mask was uncovered and open to air, but should not have been. S2 RN stated it should have been in a plastic bag. S2 RN confirmed the Ambu bag was inside a bag on the floor, but should not 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure restorative nursing services were implemented according to the resident's person-centered plan of care for 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Review of the facility's policy titled Nursing Rehabilitation/Restorative Care read in part . Rehabilitative or restorative care refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A restorative program should be started when a resident is admitted with restorative needs, but not a candidate for therapy, or when the need arises during the course of the stay. 2. Each restorative service is then recorded in the Approaches Section of the Rehabilitation Nursing Program form with the minutes per shift documented as required. Review of Resident #1's medical record revealed an admit date of 08/22/2023, with diagnoses that included: Acute and Chronic Respiratory Failure, Fracture of the Mandible, Unspecified Displaced Fracture of Fifth Cervical Vertebra, Traumatic Subdural Hemorrhage, and Dysphagia. Review of Resident #1's admission MDS with an ARD of 09/05/2023 revealed a BIMS score of 99, indicating Resident #1 was unable to complete the interview, and had severely impaired cognitive skills for daily decision making. The MDS revealed Resident #1 required 2+ persons physical assistance with bed mobility, dressing, toilet use, and bathing; and 1 person physical assist with eating and personal hygiene. Review of Resident #1's Rehab/Restorative Nursing Plan of Care with a Target Date of 11/24/2023 revealed problems of decreased ROM, inability to speak, and decreased cognition. The interventions included: passive ROM of BUE and BLE, provide verbal cues to the resident, attempt to communicate, and read script to resident daily. Resident #1's expected outcomes were to demonstrate increased ROM of BUE/BLE joints and increased level of cognition. Review of Resident #1's 10/2023 Rehabilitation Nursing Program form revealed Resident #1 started the Rehab Nursing Program on 09/24/2023. In the Approaches section, lines were drawn though the boxes for 10/01/2023 through 10/08/2023. Interview on 10/23/2023 at 2:40 p.m. with S4 Restorative CNA revealed Resident #1 went out to the hospital on [DATE], and did not have restorative from 10/01/2023 through 10/08/2023 because he needed to be evaluated by therapy before being adding back on restorative. Interview on 10/23/2023 at 4:10 p.m. with S1 DON revealed she could not find any documentation the restorative approaches were done with Resident #1 on 10/01/2023 through 10/08/2023. S1 DON stated the restorative program forgot to pick him back up after he came back from the ER. S1 DON confirmed Resident #1 did not receive restorative from 10/01/2023 through 10/08/2023. Interview on 10/24/2023 at 9:36 a.m. with S3 LPN revealed she was responsible for the restorative nursing program. S3 LPN reported Resident #1 went out to the ER on [DATE] and returned back to the facility later that day. S3 LPN confirmed Resident #1 did not receive restorative nursing from 10/01/2023 through 10/08/2023. S3 LPN stated one of the restorative aides pulled his care plan and approaches sheet from the restorative nursing binder, but should not have.

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #1, Resident #2, and Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Resident #1 Review of Resident #1's medical record revealed an admit date of 08/22/2023, with diagnoses that included: Acute and Chronic Respiratory Failure, Metabolic Encephalopathy, Fracture of the Mandible, Unspecified Displaced Fracture of Fifth Cervical Vertebra, and Traumatic Subdural Hemorrhage. Review of Resident #1's admission MDS with an ARD of 09/05/2023 revealed a BIMS score of 99, indicating Resident #1 was unable to complete the interview. The MDS revealed Resident #1 had severely impaired cognitive skills for daily decision making, and was totally dependent requiring 2+ person physical assist with bathing, and extensive 1 person physical assist with personal hygiene. Review of Resident #1's care plan with a target date of 11/22/2023 revealed a problem of Routine Care Needs related to diagnoses of Motor Vehicle Accident, Acute and Chronic Respiratory Failure, Cervical Spinal Cord Injury, Tracheostomy, Gastrostomy, Traumatic Subdural Hematoma with Loss of Consciousness. Interventions included: provide bath three times a week, and provide oral hygiene daily and PRN. Review of Resident #1's Bathing Report dated 09/01/2023 through 10/23/2023, revealed support provided was documented as activity did not occur from 09/22/2023 through 09/29/2023, 10/01/2023 through 10/04/2023, and 10/11/2023 through 10/15/2023. Interview on 10/26/2023 at 2:19 p.m. with Resident #1's sister revealed whenever she came to visit Resident #1, his face was dirty, and he did not have a bath. She stated Resident #1's facial hair was not shaved, and he would smell of body odor. She reported she always had to ask staff to have Resident #1's face cleaned, and for him to have a bath and a shave. She stated she should not have had to ask, and it should have been done. Interview on 10/26/2023 at 2:50 p.m. with S1 DON confirmed the bathing report of the dates listed above for Resident #1 stated the activity did not occur, which meant the staff documented they did not bathe Resident #1. S1 DON reported Resident #1 should have had a bath or been offered a bath in those time frames. Resident #2 Review of Resident #2's medical record revealed an admit date of 12/21/2022, with diagnoses that included: Schizophrenia, UTI, and Major Depressive Disorder. Review of Resident #2's Quarterly MDS with an ARD date of 08/08/2023, revealed a BIMS score of 99, indicating Resident #2 was unable to complete the interview. The MDS revealed Resident #2's cognitive skills were moderately impaired regarding daily decision making, Resident #2's decisions were poor and he required cues/supervision, and Resident #2 required one person assist for ADLs. Review of Resident #2's care plan with goal date of 11/2023 revealed a problem of Routine Care Needs related to diagnoses of Schizophrenia and Major Depression. Interventions included: having ADLs met on a daily basis, provide bath of choice 3 times a week (shower, bed bath or whirlpool), and assist with dressing and personal hygiene as needed. Review of the facility's bath schedule revealed Resident #2 was scheduled to receive baths on Mondays, Wednesdays and Fridays. Review of Resident #2's Bathing Report dated 10/01/2023 through 10/23/2023 revealed support provided was documented as activity did not occur on 10/03/2023, 10/09/2023 through 10/19/2023, and 10/21/2023 through 10/23/2023. Interview with S1 DON on 10/26/2023 at 2:50 p.m. revealed Resident #2 only received three baths from 10/01/2023 through 10/23/2023 according to documentation. S1 DON confirmed the bathing report of the dates listed above for Resident #2 stated the activity did not occur, which meant the staff documented they did not bathe Resident #2. S1 DON confirmed the resident should have been offered or received a bath three times a week according to his bath schedule and care plan. Resident #4 Review of Resident #4's medical record revealed an admit date of 04/19/2023, with diagnoses that included: Morbid Obesity, Type 2 Diabetes Mellitus, Bed Confinement Status, Chronic Pain, and Other Sequelae of Cerebral Infarction. Review of Resident #4's Quarterly MDS with an ARD of 09/28/2023 revealed a BIMS score of 13, indicating intact cognition. The MDS revealed Resident #4 was totally dependent requiring one person physical assistance with bathing, and extensive 1 person physical assistance with personal hygiene. Review of Resident #4's care plan with target date of 12/2023 revealed a problem of Routine Care Needs related to Morbid Obesity, Paraplegia, and CVA. Interventions included: provide bath of choice (shower, whirlpool, bed bath) every other day. Resident #4 had an Instant Care Plan with a problem of refusing ADL care, with no onset date or target date. Review of Resident #4's Bathing Report dated 09/01/2023 through 10/23/2023 revealed revealed support provided was documented as activity did not occur from 09/18/2023 through 09/22/2023 and 10/06/2023 through 10/11/2023. Interview on 10/19/2023 at 9:35 a.m. with Resident #4 revealed he does not get a bath every other day like he is supposed to. Interview on 10/26/2023 at 2:50 p.m. with S1 DON confirmed the bathing report of the dates listed above for Resident #4 stated the activity did not occur, which meant the staff documented they did not bathe Resident #4. S1 DON reported Resident #4 should have had a bath or been offered a bath every other day as per his plan of care.

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 F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure nursing staff were able to demonstrate competency in the skills and techniques necessary to provide tracheostomy care for 2 (S6 LPN and S7 LPN) of 3 (S6 LPN, S7 LPN and S8 LPN) facility staff, and 2 (S5 Agency LPN and S9 Agency LPN) of 3 (S5 Agency LPN, S9 Agency LPN, and S10 Agency LPN) agency staff. The facility had a total of 4 residents with tracheostomies. Findings: Interview on 10/24/2023 at 10:17 a.m. with S1 DON revealed the facility did not have a Respiratory Therapist. S1 DON reported the nurses provide all tracheostomy care as ordered. S1 DON stated all nurses, including agency nurses, received training on tracheostomy care and demonstrated competency as documented on a skills checklist, before providing care in the facility. Interview on 10/24/2023 at 10:51 a.m. with S1 DON revealed all nurses were required to complete the Tracheostomy Care Competency and Skills Evaluation on hire and annually. Review of S6 LPN's Tracheostomy Care Competency and Skills Evaluation revealed a date of 05/04/2022. Interview on 10/26/2023 at 2:45 p.m. with S1 DON confirmed she did not have a Tracheostomy Care Competency and Skills Evaluation for S7 LPN, S5 Agency LPN, and S9 Agency LPN. S1 DON confirmed the evaluation for S6 LPN was not done annually.

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, record review and interview, the facility failed to provide pharmaceutical services, to include the accurate administration of medication, for 1 (#R2) random sampled resident. The facility failed to reorder a blood pressure medication timely for #R2. The total sample was 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7), and 4 random sampled residents (#R1, #R2, #R3 and #R4). Findings: Review of the facility's policy titled Medication Administration - General Guidelines read in part . 14. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes. Review of #R2's medical record revealed diagnoses that included: Quadriplegia, Major Depressive Disorder, Hyperlipidemia, Hypothyroidism and Hypertensive Heart Disease without Heart Failure. Review of #R2's Physician's Orders dated 10/2023 revealed the following orders in part Amlodipine 5 mg - one tablet by mouth every day for Hypertensive Heart Disease. Observation during a medication pass on 10/24/2023 at 9:03 a.m. revealed S11 Agency LPN went into #R2's room with a cup of medications. #R2 asked S11 Agency LPN at that time if the blood pressure medication had come in. S11 Agency LPN answered #R2 by saying yes, all your medications are here. Interview with S11 Agency LPN on 10/24/2023 at 9:15 a.m., revealed she worked on 10/23/2023. S11 Agency LPN stated during administration of medications for #R2 on 10/23/2023, she noted the resident was out of Amlodipine. S11 Agency LPN stated she had to order #R2's Amlodipine on 10/23/2023, and it did not arrive from the pharmacy until 10/24/2023. Review of #R2's MAR dated 10/2023 revealed in part .Amlodipine 5 mg one tablet by mouth every day. Amlodipine was scheduled to be administered at 8:00 a.m. daily. Review of documentation for the administration of Amlodipine revealed staff initials were circled on 10/19/2023 through 10/23/2023. There was no documentation in the Nurses' Notes dated 10/2023, or on the MAR dated 10/2023 to indicate why the staff initials were circled on those dates. Interview with S1 DON on 10/24/2023 at 1:30 p.m. revealed when staff's initials were circled on a MAR, that indicated the medication was not administered for some reason. S1 DON stated there should be a written explanation on the back of the MAR when a medication was not administered. S1 DON confirmed the facility staff did not administer #R2's Amlodipine as ordered on 10/19/2023 through 10/23/2023, and there was no documentation why the medication was not administered. Interview with a Pharmacy Technician on 10/26/2023 at 2:10 p.m. revealed the pharmacy filled Amlodipine for #R2 on 10/24/2023, and 30 pills were sent to the facility that day.

CONCERN (E) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to maintain accurately documented resident medication administration records for 3 (Resident #1, Resident #2, Resident #3) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents and 2 (#R1 and #R2) of 4 (#R1, #R2, #R3, and #R4) random sampled residents. Findings: Review of the facility's policy titled Medication Administration - General Guidelines read in part . 9. Only licensed or legally authorized personnel who prepare a medication may administer it. This individual records the administration on the resident's MAR or TAR after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and al administered doses were documented. 11. The resident's MAR/TAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose following medication administration. 14. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of this notification is made in the nursing notes. Resident #1 Review of Resident #1's Physician's Orders dated 09/2023 through 10/2023 revealed orders for the following medications in part . Ipratropium bromide/Albuterol sulfate (prescribed for treatment of asthma and COPD), 0.5-3(2.5) mg/3 mL - 3 mL Neb Q 4 hours Glycopyrrolate (used to treat peptic ulcers in adults), 1 mg - per PEG Q 8 hours Metoclopramide (an antiemetic and gut motility stimulator) 5 mg - per PEG Q 8 hours Bactrim DS (an antibiotic) - 1 per PEG BID x 10 days Baclofen (a muscle relaxant) 10 mg - per PEG TID Docusate sodium (a stool softener) 50 mg/5 mL liquid -10 mL per PEG BID Acetylcysteine (used in treatment of COPD) 20% vial neb - 4 mL Q 12 hours Propranolol (antihypertensive) 20 mg - per PEG BID Protonix (used to treat GERD) 40 mg -per PEG BID Oxybutynin (a bladder relaxant) 5 mg - per PEG BID Scopolamine (used to treat N/V, and motion sickness) 1 mg/3 day patch - apply 1mg/3day patch Q 3 days Review of Resident #1's MAR dated 09/2023 revealed the following medications were not initialed as given on the following dates: Ipratropium bromide/Albuterol sulfate - 09/29/2023 at 4:00 p.m. Glycopyrrolate - 09/15/2023 and 09/25/2023 at 5:30 a.m., and 09/04/2023 and 09/21/2023 at 9:30 p.m. Metoclopramide - 09/15/2023 and 09/25/2023 at 5:30 a.m. Bactrim DS - 09/25/2023 and 09/26/2023 at 8:00 a.m. Propranolol - 10/08/2023 at 5:00 p.m. Protonix - 10/08/2023 at 5:00 p.m. Review of Resident #1's MAR dated 10/2023 revealed the following medications were either not initialed as given, or were initialed and circled on the following dates: Ipratropium bromide/Albuterol sulfate - 10/08/2023 at 4:00 p.m.; 10/03/2023, 10/06/2023, 10/13/2023, and 10/14/2023 at 8:00 p.m. Scopolamine - 10/19/2023 at 5:00 a.m. Baclofen - 10/04/2023, 10/05/2023, 10/07/2023, 10/15/2023, and 10/16/2023 at 5:30 a.m.; 10/10/2023 and 10/11/2023 at 1:30 p.m.; and 10/14/2023 at 9:30 p.m. Docusate sodium - 10/06/2023 at 5:00 a.m.; and 10/01/2023, 10/04/2023, and 10/08/2023 through 10/11/2023 at 5:00 p.m. Acetylcysteine - 10/08/2023 and 10/09/2023 at 5:00 p.m. Glycopyrrolate - 10/14/2023 at 9:30 p.m. Metoclopramide - 10/14/2023 at 9:30 p.m. Oxybutynin - 10/07/2023 at 5:00 a.m.; and 10/05/2023, 10/08/2023, 10/10/2023, 10/12/2023, and 10/13/2023 at 5:00 p.m. Interview on 10/25/2023 at 2:15 p.m. with S1 DON revealed if a box on the MAR does not have a signature, she could not say whether the medication was administered, held, etc. because there was no documentation. S1 DON reported if the medication was initialed and circled, it was not administered. S1 DON confirmed the above findings on the 09/2023 MAR and the 10/2023 MAR for Resident #1, and confirmed the MARs should not have had boxes blank without initials. S1 DON confirmed there were no reverse sides on the MARs with documentation of an explanation of the circled initials, as stated in the medication administration policy, but there should have been. Resident #2 Review of Resident #2's Physician's Orders dated 10/2023 revealed orders for the following medications in part . Lexapro (an anti-depressant/anti-anxiety agent) 10 mg tablet - give one tablet by mouth QD Flonase (steroid used to treat inflammation) 50 mcg spray - one spray in each nostril QD Vitamin B12 1000 mcg - one tablet by mouth QD Olanzapine (an antipsychotic) 5 mg - give one and a half tablets by mouth BID Baclofen (muscle relaxant) 10 mg tablet - give one tablet by mouth BID Depakote (used for Bipolar disorder) 250 mg tablet - give one tablet by mouth QD Haldol (used to treat schizophrenia) 5 mg tablet - give two tablets by mouth BID Klonopin (treats panic and seizure disorders) 0.5 mg tablet - give one tablet by mouth QD Review of Resident #2's MAR dated 10/2023 revealed the following medications were not initialed as administered on 10/11/2023 and 10/12/2023 at 8:00 a.m.: Lexapro, Flonase, Vitamin B12, Olanzapine, Baclofen, Depakote, Haldol and Klonopin. Resident #3 Review of Resident #3's Physician's Orders with a start date of 10/20/2023 revealed orders for the following medications in part . Doxycycline (an antibiotic) 100 mg tablet - one per PEG BID Buspar (an antianxiety agent) 10 mg tablet - give one per PEG TID Prevacid (used to treat GERD) 30 mg tablet - give one per PEG QD Gabapentin (treats seizures) 300 mg - give one per PEG QHS Zoloft (anti depressant) 50 mg - give one per PEG QD Augmentin (an antibiotic) 875/125 mg - give one per PEG BID Metoprolol (an antihypertensive) 125 mg - give one per PEG QD Levothyroxine (used to treat hypothyroidism) 50 mcg - give one per PEG QD Alprazolam (used to treat anxiety) 0.5 mg - give one per PEG QD Midodrine (used for blood pressure support) 2.5 mg - give one per PEG BID Review of Resident #3's MAR dated 10/2023 revealed the following medications were not initialed or were initialed and circled on the following dates: Doxycycline - 10/20/2023 and 10/23/2023 at 8:00 a.m. Buspar - 10/20/2023 through 10/22/2023 at 8:00 a.m. and 12:00 p.m.; 10/23/2023 at 12:00 p.m.; and 10/24/2023 at 12:00 p.m. Midodrine, Prevacid, Zoloft, Metoprolol and Augmentin - 10/20/2023 through 10/22/2023 at 8:00 a.m. Gabapentin - 08/21/2023 at 8:00 p.m. Levothyroxine - 10/20/2023 through 10/24/2023 at 8:00 a.m. Alprazolam - 10/20/2023 through 10/22/2023 at 8:00 a.m. #R1 Review of #R1's Physician's Orders dated 10/2023 revealed orders for the following medications in part . Miralax powder (for constipation) - give 17 gm in 8 oz. water QD Ascorbic Acid (vitamin C) 500 mg tablet - give one tablet by mouth QD Calcium 600 mg tablet - give one tablet by mouth QD Atorvastatin (used to treat elevated cholesterol) 20 mg tablet - give one tablet by mouth QHS Protonix (for GERD) (DR 20 mg tablet - give one tablet by mouth QD Keppra (used to prevent seizures) 500 mg - give one tablet by mouth BID Linzess (treats constipation) 145 mg - give one tablet by mouth QD Dilantin (used to prevent seizures) Sod EXT 100 mg capsule - give 2 capsules by mouth BID Midodrine HCL (used for blood pressure support) 2.5 mg tablet - give one tablet by mouth BID Colace (stool softener) 100 mg tablet - give one tablet by mouth BID Eliquis (anticoagulant) 5 mg tablet - give one tablet by mouth BID Olanzapine (antipsychotic) 5 mg tablet - give one tablet by mouth QD Baclofen (muscle relaxant) 20 mg tablet - give one tablet by mouth TID Lasix (diuretic) 20 mg tablet - give one tablet by mouth QD Review of #R1's MAR dated 10/2023 revealed the following medications were either not initialed or were initialed and circled on the following dates: Miralax powder - 10/07/2023, 10/12/2023, 10/13/2023; and 10/16/2023 through 10/18/2023 at 9:00 a.m. Ascorbic Acid and Calcium - 10/07/2023, 10/13/2023; and 10/16/2023 through 10/18/2023 at 8:00 a.m. Atorvastatin - 10/04/2023, 10/09/2023, and 10/14/2023 at 8:00 p.m. Protonix - 10/05/2023, 10/07/2023 and 10/10/2023 at 5:00 a.m. Keppra - 10/10/2023 and 10/16/2023 through 10/18/2023 at 9:00 a.m.; and 10/03/2023, 10/04/2023, 10/09/2023 and 10/14/2023 at 9:00 p.m. Linzess - 10/04/2023, 10/10/2023; and 10/16/2023 through 10/18/2023 at 9:00 a.m. Phenytoin - 10/04/2023, and 10/09/2023 and 10/14/2023 at 9:00 p.m.; and 10/13/2023, and 10/16/2023 through 10/18/2023 at 9:00 a.m. Midodrine - 10/07/2023, 10/13/2023, and 10/16/2023 through 10/18/2023 at 9:00 a.m.; and 10/08/2023 through 10/10/2023, 10/13/2023, and 10/15/2023 through 10/19/2023 at 5:00 p.m. Colace - 10/01/2023, 10/04/2023, 10/07/2023, 10/16/2023 through 10/18/2023 and 10/20/2023 at 8:00 a.m.; and 10/04/2023 through 10/06/2023, 10/09/2023, 10/12/2023 through 10/14/2023, and 10/18/2023 at 8:00 p.m. Eliquis - 10/07/2023, 10/13/2023, and 10/17/2023 through 10/18/2023 at 9:00 a.m.; and 10/04/2023 and 10/14/2023 at 9:00 p.m. Olanzapine - 10/07/2023, 10/13/2023, and 10/17/2023 through 10/18/2023 at 8;00 a.m. Baclofen - 10/18/2023 at 8:00 a.m. and 12:00 p.m., 10/19/2023 at 12:00 p.m. and 8:00 p.m., and 10/20/2023 at 8:00 a.m., 12:00 p.m. and 8:00 p.m. Lasix - 10/07/2023, 10/13/2023, and 10/17/2023 through 10/18/2023 at 9:00 a.m. #R2 Review of #R2's Physician's Orders dated 10/2023 revealed orders for the following medications in part . Cranberry 500 mg tablet (used as a diuretic) - give one tablet by mouth BID Lexapro (an anti-depressant/anti-anxiety agent) 10 mg tablet - one by mouth QD Gemtesa (used for overactive bladder) 75 mg tablet - give one by mouth QD Zocor (treats elevated cholesterol) 20 mg tablet - give one by mouth QHS Lyrica (treats nerve damage pain) 300 mg capsule- give one by mouth QHS Linzess (treats constipation) 145 mcg capsule - give one by mouth QD Solifenacin (bladder relaxant) 5 mg tablet - give one by mouth QD Pantoprazole (treats GERD) 40 mg tablet - give one by mouth QD Aspirin (anticoagulant) 325 mg - one tablet by mouth daily B-12 1,000 mg tablet - give one tablet by mouth QD Levothyroxine (used to treat hypothyroidism) 75 mcg - give one tablet by mouth QD Review of #R2's MAR dated 10/2023 revealed the following medications were not initialed or were initialed and circled on the following dates: Cranberry tablets - 10/19/2023 and 10/20/2023 at 9:00 a.m. Baclofen tablet - 10/14/2023 at 9:00 p.m. Lexapro tablet - 10/05/2023 and 10/20/2023 at 9:00 a.m. Gemtesa tablet - 10/07/2023, 10/19/2023, 10/22/2023 and 10/23/2023 at 8:00 a.m. Zocor tablet - 10/10/2023 and 10/14/2023 at 8:00 p.m. Lyrica, Linzess and Solifenacin - 10/14/2023 at 8:00 p.m. Pantoprazozle tablet - 10/12/2023, 10/19/2023 and 10/23/2023 at 8:00 a.m. Aspirin and B-12 tablets - 10/07/2023 at 9:00 a.m. Levothyroxine tablet - 10/01/2023, 10/02/2023, and 10/08/2023 through 10/10/2023 at 5:00 a.m. Interview on 10/25/2023 at 2:15 p.m. with S1 DON confirmed the above medications were either not initialed or were initialed and circled meaning they were not administered. S1 DON stated there should be an explanation on the back of the MARs indicating why the medications were not administered, and there was not.

Aug 2023 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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure their grievance policy and procedure was followed by failing to provide prompt efforts of an effective resolution to the resident's complaints for 1 (Resident #2) of 7 sampled residents (Resident #1, Resident #2,Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7). The facility had a total census of 58 residents. Findings: Review of the facility policy titled Complaint/ Grievance/ Missing Property revealed in part . a. Complaints may be presented to any staff member who will then report the issue utilizing the Complaint/Grievance Form to his/her supervisor and/or department head. 2. Supervisory personnel or department heads are responsible for reviewing the Complaint/Grievance form within 10 working days. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Resident #2 had diagnoses to include Schizophrenia, Major Depressive Disorder severe with Psychotic Symptoms, Generalized Anxiety Disorder, Legal Blindness and Seizures. Review of Annual MDS with an ARD of 05/04/2023 revealed a BIMS score of 12 indicating moderate cognition. Interview on 08/08/2023 at 1:50 p.m. with S2 DON revealed on 06/02/2023 Resident #2 complained to the ombudsman that she overheard S4 LPN stating Resident #2 has pseudoseizures to someone in the hall outside her room. S2 DON stated Resident #2 complained S4 LPN spoke roughly and has a harsh voice. S2 DON stated S4 LPN was in-serviced on Code of Conduct and Customer Care on 06/07/2023 before the beginning of her shift. S2 DON stated there was no grievance written to address Resident #2's complaint. Interview on 08/09/2023 at 10:28 a.m. with S1 Administrator confirmed a Grievance Form was not completed for Resident #2's complaints but should have been.

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident assessments were completed accurately for 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) residents sampled. Findings: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Peripheral Vascular Disease, Type II Diabetes Mellitus, and Alzheimers. Review of Resident #1's Discharge MDS with an ARD of 06/23/2023 revealed Resident #1 had a BIMS score of 9, indicating severe cognitive impairment. The MDS review revealed Resident #1 required extensive assistance for bed mobility, transfers, toileting and personal hygiene. Review of the MDS Assessment section P, Restraints, revealed Restraints were documented as 0. Not used, for all categories. Review of Resident #1's CPOC with a target date of 08/09/2023 revealed in part . Socially inappropriate behavior related to diagnosis of Impulse Disorder/Dementia. Approaches include on 05/25/2023 alarm to recliner, bed, and wheelchair. Review of a nurses' note dated 05/31/2023 at 9:41 a.m. revealed alarms placed to bed and chairs to alert when resident is up. Interview on 08/08/2023 at 2:35 p.m. with S5 CNA revealed Resident #1 had alarms on his bed, wheelchair and rocking chair and would get up several times a day unassisted and set the alarms off. Interview on 08/10/2023 at 9:27 a.m. with S6 CNA revealed Resident #1 had bed and chair alarms that would go off when Resident #1 transferred himself from bed to chair unassisted. S6 CNA stated Resident #1 could walk a little but was unsteady. Interview on 08/10/2023 at 9:55 a.m. with S4 LPN revealed she worked the 6:00 a.m. to 6:00 p.m. shift and was assigned to Resident #1 while he was a resident of the facility. S4 LPN stated Resident #1 was able to ambulate short distances like from his bed or chair to his bathroom. S4 LPN stated Resident #1 had alarms on his chairs but would be in the bathroom or in the bed by the time staff got to his room. Interview on 08/10/2023 at 1:40 p.m. with S4 LPN MDS Nurse revealed she was responsible for completing Section P, Restraints, of Resident #1's MDS Assessment. S4 LPN MDS Nurse revealed she was unaware Resident #1 had alarms on his chairs and bed. S4 LPN MDS confirmed alarm use was not included on Resident #1's MDS assessment and should have been. Interview on 08/10/2023 at 1:42 p.m. with S2 DON revealed chair and bed alarms had been implemented for Resident #1 on 05/25/2023 and should have been included on the 06/23/2023 assessment and had not 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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide baths, shaving, and nail care to dependent residents for 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) residents sampled for ADL's. Findings: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Peripheral Vascular Disease, Type II Diabetes Mellitus, and Alzheimers. Review of Resident #1's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/22/2023 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 11, indicating mild cognitive impairment. The MDS review revealed Resident #1 required the physical assistance of one person for toileting, bathing and hygiene and did not reject care. Review of Resident #1's CPOC (Comprehensive Plan of Care) with a target date of 08/09/2023 revealed in part . Routine Care Needs: related to diagnosis of Dementia/Impaired Mobility. Approaches include provide bath of resident choice (whirlpool, shower, bed bath,) every other day. Telephone interview on 08/09/2023 with Resident #1's RP (Responsible Party) revealed Resident #1 appeared unkempt and dirty each time Resident #1's RP visited. Resident #1 was unable to be observed or interviewed, as he was no longer a resident at the facility at the time of survey. Review of Resident #1's Bathing Report dated 05/12/2023-06/23/2023 revealed Resident #1 did not receive baths on the following dates: 05/12/2023 through 05/24/2023, 05/29/2023 through 06/02/2023, 06/07/2023 through 06/14/2023, and 06/16/2023 through 06/21/2023. Interview on 08/09/2023 at 1:30 p.m. with S1 Administrator and S2 DON (Director of Nursing) confirmed Resident #1 did not receive baths at least every other day, and should have.

May 2023 4 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the resident's right to be from sexual abuse by another resident for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention Policy revealed in part the facility is committed to protecting the residents from abuse by anyone including other residents. Review of the policy revealed sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. . It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE] with diagnoses that included: COPD, Heart failure, Edema, and Atrial fibrillation. Review of Resident #2's admission MDS with an ARD of 03/02/2023 revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition. The MDS revealed Resident #2 required extensive assistance by two persons with bed mobility and transferring and extensive assistance by one person with toilet use. Review of a grievance by Resident #2 dated 05/23/2023 to S4 Social Worker revealed in part: Resident #6 was blocking Resident #2 from her room door. She was trying to get to her room. Resident #6 stated to her you know it's been a long time while rubbing between his legs and began attempting to open center part of his pants to show Resident #2. Resident #2 stated Resident #6 pissed her off, she started cussing, reached for her phone, and said Close those britches while cursing at Resident #6. Resident #2 felt uncomfortable, uneasy, and concerned about other women residents. In an interview on 05/30/2023 at 1:30 p.m., S4 SW said the incident occurred 05/23/2023 but she didn't become aware of it until 05/24/2023. She said Resident #2 told her she was trying to get around Resident #6 in the hall and Resident #6 began fondling himself and Resident #2 thought he may expose himself to her. She said Resident #2 reported she cursed him and told him to stop. S4 SW stated she then called S1 Executive Director who told her to send Resident #6 out and to find placement for him in another facility. S4 SW reported Resident #6 was sent to emergency room on [DATE] and returned to the facility the same day after she had left for the day. S4 SW stated when she returned on the 25th and he was back in the facility, she secured placement for him with another facility. S4 SW stated she called Resident #6's RP and told her he had been accepted by the other facility. S4 SW stated Resident #6's RP stated she had spoken with S2 DON the night before and had changed her mind and didn't want him to leave this facility. Resident #6's RP stated when she talked with S2 DON, they decided to change his medication, put alarms in his chairs and bed, and change him to a room on a different hall. S4 SW stated Resident #6's RP told her Resident #6 had a history of these types of inappropriate behaviors. S4 SW reported she was aware Resident #6 had exhibited verbally inappropriate behaviors to a CNA in the past. Review of Resident #6's medical record revealed an admit date of 05/11/2023 with diagnoses that included in part: Unspecified dementia, moderate with other behavioral disturbance, Type 2 DM, Hypertension, and Seizures. Review of Resident #6's admission MDS with an ARD of 05/22/2023 revealed the resident had a BIMS of 11, which indicated the resident had moderately impaired cognition. Resident #6 required supervision with bed mobility, transferring, and eating and required extensive assistance by one person with toilet use. Review of Resident #6's nurses' notes revealed the following: 05/24/2023 at 5:16 p.m.: 4:00 p.m.: Received report from S4 SW that she had been told by a female resident that Resident #6 had displayed some inappropriate sexual behavior . S3 NP notified. New order to refer to (the local inpatient psychiatric facility). Contacted the psychiatric facility, report given. Contacted emergency room report given. Ambulance service notified. Resident #6 left facility at 4:45 p.m. Documented by S2 DON. 05/24/2023 at 5:52 p.m.: Received call from ER reporting Resident is being sent back to facility. Says does not meet criteria for admission at this time, stating he is non-aggressive and has not displayed any inappropriate behavior with female staff in ER. RP notified. Documented by S2 DON. 05/25/2023 at 12:49 a.m.: 6:30 p.m.-Resident returned to facility in stable condition. Diagnosis: Dementia. No new orders noted. Resident is in stable condition. No inappropriate behaviors noted. Will monitor. Documented by S5 LPN. 05/25/2023 at 11:59 a.m.: S3 NP in facility making rounds new order noted and carried out. Consult (psychiatric NP) for sexual behaviors. RP sister informed. Documented by S6 LPN 05/26/2023 at 1:06 p.m.: Referral to Psych NP sent. Telehealth visit for sexual behavior with sister and this nurse present. Reports mood ok. Answers questions openly. Recommended injection to help with sexual behaviors. Medical NP would manage that medication. S3 NP contacted. Psych NP will continue to follow. Documented by S2 DON. 05/27/2023 at 12:26 a.m.: Order for Depo Provera (a hormonal medication) shot inject 1 ml IM every month on the 26th, order faxed to pharmacy, MAR corrected. Resident given injection in left hip no distress noted tolerated well no signs of sexual behaviors noted at this time. Resident resting in bed with eyes closed will monitor. Documented by S7 LPN. Review of progress note by S3 NP dated 05/25/2023 revealed in part: Chief complaint/nature of presenting problem: Status post emergency room visit secondary to inappropriate sexual behaviors with Alzheimer's dementia, major depressive disorder. History of present illness: 70 y/o male seen today at staff request after receiving after hours phone call on 05/24/2023 with reports of patient having increased sexual inappropriate behavior and exposing himself to another resident. According to the resident patient began fondling himself in the hallway reporting it had been a long time since she had had a sexual encounter, he has apparently had sexual inappropriate comments toward therapy staff and nursing staff.He was sent to the ER yesterday for possible placement in the behavioral unit. However the ER reports the patient did not exhibit any increased behaviors therefore he was discharged and sent back to the facility .he has not been seen by the Psych NP. DX: Alzheimer's disease, Dementia, MDD, and abnormal sexual behavior Plan: Status post ER visit secondary to inappropriate sexual behaviors with Alzheimer's dementia, Major Depressive Disorder .monitor for increased behaviors. Order psychiatric NP to evaluate patient. Review of Psych NP progress note dated 05/26/2023 revealed in part: Initial evaluation of patient's response to psychotropic meds; .Patient has been reported to be complimentary to staff and patients. Staff reports that the resident was flattered by his compliment but politely declined his advance. He was not aggressive and polite about the declination. Staff, family, and patient denies any aggression physical or sexual .however family desired to explore behavioral interventions to decrease his compliments and friendliness. Requires 24 hour supervision Insight and judgment are grossly impaired due to disturbance of executive functioning Continue regimen as previously ordered related to good adaptive functioning on present regimen. Continue to redirect as needed. Refer to medical for consult. In an interview at 8:00 a.m. on 05/31/2023, S8 COTA stated during the early part of last week she went in Resident #6's room to get him for therapy. She said he was sitting in his wheelchair and she leaned over to unlock the wheelchair and he reached out to touch her breast. She said she told him that was a No, no and We don't do that. She said she went to unlock the other wheel and he did it again and she told him no again. She said he said, You'll enjoy it and she said she explained to him that was not appropriate. She said she reported it to his nurse. In an interview on 05/31/2023 at 8:05 a.m., S10 CNA stated Resident #6 has inappropriate behaviors, like touching her butt when she walks by. She said it has happened multiple times and to multiple people. In a telephone interview at 05/30/2023 at 4:30 p.m., _____, Psych NP discussed her progress note from 05/26/2023 and stated no one told her Resident #6 had fondled himself in front of another resident. She stated she was told that he complimented another resident who politely declined. She said she spoke with his sister who was also a nurse who stated she wanted to do an intervention to stop that behavior and asked about a Depo shot. She said she talked with them about adjusting meds and at that time since he wasn't aggressive she chose to consult medical for the depo shot. She then reported that today the facility had notified her Resident #6 had exhibited aggressive sexual behaviors and she adjusted his medications. She said she prescribed Risperdal (an anti-psychotic) 0.25mg bid in conjunction with Paxil (an antidepressant) 10 mg bid and discontinued the Zoloft (antidepressant). She said those two work well together. She said after 3 days he should settle down. She said it may need to be increased but she is starting him at this dosage. She said the depo shot takes about two weeks to work. Review of Resident #6's nurses' notes revealed in part: 05/30/2023 at 2:57 p.m.: After giving meds to this resident, this nurse was standing at the med cart in the door way looking at the MAR when something touched me on my rear end. I turned around and the resident was standing right behind me pulling his pants down. I instructed the resident to go back to his chair. He hollered to me Be Still! Resident was instructed to go sit in his recliner. He then turned around and walked over to his recliner and had a seat. DON was notified about the incident. Documented by S9 LPN. In an interview on 5/31/2023 at 9:30 a.m., S2 DON reported she contacted the Psych NP again on 05/30/2023 to adjust Resident #6's medication because he made a comment to S4 SW yesterday about her dress being short and he stepped up behind the nurse and said something inappropriate to her but never touched her. In an interview on 05/30/2023 at 2:00 p.m., S2 DON stated she became aware of Resident #6's sexually inappropriate behaviors after he had been here several days, when the Activity Director, Social Worker, and MDS nurse reported during assessments Resident #6 had answered some questions in a sexually inappropriate manner. S2 DON stated she became aware on the afternoon of 05/24/2023 of what had occurred between Resident #2 and Resident #6. She said she consulted the NP so Resident #6's medication could be reviewed. She said a recommendation was made by the NP to refer to Resident #6 to the psychiatric inpatient facility for medication adjustment. On 05/24/2023, he was sent to the emergency room to be admitted to the psychiatric inpatient facility. She said she called report to the ER and then a couple hours later the ER called back and said he was non-aggressive, not exhibiting any behaviors, and didn't meet criteria for admission and the resident was sent back to the facility. She said upon return they moved him to Hall X, which was the hall where the male residents reside. She said they also put alarms on his wheelchair and bed so they would know when he was up. She stated she called S3 NP who saw him the next morning on 05/25/2023 who then referred the resident to the Psych NP. S2 DON stated when she returned to work on 05/26/2023, Resident #6 had not been seen yet by the Psych NP so she called and arranged a telehealth visit, where a Depo shot was recommended. She stated Resident #6 received the shot the night of 05/26/2023. She reported this past weekend, Resident #6 touched a CNA on her behind. S2 DON confirmed she didn't put Resident #6 on 1 on 1 observation but told staff to observe him attentively and listen for his alarms. She confirmed she did not in-service the staff on abuse or the incident and didn't put anything in writing. In an interview on 05/30/2023 at 2:35 p.m., S1 Executive Director stated she became aware of the incident on 05/24/2023 at 3:30 p.m. when S4 SW called her. She said she called her [NAME] President and they discussed that Resident #6 needed to be evaluated and moved to the other hall. She said she called S4 SW back and told her what to do. She said he was sent out and came back that same day. She said they moved him to the other hall when he returned. She said on Friday, 05/26/2023, they had a conference with the Psych NP and got an order for medication to help deter those urgencies. S1 ED stated since then she has been looking at his progress notes and hasn't seen any misconduct. She stated to prevent it from reoccurring, staff are making rounds and trying to keep an eye on him. She confirmed staff didn't do 1 on 1 observation because the hospital said he wasn't showing signs of aggression. She stated as far as his care plan goes, she hadn't even looked at it. S1 ED confirmed they did not do any in-services or put any extra monitoring in place to her knowledge. S1 ED confirmed she did not report the incident to the state because she did not feel like it was abuse.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an alleged violation of sexual abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention Policy revealed in part: The facility is committed to protecting the residents from abuse by anyone including other residents. Review of the policy revealed sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the Administrator of the facility and to other officials including the State Survey Agency. Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE] with diagnoses that included: COPD, Heart failure, Edema, and Atrial fibrillation. Review of Resident #2's admission MDS with an ARD of 03/02/2023 revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition. The MDS revealed Resident #2 required extensive assistance by two persons with bed mobility and transferring and extensive assistance by one person with toilet use. Review of a grievance by Resident #2 dated 05/23/2023 to S4 Social Worker revealed in part: Resident #6 was blocking Resident #2 from her room door. She was trying to get to her room. Resident #6 stated to her you know it's been a long time while rubbing between his legs and began attempting to open center part of his pants to show Resident #2. Resident #2 stated Resident #6 pissed her off, she started cussing, reached for her phone, and said Close those britches while cursing at Resident #6. Resident #2 felt uncomfortable, uneasy, concerned about other women residents. In an interview on 05/30/2023 at 2:35 p.m., S1 Executive Director stated she became aware of the incident on 05/24/2023 at 3:30 p.m. when S4 SW called her and reported it. She said she called her [NAME] President and they discussed that Resident #6 needed to be evaluated and moved to the other hall. She said she called S4 SW back and told her what to do. She said he was sent out and came back that same day. She said they moved him to the other hall when he returned. She said on Friday, 05/26/2023, they had a conference with the Psychiatric NP and got an order for medication to help deter those urgencies. She stated to prevent it from reoccurring, staff are making rounds and trying to keep an eye on him. S1 ED confirmed she did not report the incident to the state because she did not feel like it was abuse.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and interview the facility failed to develop a comprehensive care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. Findings: Review of the facility policy titled Comprehensive Person Centered Care Plans revealed in part . Procedure: 1. The Comprehensive Person Centered Care Plan shall be fully developed within 7 days after completion of the admission MDS Assessment. Review of Resident #5's Face Sheet revealed an admit date of 03/17/2023. The resident was admitted with Pressure Ulcer of Right Hip, Stage 4; Moderate Protein-Calorie Malnutrition; PTSD, unspecified; Other Mental Disorders due to know Physiological Condition; Other recurrent Depressive Disorders; Other Psych Disorder not due to a sub or known physiological condition; Pressure Ulcer of other side, Stage 2; and Pressure ulcer of other site, Stage 3. Review of Resident #5's AM5 MDS with an ARD of 03/24/2023 revealed Resident #5 had a BIMS of 0 (severely impaired cognition). Resident #5 required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene. Resident #5 was totally dependent with bathing. Resident #5 had pressure ulcers which included 3 Stage 2 pressure ulcers, 1 Stage 4 pressure ulcer, and 2 unstageable pressure ulcers. Review of Resident #5's care plan revealed only a baseline care plan. Interview on 05/31/2023 at 10:14 a.m. with S2 DON revealed there was no comprehensive care plan for Resident #5. S2 DON stated only a baseline care plan had been completed. She confirmed Resident #5 was admitted in 03/2023 and a comprehensive care plan should have already been completed.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review and interview the Facility failed to ensure that Residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled Residents. Findings: Review of the facility policy titled Telephone Orders revealed the following including: Procedure: 1. Whenever telephone orders are received by physician, the order is to be written on a Physician Telephone Order form or entered into the eTelephone order application. Review of Resident #4's Face Sheet revealed an admit date of 12/02/2022. Resident #5 had the following diagnoses including other Diabetes due to underlying condition with diabetic nephron; Dependence of Renal Dialysis; and End Stage Renal Disease. Review of Resident #4's 05/2023 MD Orders revealed the following in part . 12/02/2022 - Insulin Lispro 100U/ml vial <60 give Glucagon IM and call MD; >400 give 12U and call MD; 200-250 = 2U; 251-300 = 4U; 301-350 = 6U; 351-400 = 9U AC & HS 01/05/2023 - Finger stick AC & HS Review of Resident #4's 04/2023 - 05/2023 e-MAR revealed the following dates and Capillary Blood Sugar (CBS) readings greater than 400 when the MD was not notified: 04/02/2023 at 11:30 a.m. - 431 04/02/2023 at 4:30 p.m. - HI 04/04/2023 at 4:30 p.m. - 402 04/05/2023 at 9:00 p.m. - 448 04/06/2023 at 9:00 p.m. - 402 04/07/2023 at 11:30 a.m. - 438 04/08/2023 at 4:30 p.m. - 598 04/09/2023 at 4:30 p.m. - 453 04/11/2023 at 9:00 p.m. - 442 04/13/2023 at 4:30 p.m. - 477 04/15/2023 at 4:30 p.m. - HI 04/16/2023 at 11:30 a.m. - HI 04/16/2023 at 4:30 p.m. - HI 04/17/2023 at 11:30 a.m. - 493 04/18/2023 at 11:30 a.m. - 422 04/19/2023 at 4:30 p.m. - 476 04/21/2023 at 11:30 a.m. - 413 04/22/2023 at 4:30 p.m. - HI 04/23/2023 at 11:30 a.m. - 594 04/23/2023 at 4:30 p.m. - 544 04/24/2023 at 4:30 p.m. - 569 04/25/2023 at 11:30 a.m. - 535 04/25/2023 at 4:30 p.m. - 477 04/26/2023 at 4:30 p.m. - HI 04/30/2023 at 4:30 p.m. - 556 05/02/2023 at 4:30 p.m. - HI 05/03/2023 at 4:30 p.m. - 514 05/08/2023 at 11:30 a.m. - 499 05/08/2023 at 4:30 p.m. - HI 05/09/2023 at 4:30 p.m. - 480 05/16/2023 at 11:30 a.m. - 418 05/17/2023 at 11:30 a.m. - HI 05/17/2023 at 4:30 p.m. - 541 05/18/2023 at 11:30 a.m. - HI 05/19/2023 at 4:30 p.m. - 532 05/20/2023 at 4:30 p.m. - HI 05/20/2023 at 9:00 p.m. - HI 05/21/2023 at 11:30 a.m. - 482 05/21/2023 at 4:30 p.m. - 415 On the following dates/times Resident #4's CBS was not checked: 04/05/2023 at 6:30 a.m. 04/06/2023 at 4:30 p.m. 04/17/2023 at 4:30 p.m. 04/20/2023 at 4:30 p.m. 04/26/2023 at 9:00 p.m. On the following dates/times the incorrect dosage or no insulin was given to Resident #4: 04/02/2023 at 11:30 a.m. - 431 - 9U Lispro given 04/02/2023 at 4:30 p.m. - HI - 9U Lispro given 04/04/2023 at 4:30 p.m. - 402 - No documentation of insulin given 04/23/2023 at 11:30 a.m. - 594 - No documentation of insulin given 04/26/2023 at 4:30 p.m. - HI - No documentation of insulin given 05/09/2023 at 4:30 p.m. - 480 - 9U Lispro given 05/20/2023 at 9:00 p.m. - HI - No documentation that insulin was administered 05/21/2023 at 4:30 p.m. - 415 - 6U Lispro given Interview on 05/30/2023 at 2:49 p.m. with S2 DON confirmed Resident #4's CBS readings were above 400 and there was no documentation where the MD had been notified according to his order. Interview on 05/30/2023 at 3:13 p.m. with S2 DON revealed there was a communication book at the nurse's station for the nurses to write down any calls made to the MD. S2 DON stated that a nurse stated she had received permission from Resident #4's NP that staff did not have to notify her of Resident #5's elevated blood sugars, just give the highest dose (12U) and recheck the blood sugar. S2 DON confirmed there was no order written with these instructions. S2 DON stated the rechecks had not been performed and it could be because staff were unaware of the order. Interview on 05/31/2023 at 9:18 a.m. with S3 NP revealed she was notified of some of the resident's elevated blood sugars and she had instructed staff that they did not have to call all the time with the elevated CBS readings. S3 NP stated she instructed staff to give 12U of insulin, recheck and call if it had not gone down. S3 NP stated she was unable to remember when she gave the instructions. S3 NP stated she did expect to be notified of the recheck and that there should be a record that the recheck was performed.

Mar 2023 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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review the facility failed to ensure all equipment was maintained in safe operating condition by failing to ensure the electrical outlet for the coffee machine and tea machine did not throw a breaker when both were used at the same time in the kitchen. Findings: Observation on 03/28/2023 at 9:30 a.m. revealed both the coffee machine and tea machine were sitting on the same table and behind the table was one electrical outlet. The coffee machine was plugged into the electrical outlet, but the tea machine was unplugged and not in use. Interview with S7 Dietary Staff on 03/28/2023 revealed they were not able to plug the coffee machine and the tea machine into the same plug. S7 Dietary Staff revealed when they tried to do it, a terrible sound would come from the outlet area and then the electrical breaker would throw and all things would shut down in the kitchen. S7 Dietary Staff revealed this had been reported to the maintenance staff in the past but nothing was ever done. S7 Dietary Staff revealed he was not sure if the current maintenance staff knew of the issue. Review of the Maintenance logs that were presented by S1 ADM revealed no documentation of an issue with the electrical outlet in the kitchen. Interview with S8 Maintenance Staff on 03/29/2023 at 1:00 p.m. revealed he had only been in his role as the Maintenance Staff for 5 weeks. S8 Maintenance Staff revealed no one had reported an issue with the electrical outlet in the kitchen. S8 Maintenance Staff also provided his maintenance logs that had reported issues that needed to be fixed and there was no documentation that an electrical outlet in the kitchen was not functioning properly.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the Facility failed to ensure a Resident received the treatments necessary to promote wound healing for 1 (Resident #3) of 3 (Resident's #2, #3, and #4) Residents reviewed for pressure ulcers. Findings: Review of Resident #3's medical record revealed an admit date of 07/09/2020 with diagnoses that included, in part . Spondylosis with Myelopathy of Cervicothoracic Region, Fibromyalgia, Pressure Ulcer of Sacral Region, PVD, UTI and Psychosis not due to substance or known physiological condition. Review of Resident #3's MDS with an ARD date of 02/20/2023 revealed Resident #3 had a BIMS score of 15 which indicated the Resident was cognitively intact. Resident #1 required extensive assistance of two persons with bed mobility and was totally dependent on two person physical assist with transferring and toilet use. Review of a skin assessment dated [DATE] revealed Resident #3 had a Stage 2 Pressure Ulcer to her sacrum that measured 2.0 cm X 2.0 cm X 0.1 cm. Review of nurses' notes dated 01/25/2023 at 4:50 p.m. revealed Resident #3 had excoriation to buttocks, change in condition, pressure ulcer to sacrum that measured 2.0 cm X 2.0 cm X 0.1 cm with orders noted to cleanse with wound cleanser, pat dry apply medihoney and calcium alginate cover with dry dressing once daily and prn until resolved. Resident's RP was notified. Review of Resident #3's physician's order read to treat Pressure Ulcer to sacrum with wound cleanser, pat dry apply medihoney and calcium alginate cover with dry dressing once daily and prn until resolved. Resident's RP was notified. Review of Resident #3's TAR for January 2023 revealed the wound treatment was initiated on 01/25/2023 the pressure ulcer to the sacrum, to cleanse with wound cleanser, pat dry apply medihoney and calcium alginate cover with dry dressing once daily and prn until resolved. Review of S5 RD note dated 01/29/2023 revealed in part .Resident #3 with new pressure ulcer dated 01/25/2023, Stage 2 Pressure Ulcer to Sacrum and Stage 3 Pressure Ulcer to Right lateral foot. Resident #3 recently had Covid and she refuses baths at times. Recommendations: Arginaid 1 pkg BID and Prostat 30 mls BID to help promote wound healing. Review of the physician's orders for January and February 2023 MARs revealed the RD recommendations dated 01/29/2023 were never initiated to help promote healing of Pressure Ulcers. Interview with S3 Corporate Nurse on 03/29/2023 at 2:05 p.m. confirmed the RD recommendations were never initiated as they 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 F0800 (Tag F0800)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review the facility failed to ensure each resident received a well-balance diet that meets his or her daily nutritional dietary needs by failing to ensure: 1. That enough food was prepared according to recipe; 2. Staff were knowledgeable and used the correct scoop and ladle size; and 3. The dietary manager had received proper training to provide oversite. This deficient practice had the potential to affect all 62 residents who received meals prepared by the kitchen. Findings: 1. Observation on 03/28/2023 at 11:30 a.m. of the food on the serving ling revealed Ranch Chicken, gravy, carrots, roasted cauliflower, dessert and rolls were the main meal and pork boneless ribs and green beans were the alternate meal served. At 12:25 p.m. with 17 trays left there was no cauliflower left to serve and S6 Dietary Staff began servicing his alternate vegetable of green beans to the 17 trays left. At 12:30 p.m. with 11 trays left there was no green beans left to serve. S6 Dietary Staff began giving the remaining 11 trays double portions of the Ranch Chicken and one serving of carrots, a dessert, and a roll. Interview with S6 Dietary Staff on 03/28/2023 at 12:40 p.m. revealed that they had not cooked enough cauliflower to serve all residents and began to substitute the green beans for the cauliflower. S6 Dietary Staff also revealed that he ran out of the green beans quickly because that was just an alternate, so he began giving the remaining trays a double portion of Ranch Chicken to substitute the missing vegetable. S6 Dietary Staff revealed he did not follow the menus provided for cooking the food. 2. Observation on 03/28/2023 at 11:45 a.m. revealed S6 Dietary staff used 2 oz. ladles in the pureed carrots, pureed chicken and pureed bread. Observation revealed there were only 2 trays served a pureed diet and each tray received only one 2 oz. serving of pureed food. Interview with S4 DM on 03/28/2023 at 12:40 p.m. revealed she was not aware the pureed diet trays did not receive their 4 oz. serving of meat and 4 oz. serving of vegetables. S4 DM stated she relied on the dietary staff to know the correct serving sizes to serve. S4 DM revealed she had not learned the serving sizes of the serving scoops or ladles. 3. Interview with S4 DM on 03/28/2023 at 9:30 a.m. revealed her DOH was 03/15/2023. S4 DM revealed she had just graduated culinary school last month but had no prior history as a DM. S4 DM revealed she had received training from S5 DM on 3 separate days but only on how to order items and complete paperwork for the dietary department. S4 DM revealed she did not know the size portion of the scoops or ladles. S4 DM also revealed she had not received training on checking the sanitizer levels for the dish machine or the three compartment sink. S4 DM revealed she relied on the kitchen staff to know how to do those tasks properly. Interview with S5 DM on 03/29/2023 at 1:00 p.m. revealed she was the dietary manager for another sister facility. D5 DM revealed she was asked to help train S4 DM but had only come for a few hours three times since S4 DM had taken the position. S5 DM revealed she had only trained S4 DM on the paperwork portion of her duties as a DM. S5 DM revealed today she had posted a serving size list of all scoops and ladles for the dietary to use as a reference and had instructed the staff and S4 DM on the proper amounts of food to use, to ensure they did not run out of food during the meal service. S5 DM also revealed she instructed the dietary staff on how to properly use the menus when preparing the food. S5 DM revealed S4 DM had not been completely trained on all her duties in the dietary department at this time. S5 DM confirmed S4 DM should have received more training and supervision until she had been fully trained as a DM.

Jan 2023 15 deficiencies

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and interview the facility failed to ensure that a Resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 (#33) of 3 (#32, #33 and #58) Residents sampled for nutrition. Findings: Facility's Policy on Weights read in part .(1). Each Resident will be weighed by the 10th of each month. (4). Weights will be entered electronically. (6). Weight loss or gain of 5% in one month and/or 10% in 6 months must be reported to the Dietician and Physician. Review of Resident #33's Clinical Record revealed an admit date of 11/30/2022 with diagnoses which included: Functional Quadriplegia, Abnormal Weight Loss, Major Depressive Disorder, Anxiety Disorder, Neuralgia and Neuritis Unspecified and Low back pain. Review of Resident #33's Care Plan with a target date of 02/28/2023 revealed an Alteration in Nutrition/Resident is on a regular diet with approaches to serve diet as ordered, Monitor and record for food intake, Offer sub/house supplement if 50% or more not consumed at a meal. Registered Dietician to evaluate accordingly and obtain weights according to protocol. If any significant weight changes occur Registered Dietician will address and MD and RP will be notified. Review of Residents #33's admission MDS with an ARD of 12/07/2022 revealed a BIMS score of 14 (indicating intact cognition). Further review of Resident #33's MDS revealed he required extensive physical assistance of two persons for bed mobility and transfers and extensive physical assistance of one person for dressing, toilet use and personal hygiene; and set-up help with supervision for eating. Resident's weight was assessed at 147 pounds on this MDS. Record review of Resident #33's weight history revealed the following weights: 11/30/2022-127# 12/14/2022-120.8# (6.2# weight loss in 2 weeks) 12/19/2022-120.8# 12/24/2022-125.2# Record Review of Resident #33's Clinical Record revealed no documentation of the Registered Dietician's assessment of Resident. Interview on 01/09/2023 at 3:03 p.m. with S2 DON confirmed Resident #33 had not been seen by the Registered Dietician. Interview on 01/10/2023 at 9:06 a.m. with S2 DON confirmed paper documentation of weights and stated she was responsible for entering weights in the computer but had not entered Resident #33's weights. Telephone interview on 01/10/2023 at 9:28 a.m. with S10 Registered Dietician confirmed she had not seen Resident #33 and she should have. S10 Registered Dietician stated she was not aware of Resident #33 being at the facility.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

FACILITY Medication Storage and Labeling Based on observation and interview the facility failed to ensure controlled medications were secured in a double locked storage area according to state and federal laws for 2 (#51 and R10) Resident's in a total sample of 36. Findings: Review of the facility's policy and procedure on controlled medications read in part .2. (a) Medications are stored in a well illuminated, locked storage device, cabinet, or room that is accessible only to authorized personnel. Maintain double-lock system for all controlled medications, if required by state law. Resident #51 Review of Resident #51's Clinical Record revealed an admit date of 09/30/2022 with the following diagnoses: Malignant Neoplasm of Unspecified Part of Right Bronchus or Lung and Chronic Obstructive Pulmonary Disease. Review of Resident #51's January 2023 Medication Administration Record revealed an order for Morphine Sulfate 100 MG/5ML Concentrate Give 1 ML PO Q4HRS PRN Observation on 01/10/2023 at 2:06 p.m. of S17 LPN's medication cart revealed two bottles of Morphine Sulfate Concentration. One bottle with Resident #51's name on it. Interview with S17 LPN at this time confirmed the controlled medication was not in a double-locked area of the medication cart and it should have been. R10 Review of R10's Clinical Record revealed an admit date of 10/04/2022 with the following diagnoses: Hepatic Failure Unspecified without Coma, Diabetes Type 1, Hypertension and Anxiety Disorder. Review of Resident R10's January 2023 Medication Administration Record revealed an order for Morphine Sulfate 100 MG/5ML Concentrate Give 0.5MLS SL Q2HRS PRN Observation on 01/10/2023 at 2:06 p.m. of S17 LPN's medication cart revealed two bottles of Morphine Sulfate Concentrate. One bottle with R10's name on it. Interview with S17 LPN at this time confirmed the controlled medication was not in a double-locked area of the medication cart and it should have been. Observation and interview on 01/10/2023 at 2:17 p.m. with S17 LPN and S2 DON revealed 2 bottles of Morphine Sulfate Concentrate on S17's medication cart belonging to Resident #51 and R10. S2 DON confirmed all controlled medications should be in a double-locked area on the medication cart.

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility. This failed practice had the potential to affect all of the residents residing at the facility. The facility census was 65. Findings: Interview of S2 DON on [DATE] at 9:07 a.m. revealed the facility performs rapid COVID-19 tests and accuchecks. Review of the CLIA certificate provided by the facility revealed CLIA ID number of 19D0465092 with the effective date [DATE] and the expiration date [DATE]. Interview of S2 DON on [DATE] at 2:14 p.m. revealed the CLIA certificate with the expiration date of [DATE] is the only CLIA certificate the facility has and that the certificate is expired.

CONCERN (D)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation and interview the facility failed to ensure the facilities garbage was disposed of properly. Total facility census was 65. Findings: Observation on 01/08/2023 at 9:25 a.m. of the area outside of the facility's kitchen revealed one blue dumpster with two sliding doors on each side. Both doors of the dumpster were open. Dirty gloves and trash littered the ground surrounding the dumpster and a foul odor was detected. Further investigation revealed a grease barrel located beside the dumpster with a dead animal floating in it. A sign on the dumpster door read .please be sure to keep the door on the dumpsters closed at all times to decrease the amount of rodent activity/and or trash spillage. Observation and interview on 01/08/2023 at 9:35 a.m. with S1 Executive Director confirmed the dumpster doors were open and the ground surrounding the dumpsters were littered with dirty gloves and trash and it should not have been. S1 Executive Director instructed S3 dietary to use a shovel and lift the dead animal out of the grease barrel. The dead animal was identified as a raccoon. S1 Executive Director confirmed it should not have been in the grease barrel

CONCERN (D)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review the facility failed to ensure a resident or his or her representative acknowledges that he or she understood the binding arbitration agreement that was signed on admission for 3 (#30, #51,and #115) of 3 residents reviewed for arbitration. Findings: 1. Review of Resident #30's record revealed a form titled Resident and Facility Alternative Dispute Resolution and Arbitration Agreement was dated and signed by Resident #30 and S9 Admissions Coordinator on 10/03/2022. Interview with Resident #30 on 01/10/2023 at 11:50 a.m. revealed when she and her son were both admitted to the facility they signed multiple forms. Resident #30 stated the facility may have read the form to her but she had no idea what she was signing. Resident #30 stated it took hours to get all the paper work signed to enter the facility. The definition of what an arbitration agreement was read to the resident as: Arbitration - It's typically a clause in a broader contract in which you agree to settle out of court, through arbitration cases, any dispute that arises with your counterpart. Further interview with Resident #30 at that time stated I would not have signed the agreement, if I had known what it meant. 2. Review of Resident #51's record revealed a form titled Resident and Facility Alternative Dispute Resolution and Arbitration Agreement was dated and signed by Resident #51's RP and S9 Admissions Coordinator on 10/12/2022. Telephone interview with Resident #51's RP on 01/10/2023 at 1:08 p.m. revealed when he signed the paperwork for his brother to be admitted to the facility, there were many forms signed that day. Resident #51's RP stated the facility may have read the arbitration form to him, but he had no idea of what he signed. Resident #51's RP stated it took hours to get all the paper work signed to enter the facility. The definition of what an arbitration agreement was read to the resident as: Arbitration - It's typically a clause in a broader contract in which you agree to settle out of court, through arbitration cases, any dispute that arises with your counterpart. Further interview with Resident #51's RP at that time stated I would not have signed the agreement, if I had known what it meant and I want that removed as soon as possible. 3. Review of Resident #115's record revealed a form titled Resident and Facility Alternative Dispute Resolution and Arbitration Agreement was signed by Resident #115's RP and S9 Admissions Coordinator but it was not dated. Telephone interview with Resident #115's RP on 01/10/2023 at 1:08 p.m. revealed when she signed the paperwork for her uncle to be admitted to the facility, there were many forms signed that day. Resident #115's RP stated the facility may have read the arbitration form to her, but she had no idea of what she signed. Resident #115's RP stated it took hours to get all the paper work signed to enter the facility. Resident #115's RP stated she received a book of the forms signed and at no time had she seen a form regarding arbitration. The definition of what an arbitration agreement was read to the resident as: Arbitration - It's typically a clause in a broader contract in which you agree to settle out of court, through arbitration cases, any dispute that arises with your counterpart. Further interview with Resident #115's RP at that time stated I would not have signed the agreement, if I had known what it meant, and she would be contacting the facility regarding this issue. Interview with S9 Admissions Coordinator on 01/10/23 at11:07 a.m. revealed that she had been working in the facility since the beginning of Oct. 2022. S9 Admissions Coordinator revealed the Arbitration form was part of the Admissions packet. S9 Admissions Coordinator revealed the paperwork with the resident or resident's RP could take up to 2-3 hours. S9 Admissions Coordinator revealed when she got to the Arbitration form in the admissions packet she would read the first two lines of each paragraph as a way of explaining the form and then she would tell the residents or resident's RPs to sign if they understood.

CONCERN (D)

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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review and interview the Quality Assurance and Performance Improvement (QAPI) committee failed to make a good faith effort to address any deficient practices related to staffing shortages. The deficient Practice had the potential to affect all 65 residents residing in the facility. Findings: Review of Records revealed there was no Registered Nurse coverage in the facility for 5 days (07/21/2022, 07/22/2022, 07/25/2022, 07/27/2022, 08/02/2022). An interview on 01/09/2023 at 9:04 a.m. with S1 Executive Director confirmed that the facility had no Registered Nurse coverage for that 5 days listed above. Review of Nursing/Ancillary Personnel Staffing form from 12/25/2022 to 01/07/2023 revealed that staffing hours were negative -13.66% on 12/25/2022 and there were no Aides in the building on the entire 11-7 shift on 12/26/2022. These staffing issues were confirmed by S8 Corporate Nurse on 01/11/2023 at 11:30 a.m. Record review on minutes of the last 6 months of QAPI High Risk Meetings revealed documentation of the following topics covered during each meeting: pressure ulcer, falls, antipsychotic meds, catheters, ADL, weight loss, Antibiotic stewardship audits, Medication cart/storage, glucometer log, Environmental issues. Further review of the last 6 months of QAPI Meetings revealed no documentation related to identifying deficient practice related to staffing shortage. On 1/10/2023 at 4:00 p.m. an interview conducted with S1 Executive Director confirmed the QAPI team had not addressed any of the identified deficient practice related to staffing shortages. S1 Administrator further confirmed Staffing issues were not documented as being addressed in the past 6 months of QAPI meetings.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

FACILITY Based on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment for 3 resident rooms observed during the initial facility observation by failing to ensure the toilets were in good repair for Rooms A, B and C, ensure the heater was in good repair for Room D, ensure hot water was available for room E, and the door knob and floor were in good repair in room A. This deficient practice had the potential to affect 5 residents residing in those rooms out of a total of 65 residents in the facility. Findings: Room A In an observation and interview on 01/08/2023 at 10:20 a.m., Resident #13 who resides in room A pointed out where the metal threshold between the bedroom and bathroom was unattached and raised up in the air and was a tripping hazard. Further observation revealed a hole in the linoleum in the bathroom floor that exposed the ground beneath it. The hole was approximately 4 or 5 inches long and approximately three inches wide. Observation of the toilet revealed towels wrapped around the base of it. Resident #13 stated the toilet leaks and that he had reported it to the maintenance man about 3 or 4 months ago and nothing had been done. Resident #13 further reported having to plunge the toilet twice last week because it wouldn't flush down the contents in the toilet. Resident #13 also reported that their door knob was broken. In an interview at 10:27 a.m. on 01/08/2023, Resident #61 complained the door knob was broken to his room and the door would not stay closed. An observation revealed the door knob was loose and the door would push open without turning the knob. Resident #61 confirmed the toilet was leaking and not flushing properly. Room B & C Observation of the toilet shared between Rooms B and C revealed towels around the base on 01/08/2023 at 10:30 a.m. and on 01/09/2023 at 10:15 a.m. In an interview on 01/09/2023 at 10:20 a.m. S12 LPN confirmed the bathroom was used by two of the four Residents who reside in Rooms B and C. Room D In an interview on 01/09/2023 at 12:53 p.m. Resident #37 reported the heat was out in her room for three days in December 2022 when it was really cold. Resident #37 explained she reported it to S13 Maintenance on the first day the heat went out but it wasn't repaired for three days. Resident #37 reported it was cold and uncomfortable and she had to put extra blankets on her bed. In an interview on 01/10/2023 at 8 a.m. S14 LPN confirmed Resident #37 had complained of her heater being out. S14 LPN reported the Resident told her she had already reported it to maintenance and pointed out the front cover had been removed and there were tools in the room near the unit. S14 LPN confirmed Resident #37 was without heat for approximately 2 or 3 days. Room E In an observation and interview on 01/08/2023 at 11:21 a.m. it was noted that the sink was missing a faucet handle to turn on the hot water. Resident #30 reported staff would go next door to get hot water. Review of the Maintenance Log revealed no recent entries for Rooms A, B, D, or E. Observations were made of Rooms A, B, C, D, and E on 01/09/2023 at 10:42 a.m. with S1 ED who acknowledged Rooms A, B, C, D, and E were in need of the repairs named above.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan for 12 (#17, #30, #58, #61, #63, R1, R2, R3, R4, R5, R6 and R7) sampled resident. The facility also failed to implement a comprehensive person centered care plan to meet a Resident's medical needs for 2 (#58 and #39) of 36 sampled residents reviewed for care plans. The facility failed to: 1. Ensure Resident #58's orders were followed to obtain a CBC and a urinalysis, as ordered by the nurse practitioner, 2. Ensure Resident #39 orders were followed to administer Keflex 500 mg one QID X 7 days as ordered by the physician, 3. Ensure Resident #17 had a Comprehensive care plan in place to include PASARR, 4. Ensure Residents #30, #58, #61, #63, R1, R2, R3, R4, R5, R6 and R7 Comprehensive Care Plans were developed. Findings: Resident #58 Review of Resident #58's medical record revealed an admit date of 10/07/2022 with diagnoses that included, in part, Vascular Dementia, Type 2 Diabetes Mellitus, and Schizoaffective Disorder. Review of Resident #58's progress note dated 12/06/2022 revealed the Resident was seen by the NP for increased behaviors, becoming aggressive with other Residents and staff, attempting to elope, and becoming aggressive threatening physical violence. Further review of the progress note revealed the NP ordered a urinalysis with reflex. Review of Resident #58's medical record revealed no urinalysis had been done as ordered. In an interview on 01/10/2023 at 9:10 a.m., S7 RN confirmed the urinalysis was not done as ordered in December 2022. Resident #39 Review of Resident #39's clinical record revealed an admit date of 05/06/2021 with diagnoses that included: Hemiplegia following Cerebral Infarction affecting left non-dominate side, Fracture of Metatarsal bone in left foot, Chronic pain, Overactive bladder, Manic episodes, Epilepsy, Morbid Obesity, and Dysphagia. Review of Resident #39's admission MDS with an ARD of 10/14/2022 revealed a BIMS score of 10 indicating moderate cognitive impairment. Further review revealed Resident #39 required extensive assistance of two person with toileting. Review of Resident #39's Dec. 2022 Physician's orders revealed the resident was treated for a UTI on 12/09/2022 and again on 12/26/2022 the resident was diagnosed and treated for a UTI. Further review of the physician order's dated 12/26/2022 revealed the physician ordered Keflex 500 mg one tab QID for 7 days. Review of the Dec. 2022 MARs revealed the Keflex 500 mg one tab QID X 7 days began on 12/27/2022 was to continue until 01/02/2023. Review of the Jan. 2023 MARs revealed no order for the administration of Keflex. Interview with S18 RN Corporate on 01/10/2023 at 8:30 a.m. confirmed that the Keflex was not brought over to the [DATE] Physician's orders or MARs and there was no documentation that the antibiotic (Keflex) was administered as ordered. S18 RN Corporate revealed that according to the Jan. 2023 Nurses Notes the antibiotic was not completed until 01/05/2023, which was late and not as the physician had ordered. S18 RN Corporate confirmed that the Physician's orders for 2023 were not on the resident's records. Resident #17 Review of Resident #17's admission MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Non-Traumatic Spinal Cord Dysfunction, Hypertension, Gastroesophageal reflux disease, Neurogenic Bladder, Schizophrenia, Psychosis and Insomnia. Resident #17's BIMS was 14 which indicated he was cognitively intact. Review of Resident #17's PASARR revealed the resident was approved for admission by level II Authority for a temporary period effective - 10/18/22 to 01/17/2023. Review of Resident #17's interim care plan dated 12/9/2022 revealed no care plan related to the PASARR. Interview with S19 MDS on 01/09/2023 at 11:25 a.m. confirmed, Resident #17's Comprehensive Care plan had not been completed, which would include a care plan for PASARR. Resident #30 Review of Resident #30's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Pressure Ulcer of Left hip (Unstageable), Pressure Ulcer of Sacral Region (Unstageable), and Muscle Spasm. Review of Resident 30's admission MDS with an ARD date of 10/19/2022 revealed a BIMs of 15 (indicating the resident was cognitive intact). The MDS revealed Resident #30 was totally dependent on staff for transfers and toileting (2 persons) and totally dependent on staff for eating, dressing and personal hygiene (1 person). Review of Resident #30's medical record revealed an Instant Care Plan dated 10/14/2022. There was no documentation of a Comprehensive Plan of Care. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #30 due 11/01/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #58 Review of Resident #58's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #58 due 11/17/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #61 Review of Resident #61's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Diabetes, Mood Disorder, Schizophrenia, Depression, Insomnia, and Psychosis. Review of Resident 61's admission MDS with an ARD date of 12/03/2022 revealed a BIMs of 09 (indicating the resident was moderately impaired). The MDS revealed Resident #62 required supervision (1 person) transfers, dressing and personal hygiene. Review of Resident #61's medical record revealed an Instant Care Plan dated 12/10/2022. There was no documentation of a Comprehensive Plan of Care. Interview on 01/09/20223 at 2:15 p.m. with S19 MDS Nurse revealed she was new to the MDS position. S19 MDS Nurse revealed she started this position in October, 2022. S19 MDS Nurse confirmed Resident #30 and Resident #61did not have a Comprehensive Plan of Care. Interview on 01/09/2023 at 2:30 p.m. with S2 DON revealed she started in November, 2022 and the facility was behind on developing several Comprehensive Care Plans. S2 DON revealed the facility did not have a fulltime MDS nurse until October, 2022. S2 DON confirmed Residents (#30 and #61) did not have a Comprehensive Plan of Care, and they should have. Interview on 01/09/2023 at 2:45 p.m. with S8 Corporate Nurse revealed the facility did not have a MDS nurse until October, 22. S8 Corporate Nurse revealed the facility used the company's nurse consultant to help develop the Comprehensive Care Plans. S8 Corporate Nurse confirmed Resident #30 and Resident #61 did not have a Comprehensive Care Plan. Resident #63 Review of Resident #63's closed record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #63 due 05/15/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #R1 Review of Resident #R1's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #R1 due 11/03/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #R2 Review of Resident #R2's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #R2 due 11/09/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #R3 Review of Resident #R3's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #R3 due 01/02/2023. S19 MDS revealed that due to staffing care plans had not been completed. Resident #R4 Review of Resident #R4's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #R4 due 12/22/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #R5 Review of Resident #R5's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #R5 due 12/25/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #R6 Review of Resident #R6's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #R6 due 12/26/2022. S19 MDS revealed that due to staffing care plans had not been completed. Resident #R7 Review of Resident #R7's record revealed he was admitted to the facility on [DATE]. Further review of the record revealed no documentation of a CPOC on the record. Interview with S19 MDS on 01/09/2023 at 3:09 p.m. confirmed several Comprehensive Care Plans had not been completed timely which included Resident #R7 due 10/27/2022. S19 MDS revealed that due to staffing care plans had not been completed.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to have sufficient staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 11 (Resident #2, Resident #30, Resident #32, Resident #37, Resident #39, Resident #40, Resident #45, Resident #53, Resident #R2, Resident #R8, and Resident #R9) of 65 total sample by failing to answer call lights in a timely manner or provide care according to the resident's plan of care. Findings: Resident #2 Review of Resident #2's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Acquired absence of left leg above the knee and Acquired absence of right leg above the knee. Review of Resident #2's Annual MDS with an ARD date of 10/20/2022 revealed a BIMs of 15 (indicating the resident was cognitive intact). The MDS revealed Resident #2 required extensive 2 persons assist for transfers. Review of Resident #2's Comprehensive Plan of Care revealed impaired mobility related to left sided hemiplegia and bilateral AKA. Resident #2 required stand by assist with transfers and required staff assistance to perform dressing, bathing, personal hygiene, and toileting. Interview on 01/08/23 12:03 PM with Resident #2 revealed the facility was short of staff and he only used the call the light for assistance if necessary. Resident #2 revealed he had to wait 45 minutes to a 1 hour at times before staff answered his call light. Resident #2 revealed he used his cell phone and television to keep up with the time. Resident #30 Review of Resident #30's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Pressure Ulcer of Left hip (Unstageable), Pressure Ulcer of Sacral Region (Unstageable), and Muscle Spasm. Review of Resident #30's admission MDS with an ARD date of 10/19/2022 revealed a BIMs of 15 (indicating the resident was cognitive intact). The MDS revealed Resident #30 was totally dependent on staff for transfers and toileting (2 persons) and totally dependent on staff for eating, dressing and personal hygiene (1 person). Review of Resident #30's Instant Care Plan revealed no documentation of required assistance. Interview on 01/08/23 11:18 a.m. with Resident #30 revealed sometimes he had to wait 1 hour for assistance. Resident #30 revealed he was told the facility was short of nursing staff (CNAs) and sometimes 1 CNA would work the hall alone. Resident #30 revealed he had Contractures and he needed help with everything. Resident #30 revealed he used his television to keep up with the time. Resident #32 Review of Resident #32's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included muscle weakness and unspecified lack of coordination. Review of Resident #32's Quarterly MDS with an ARD date of 08/30/2022 revealed no score for BIMs. The MDS revealed Resident #32 totally dependent on staff for Locomotion (1 person); required extensive assistance (2 person) for toileting and transfers; required extensive assistance (1 person) for personal hygiene and dressing; and supervision (1 person) for eating. Review of Resident #32's Comprehensive Plan of Care revealed impaired and self-care deficits related to history of CVA with left sided hemiplegia. Further review of the CPC revealed the resident required assistance with ADLs. Interview on 01/08/23 12:52 PM with Resident #32 revealed when he pressed his call light he had to wait at least half an hour for assistance. Resident #32 revealed he had a BM and he had to wait 1 hour before he was changed. Resident #37 Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included Spondylosis with myelopathy cervicothoracic region, Fibromyalgia, and Peripheral Vascular Disease. Review of Resident #37's Quarterly MDS with an ARD date of 11/17/2022 revealed a BIMs of 12 (indicating the resident was cognitive intact). The MDS revealed Resident #37 required extensive (2 persons) for transfers and toileting, and required extensive (1 person) for personal hygiene, dressing, and eating. Review of Resident #37's Comprehensive Plan of Care revealed impaired mobility and self-care deficits related to quadriplegia, fibromyalgia, poor motor control in all limbs, bilateral lower extremities contracted. Further review revealed Resident #37 required total assistance with dressing, personal hygiene, bathing, and toileting. Review of a Grievance filed by Resident #37 on 12/06/2022 for concern of Not answering call lights timely, not making rounds timely. Interview on 01/08/23 10:53 a.m. with Resident #37 revealed the call lights stay on for hours before staff came to assist her. Resident #37 revealed yesterday, 01/07/2023, she pressed her call light about 11:00 am and they did not come to assist her until about 1:30 pm. Resident #37 revealed she was completely wet. Resident #37 revealed someone came into her room about 12:00 pm and turned her light off and said they would be right back but didn't come back until 1:30 pm. Resident #37 revealed the facility was short of staff. Resident #37 revealed she received a bed bath; however, she hadn't received a bath since last Monday (01/02/2023). Resident #37 revealed the facility didn't have a shower aide. Resident #37 revealed the facility was short of staff. Interview on 01/10/2023 at 8:00 a.m. with S14 LPN revealed Resident #37 required a lift for transfers and she revealed once the CNAs got Resident #37 up in the chair for the day they did not want to put her back in bed to change her and then put her back in the chair because it's too much trouble. S14 LPN confirmed the facility was short of staff. Resident #37 revealed she may not have received bathes when she wanted one. Resident #39 Review of Resident #39's medical record revealed she was admitted the facility on 05/06/2021. Diagnoses include Hemiplegia affecting left side, Muscle Weakness, Muscle Spasms, and Chronic pain. Review of Resident #39's Quarterly MDS with an ARD date of 10/14/2022 revealed a BIMs of 10 (indicating the resident was moderately impaired). The MDS revealed Resident #39 required extensive (2 person) for dressing and personal hygiene and extensive (1 person) for transfer. Review of Resident #39's Comprehensive Plan of Care revealed impaired transfers with a Hoyer Lift. Further review of CPC revealed Resident #39 required max assist with dressing, grooming, and bathing. Interview on 01/08/23 03:20 p.m. with Resident #39 revealed the facility did not have enough staff to help her get to the bathroom without her wetting on herself. Resident #39 revealed she would push her call light and she would wait long periods of time. Resident #40 Review of Resident #40's medical record revealed she was admitted to the facility on [DATE]. Diagnoses include unilateral primary osteoarthritis, pain, polyneuropathy, and obesity. Review of Resident #40's Quarterly MDS with an ARD date of 10/20/2022 revealed a BIMs of 15 (indicating the resident was cognitive intact). The MDS revealed Resident #40 required extensive (2 persons) for transfers, toileting, and dressing and required extensive (1 person) for personal hygiene. Review of Resident #40's Comprehensive Plan of Care revealed impaired mobility related to required staff assistance with bed mobility, transfers, via Hoyer lift, and Resident #40 had decreased ROM to BLE. Further of CPC revealed inability to maintain appearance at satisfactory level related to required staff assistance with dressing, bathing, personal hygiene, and toileting. Observation on 01/08/2023 at 9:28 a.m. during the initial tour of the facility revealed S15 CNA was the only staff on Hall A. Further observation revealed Resident #40's call light was on. Further observation revealed the call light was on for 20 minutes before staff answered. Observation revealed Resident #40 was lying in bed and she revealed she needed to be cleaned. Interview on 01/08/23 at 9:27 a.m. with Resident #40 revealed she had her light on for 15 minutes. Resident #40 revealed she had a bowel movement and she needed to be changed. Resident #40 revealed she did not know who her CNA was today (01/08/2023). Resident #40 revealed she used her television to keep up with the time and sometimes she watched 2 shows before staff answered her call light. Resident #40 revealed sometimes it would take an hour before she received assistance. Resident #40 revealed on 12/26/2022 there were no CNAs in the building. Interview on 01/08/2023 at 9:30 a.m. with S15 CNA revealed she was working with S16 CNA. S15 CNA revealed she was responsible for rooms 32 to 40 and S16 CNA was responsible for rooms 41 to 53. S15 CNA revealed S16 CNA was responsible for Resident #40. Interview on 01/08/2023 at 9:45 a.m. with S16 CNA revealed she was listed on the staffing schedule to provide care for rooms 41 to 53. However, she was pulled to work in the kitchen. Resident #45 Review of Resident #45's medical record revealed she was admitted to the facility on [DATE]. Diagnoses include encephalopathy, Acute and Chronic respiratory failure with hypoxia, and Epilepsy, and Dysphagia. Review of Resident #45's Discharge MDS with an ARD date of 12/05/2022 revealed no score for BIMs. The MDS revealed Resident #45 required extensive assistance for transfers, dressing, eating, toileting and personal hygiene. Review of Resident #45's Comprehensive Plan of Care revealed impaired mobility and inability to perform ADLs related to diagnosis of Anoxic Encephalopathy. Further review of CPC revealed Resident #45 required total staff assistance for bed mobility, transfers, dressing, bathing/personal hygiene, and toileting. Resident #45 had bilateral upper and lower extremity contractures and required a Hoyer lift for transfers (2 person assist). Resident #53 Review of Resident #53's medical record revealed she was admitted to the facility on [DATE]. Diagnoses include chronic pain and Seizures. Review of Resident #53's Quarterly MDS with an ARD date of 12/15/2022 revealed no score for BIMs. The MDS revealed Resident #53 required extensive (2 person) assist with transfers and toileting, extensive (1 person) assist with eating, and personal hygiene. Review of Resident #53's Comprehensive Plan of Care revealed impaired mobility and self-care deficits related to diagnosis of cachexia, metabolic encephalopathy, and severe intellectual disability. Resident #53 required extensive staff assistance with bed mobility, locomotion, dressing, bathing, personal hygiene, toileting, and lift transfer (2 person) assist. Resident #R2 Review of Resident #R2's medical record revealed she was admitted to the facility on [DATE]. Diagnoses include lower pain, and Rheumatoid Arthritis of multiple sites. Review of Resident #R2's admission MDS with an ARD date of 10/02/2022 revealed a BIMs of 12 (indicating the resident was cognitively intact). The MDS revealed Resident #R2 required extensive (2 person) assist with transfers and toileting, and extensive (1 person) assist with dressing and personal hygiene. Review of Resident #R2's medical record revealed no Comprehensive Plan of Care. Resident #R8 Review of Resident #R8's medical record revealed she was admitted to the facility on [DATE]. Diagnoses include Disorder of Muscle, Dementia, Aged related Osteoporosis, Muscle Weakness, and Muscle Spasms. Review of Resident #R8's Annual MDS with an ARD date of 11/10/2022 revealed a BIMs score 03 (indicating the resident was not cognitively intact). The MDS revealed Resident #R8 required extensive assist for transfers, dressing, toileting, eating, and personal hygiene. Review of Resident #R8's Comprehensive Plan of Care revealed physical mobility impaired related to generalized weakness, resident required extensive assist (2 person) for bed mobility and mechanical lift, and the resident required extensive assist (1 person) for dressing, grooming, and toileting. Resident #R9 Review of Resident #R9's medical record revealed she was admitted to the facility on [DATE]. Diagnoses include Quadriplegia C-5 and C-7 incomplete, Contracture to right hand, Contracture to left hand, Chronic Pain, Muscle Spasms, and Muscle weakness. Review of Resident #R9's Quarterly MDS with an ARD date of 07/14/2022 revealed a BIMs score of 15 (indicating the resident was cognitive intact). The MDS revealed Resident #R9 required extensive (2 person) assist with transfers, dressing and personal hygiene. Review of Resident #R9's Comprehensive Plan of Care revealed impaired mobility with risk for Falls related to Quadriplegia limited to extensive assist with all ADLs and mobility. Further review of CPC revealed Resident #R9 had bilateral upper extremity Contractures. Interview on 01/09/2023 at 9:00 a.m. with S6 SDC revealed the facility was short of staff. S6 SDC confirmed on 12/26/2022 (Monday) there were no CNAs on the night shift (11:00 p.m. to 7:00 a.m.). Interview on 01/09/2023 9:51 a.m. with S2 DON revealed the following residents were dependent on staff for ADL care: Resident #2, Resident #30, Resident #32, Resident #37, Resident #39, Resident #40, Resident #45, Resident #53, Resident #R2, Resident #R8, and Resident #R9. S2 DON revealed the facility was short of staff. S2 DON confirmed on 12/26/2022 the facility did not have any CNAs on the night shift (11:00 p.m. to 7:00 a.m.) to provide care.

CONCERN (E)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review and interview, the facility failed to ensure the facility had 8 consecutive hours per day of Registered Nurse (RN) coverage for 5 of 92 days reviewed for RN hours. This deficient practice had the potential to affect any of the 65 Residents residing in the facility according to the facility's Resident Census and Conditions Form (CMS 672). Findings: Review of the PBJ Staffing Data Report for Fiscal Year Quarter 4 2022 (July 1-September 30) revealed the facility had no RN coverage on 07/21/2022, 07/22/2022, 07/25/2022, 07/27/22, and 08/02/2022. In an interview on 01/09/2023 at 9:04 a.m., S1 Executive Director confirmed the facility did not have an RN in the facility for at least 8 consecutive hours on 07/21/2022, 07/22/2022, 07/25/2022, 07/27/2022, and 08/02/2022 and should have.

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and interview the facility failed to ensure that the nurse staffing pattern was posted daily. The facility census was 65 according to the Residents Census and Conditions of Residents dated 01/08/2023. Findings: Observation on 01/08/2023 at 9:00 a.m. of the posted facility staffing pattern revealed a date of 01/06/2023 (Friday). Interview on 01/09/2023 at 12:02 p.m. with S6 Staff Development Coordinator revealed she was responsible for the daily posting of the facility's staffing pattern. S6 Staff Development Coordinator revealed she posted the staffing pattern on 01/06/2023 (Friday). S6 Staff Development Coordinator confirmed the staffing pattern was not updated on 01/07/2023 or 01/08/2023, and it should have been.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on record review and interview the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The physician failed to evaluate the appropriateness for the continued use of a PRN psychotropic medication beyond 14 days and failed to document in the medical record the rationale to extend the use beyond 14 days for 1 (#32) of 5 (#6, #30, #32, #58, #61) Residents reviewed for unnecessary medications. Findings: Resident #32 Review of Resident #32's medical record revealed an admit date of 05/10/2022 with diagnoses that included, in part, Cerebral Infarction, Left Femur fracture, Dysphagia, and Major Depressive Disorder. Review of Resident #32's current physician's orders revealed the following order: 08/23/2022-Oxycodone HCL (IR) 5mg capsule, give one tablet (5mg) by mouth every 4 hours prn pain Further review of Resident #32's medical record failed to reveal evidence the physician had documented the rationale to extend the use beyond 14 days for the use of the Oxycodone ordered as needed. In an interview at 4:45 p.m. on 01/10/2023, S2 DON acknowledged the physician had failed to document a rationale in the medical record to extend the use of prn Oxycodone beyond 14 days.

CONCERN (E)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review the facility failed to ensure there was sufficient staff to ensure adequate oversight and training was provided for the dietary staff to prevent the problems associated with not maintaining daily temperature readings of the refrigerator and freezers; and the dish washing machine temperature and sanitizer status. The facility also failed to ensure meals were served according to the posted times. Findings: Initial observation of the kitchen on 01/08/2023 at 09:29 a.m. revealed only one dietary staff person (S3 Dietary) and one CNA (S5 CNA) working the 5:00 a.m. - 1:30 p.m. shift. Interview with S3 Dietary Staff on 01/08/2023 at 9:30 a.m. revealed that the facility had not had a Dietary Manager for at least 2 weeks. S3 Dietary Staff stated he and another dietary staff person were scheduled this morning, but the other dietary staff person was a no call/no show. S3 Dietary Staff revealed at around 6:00 a.m., S5 CNA was sent to help out in the kitchen. Further interview with S3 Dietary Staff revealed that he had not had time to check the refrigerator temps, the freezer temps or the sanitizer on the dish machine due to not having enough staff. Interview with S5 CNA on 01/08/2023 at 9:35 a.m. revealed she was hired as a CNA not a dietary staff person, but had been pulled to the kitchen to work, due to the kitchen not having enough staff. S5 CNA revealed she had not been trained to work in the kitchen but had been pulled before to work in it. S5 CNA stated she did whatever the dietary staff told her to do. S5 CNA revealed she was washing the dishes using the dish machine, but did not know how to check the sanitizer prior to her morning use. Review of the Pot and Pan Temperature and Sanitizer Bucket Form for January 2023 revealed the sanitizing sink temperature and ppm; and the sanitizing bucket ppm were supposed to be checked at breakfast, lunch and dinner and initialed by the person checking. Further review revealed there was no documentation that the sanitizing sink or bucket temps or ppm were checked as follows: 01/02/2023 - dinner 01/03/2023 - lunch and dinner 01/04/2023 - breakfast, lunch or dinner 01/05/2023 - breakfast, lunch or dinner 01/06/2023 - breakfast 01/07/2023 - breakfast 01/08/2023 - breakfast Review of the Equipment Temperature Log for the refrigerator and two freezers revealed the temperatures were not checked on 01/5/2023, 01/06/2023, and 01/07/2023 on the morning or evening shifts or on the morning shift of 01/08/2023. Interview with S3 Dietary Staff on 01/08/2023 at 9:45 a.m. revealed the Dietary Manager from a sister facility had just started coming to the facility on Tuesdays and Thursdays, starting last week to help with the ordering of groceries and printing of the dietary cards for the week. S3 Dietary Staff revealed lunch was to be served at 11:30 a.m. Observation of the kitchen at 11:15 a.m. revealed S4 Dietary Manager from a sister facility and the evening kitchen crew were in the kitchen. S4 DM on 01/08/2023 at 11:20 a.m. confirmed she was called in to help after the surveyors arrived. S4 DM revealed that she called in two additional staff members who were scheduled to work the evening shift to come in early. S4 DM confirmed there was only one trained staff person on duty when she arrived prior to lunch. S4 DM confirmed S3 Dietary Staff and S5 CNA were trying to do the best they could in a bad situation and confirmed there should have been another trained dietary staff person called in to work when the other dietary staff person was a no call/no show to ensure all task such as the refrigerator and freezer temps were checked daily and the sanitizer for the dish machine was check prior to washing the dishes, among other things. Observation with S4 DM revealed the first lunch tray being served was at 12:02 p.m. S4 DM confirmed the lunch meal should have started at 11:30 a.m., but dietary was running late.

CONCERN (E)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to implement an antibiotic stewardship program to ensure antibiotic use was being monitored and trending was being done for residents receiving antibiotics. This failed practice had the potential to affect all of the residents residing at the facility. The facility census was 65. Findings: Review of the facility's Antibiotic Stewardship Program Policy revealed in part: Tracking: Process measures: Track types and locations of infections, and where the resident is located in the facility .Complete Antibiotic Stewardship Monthly Summary Report and/or Antibiotic Agents in Use and present at QI Committee meeting. Record review of the Antibiotic Stewardship binder on 01/08/2023 at 9:28 a.m. revealed there was no tracking and trending of infections and antibiotic use for the months of June, July, August, September, October and November of 2022. Interview of S7 RN on 01/08/2023 at 9:28 a.m. confirmed tracking and trending was not done for the months of June, July, August, September, October and November of 2022. She stated there had been some staffing changes at the facility and she has recently taken over the task of Antibiotic Stewardship.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The facility failed to create a water management policy to prevent the growth of Legionella and other waterborne pathogens in the building's water systems. This failed practice had the potential to affect all of the residents residing at the facility. The facility census was 65. Findings: Interview with S7 RN, Infecction Preventionist on 01/08/2023 at 09:20 a.m. revealed she had no knowledge of a water management policy. Interview with S1 Administrator on 01/09/2023 at 2:34 p.m. revealed she had no knowledge of a water management policy but would check into it. Interview with S11 Maintenance on 01/10/2023 at 2:16 p.m. revealed he will be responsible for checking for waterborne pathogens and will be attending a webinar about his new responsibilities. He stated at this time, he is not checking the facility's water for waterborne pathogens. He stated there is no policy right now, but there will be one. Interview with S8 Corporate Nurse on 01/10/2023 at 2:25 p.m. revealed she has looked for a policy regarding water borne pathogens and was unable to locate one. She confirmed there is no water management policy in place at this time.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 4 life-threatening violation(s), 2 harm violation(s), $731,236 in fines. Review inspection reports carefully.
• 70 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $731,236 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 4 Immediate Jeopardy findings. Serious concerns require careful evaluation.

Email me this report

About This Facility

What is Natchitoches Nursing And Rehabilitation Center, Ll's CMS Rating?

CMS assigns Natchitoches Nursing and Rehabilitation Center, LL an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Natchitoches Nursing And Rehabilitation Center, Ll Staffed?

CMS rates Natchitoches Nursing and Rehabilitation Center, LL's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 69%, which is 23 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Natchitoches Nursing And Rehabilitation Center, Ll?

State health inspectors documented 70 deficiencies at Natchitoches Nursing and Rehabilitation Center, LL during 2023 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 64 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Natchitoches Nursing And Rehabilitation Center, Ll?

Natchitoches Nursing and Rehabilitation Center, LL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NORBERT BENNETT & DONALD DENZ, a chain that manages multiple nursing homes. With 98 certified beds and approximately 55 residents (about 56% occupancy), it is a smaller facility located in NATCHITOCHES, Louisiana.

How Does Natchitoches Nursing And Rehabilitation Center, Ll Compare to Other Louisiana Nursing Homes?

Compared to the 100 nursing homes in Louisiana, Natchitoches Nursing and Rehabilitation Center, LL's overall rating (1 stars) is below the state average of 2.4, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Natchitoches Nursing And Rehabilitation Center, Ll?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.

Is Natchitoches Nursing And Rehabilitation Center, Ll Safe?

Based on CMS inspection data, Natchitoches Nursing and Rehabilitation Center, LL has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Natchitoches Nursing And Rehabilitation Center, Ll Stick Around?

Staff turnover at Natchitoches Nursing and Rehabilitation Center, LL is high. At 69%, the facility is 23 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Natchitoches Nursing And Rehabilitation Center, Ll Ever Fined?

Natchitoches Nursing and Rehabilitation Center, LL has been fined $731,236 across 4 penalty actions. This is 18.1x the Louisiana average of $40,391. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Natchitoches Nursing And Rehabilitation Center, Ll on Any Federal Watch List?

Natchitoches Nursing and Rehabilitation Center, LL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 98
Avg. Residents: 55
Occupancy: 56.2%
Ownership: For profit - Limited Liability company
Chain: NORBERT BENNETT & DONALD DENZ
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
4 Immediate Jeopardy citations: -48
2 Actual Harm citations: -10
70 Deficiencies: -10
Fines ($731,236): -15
Final Score: 0/100

Nearby Alternatives

COURTYARD OF NATCHITOCHES 2-star NATCHITOCHES COMMUNITY CARE CE... 2-star

View all in NATCHITOCHES →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 195293